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04100168CITY OF CUPERTINOz'ava: BUILDING DIVISION PERMIT CORACTOR iN'RMATtf.11V+F% BUILDING ADDRESS: C WY JOE S BARRAZA MASONRY INC PL-RMMNO. 04100168 OWNER'S NAME: PERMIT ISSUE DATE ONE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUME MECH 0 0 0 0 ji LICENSEDCONTRACTORSDECLARATION 1 by Affirm that 1 am Ikmucd under opmom of Chopin 9 (commencing mol on Code. and my license is IOs Ei zry'{me..t 1� Lm.a .,9Q1 CHIMNEY REPAIR j� Dere Convector ARCHITECTS DECOVA�ON him/ g 2004 ]5 I unMnund my plate shall be teed u public record U Livened B ■ p p /� 3 conal OWNER -BUILDER DECLARATION {DJ ®' I BUILDING /V' 1 g: 1 worry that 11. exempt from Ne C Cacaos Lew for the worry U L N p m0 roti Pmruanns Cam: Any city as county meson. . (Sce 71D usions Co d LL S^ < which permit t no t,man, ler a Ag,ey structure Coma the man, Impma, denlnl Permit to which rtquI.ssu n e, also brairtima the theapplianl forsuch acturmecrse Law stsem,m poor On its, iensed0.nme 9 Sq. Ft. Floor Area Valuat o CC bac t to C $ (not commescanwithSemasn7")ofDinimunrNeCanbactoraliarommio Code) (commencing with Stt11om, and the basis froftMBedassmd Profusions CmM)or Natio is therefrom and dte beer for alleges assumption. Any violation of 3 rN`Dl�y�er0 0 Occupancy Type be 31.5 b fora permit subjects Nc applicant Ip a civil penally of Section ]831.5 by airy red doll not more Nen 8ve hundred dollars (g5W). ❑ I,uownerofthepmpeny.mmyempla wINwgoruNoirelecompenutlon, Required Inspections will M Ne work, and Ne,wcture is natintended proffered rmsale (Sec. 7014, Business and Profusions Code: The ConussuYs Lianse Law door wt apply to an owner of property, who builds or improve ,cram, and who doesauch mark himself or through his Own employees, provided NeI such improvements lee not intended or offered for sale. IL however, the, Wilding or improvement is sold within one year of completion. Ne owner. Wilder will have the burden or proving that he did not Wild or improve fm purpose of sam ). ❑ 1, u owner of de property, em eeclusively contracting wish licensed conhacNn to common the project (Sec. 78th, Bminess and Profusions Code:) The Contractor. Li. cense Law does not apply to an owner of property who Wilds or improves demon, and, who convacu for such pmjcm win .,.moons() livened p ewcam to Ute Conmclo's License law. ❑ I am exempt under Sae. , B& P C for this moan Own. Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of Perjury, one ler the following declarations: I baro and will maintain a CcNfiute of Consent to elf-imum for Workmes Compen. satlun, as provided for by Section 3788 of Ne Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain Worked Compensation Insurance, u required by Section 37W of Ne labor COM. for Ne performuce offt work fmwhich this permit is issued. My Worker's Compensation Insurance carrier and Policy number art: m Cj�yaVJulT M1LLT PoIIryA c.: Z E TIFlCF�ATE OF E%EMI'I70N F1,0 ORKERS' COMPENSATION INSUR CE (This marinas wed not Imcomple ed If Ile permit Is foram, hundred dollars (SIM) nr Iaa) 1 cedfy out In the performance of dte work for which this permit is inwd. I shall or employ any person in any manner an as in become subject o the Worken' Compensadon Laws of C.111.mm One Applianl NOTICE TO APPLICANT: If, after making this Ccri fiete of Exemption, you should become subject In the Worker's Compensation provisions of she Labor Code, you must ronhwith comply with such provisions "is Permit shall be deemed rtrokcd. O y CONSTRUCTION LENDING AGENCY > 1 morty,Rum Na that. is a xw xOnn lendingagency for the p,r(ormmcc of the work for which this permit Is issued (Sec. 31197, Civ, Cd sNssmc QLcnM lender, Add. z Q 1 certify that 1 have reed thb application and state thin th, above informNun la correct. 1 gree In comply with all city and county ordinance and sum laws miring to building construction, and hereby authoore representatives Of this city to enter upon Ne {Ii shove-men,owd property(Or inspccd,n Pugwes d to (W)agreeto an. indemnify and keep hainMshe Cityo AiRiMLoidiner may In anyway acemn )slutmid City .w ,Z incoidesunce of theSomalia,expcesawbich in of of shin Permit. U ^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT UNDERSTANDS Issued by: Date SOURCE R CATION j Re -roofs 4 Signa fvvcw lowelif, Dae HAZARDOUS MATERIALS DISCLOSURE Type of Roof I Ne applicant or future Wilding acummmoro or handle hamodous material u Mftwd by rte Cupertino Municipal Code. Chapter 9.12. and the Health and Safely Code, Stenion 25532()?All ❑ Yes roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will Ne applicant or future building occupant use equipment or device which emit harardus air cowarru ante u will by Ne Bay Arta Air Quality Maegcmcnt all new materials for inspection. D;WICI? ❑Ya I have must she hoard o, macomr req.1remenB amici chapter 6.95 of t Califm. nice Health Jr Safely Code, Sections 25515.25533 wall 2553x. l undcnun, shat if N, building Ontonot commonly hew a tenant, Net it is my msponsibility in notify the oeeupatt of the mquimon otsw ichmum bemet poor to Issuance oraCcrtiOeae,afOcca.nay. Signature of Applicant Date �� "B" � All roof coverings to be Class or better � r thori%ctl egc Dae f' 4 CITY OF UPERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: I :72 9ci L PERMIT # OWNER'S NAME: -r „� u PHONE # GENERAL CONTRACTOR q2A r FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followinq information- ,Xer'rCon5At4f8ir Signature . Date 60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry A A 2� M �` Ornamental Sheet Metal Painting / Wallpaper Paving . Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ,Xer'rCon5At4f8ir Signature . Date WITo CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM APN # > s— s d Fee Description Fee Group Date: a MECHANICAL BBOILERI Boiler <= 100,000 Btu Building Address: BBOILER2 Mailing Address (if different from building address): -799 L. �c ix, Owner' Name: BBOILER4 Boiler> 1M to 1.75 M Btu Phone #: 1� J, u u 255-114 Contractor: BUILDING BCONSTAX License #: 'UArrA BCONSTAXBQ Con. Tax for BQ Zone 40(o2c11 Contact: Hotel and Motel U Cupertino Business License#: Z -Q AYY ZA Fax: 4oe- 72:7- 1 1 BELEC1000 Building Permit Info: ELECTRICAL BELEC1001 Bldg2S Elect ❑ Plumb ❑ Mech ❑ Job Desc ' tion: ELECTRICAL BENERGY Residen al I chl e 11 Commercial ❑ Sq.Ft. F onArea: BUILDING BINVESTIGA $/Sq.Ft.: C of Project: ,� — Occupancy Gr p: V)Me of struction: Please check this ox �f the project is a I s I second-storyaddition: ❑ Project Size: Standard tR Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING � z�Ssz 1 of 3 &—/ 22, s—_(> WE CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMIfIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTWE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/A.lter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Ligbting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Fumace > l OK btu -MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 w,,To CITY OF CUPERTINO CU O PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group i BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Maz uee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL: BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL: PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 0 3 of 3