04020161 CITY OF CUPERTINO x teams ,,x,'}
BUILDING DIVISION PERMIT CONTItACT+OR TN 'ORMATION'•`..
BUILDING ADDRESS: CLIFF W COUEY CONSTRUCTION """'04020161
OWNER'S NAME: PERMIT ISSUE DATE
GUPTA
E; SANITARY NO, CONTROL NO,
(408) 252-07S3
ARCHITICTIENGINEER
08 252-
ARCHITELTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LGZp LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby afrtr that L am licensed under provisioru of Chapter 9(commencing
^� with Section 700h of Division 3.f Me Business and Professions Code.and my license is
mfall eClon, error''
5J� UPGRADE CEI LINE & ELECT BRANCH CIRCUITS
Dow Ctw Could
ARCHITECTS DECLARATION
�i 1 understand my piano shell M used as public records
3 00 Licensed Professional
OWNER-BUILDER DECLARATION
.�0 0 1 hereby a(rr that I am exempt from Ne Comn,Co Licence Law for the
pa whowingress .Permit 7B3Ld,Buirpeurn and os,.thuOns Codd:My cmmrountye
a'$�i which m9uima s perp m crams; be spec.Wpmw,h Permit t fi mash any swcture
�`� rtdormslimmance,saw
galin Me rhovisio csoffor suchctori'm..Lawtlnammcm
thuburlkenwit pumtam in Me of Division
of the Contractors',nd Pre uAw(Chaprer9 Sq.FL Floor Area Valuation
o Met(connormo
sectoith Section 7000)of basis n3 the
theege exempo...Anynns Code)of
S Jon Section
LL exempt taerefrom and the aper for the alleged eampu to Any violation of
not. 7Manfyany
redd.IWa(aperltaubjecuthe applicanuoadvllpenalty of 35UT8Nuh(bi;r00 Occu ane e
not more Nan five hundred dOlrn(g500). P Y zYP
❑L u owner of rhe propene,m my employch wrth Lagar u devote campnuiness
will Professional and the eComences Lidedo Law ed den ntapply.7044.BusOwner of Required Inspections
and Professions Code:The Comracmh License Law doh not apply lf an owner of q P
Ownproemploywho a.Provieddhor Met such
mprove who dmaamhavark ended cmalfor duough his
f, -
how employee,provided Nat such improvements are not Intended monered for owmer,
however,Ne buildingorimprovement Is sold within one you of reprove for
Ne owan
Wilda will neve the burden of proving Jur he did rot build or Improve for puryoa of
tial).
❑1,u owner of the property,,B straws and contracting with:)Th ed contractors to
construct tMprojem(Sec. sin Buinwandrty ho Wilds
Cade:)Them Memori Lid
who Laradopenot apply men owetotorproperty who sedporimproves there¢.and,
whocontractsfor such projects with aconuaotor(q licensed puraemmJRContnaOM1
License nave. A
❑lam axe under ,BkPCf thlsm on /
WORKER'S OMP ATION DE N
IhereayaBlrunder puWtYn perjuryoneaf lowing declarations:
haw and will mains n aCenifiute of Conant to self-insure rm Wmkeri Compcn-
cation,u provided for by Session 3700 of the Labor Code,for Jte performance of Ne
work for which this peril is issued.
0 1 have and will maintain Worker's Compensation Insurance,as mounted by Section
3700 of Me,Labor Cade.for Me performance of Ne work for which this permit is issued.
My Worke's Compensation Insurance cannot and Policy number art:
Cattier. Policy No,: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thr aching mend not he completed If rhe p=rlt Is from=hundred dollars({10(7
Or Mss.)
1 unify Out a forence of Pec work five which this permit u issued.I Nall raw
employ any nJman atter um become abject m the Workero Compensation
Lawaof CeIRorvig. a
A L�
NOTTA TOA CANT:IL
Worker's kr Ceni6ute Exemption.
ug
become sec m the Compernsa rmiof Me"her Code,you mute
JO forthwith comply with such provisions or this permhtOatl ane deemed revoked.
y
�
CONSTRUCTION LENDING AGENCY
I—e IWmby affirm that More is a construction lending agency for Ne perfurmace Of
the work for which this permit is issued(S..3097.Civ.C.)
tr.1 0 Lendme,Name
]z renders Addy
U 0 1 certify Nn I be.read Wio application ad sone Net Ne above inforetiun is
LI,r cora 1 agree m comply with all city and county ordinances and sum laws relating m
0U building construction,and hereby authoda tepmanuom of this city to emu Orton the
W shove.mentioned pmpcny for inspection purposes.
L (We)agree to sew,indemnify ad keep ham less the City of Cupertino against
N liabilities,judgmenu,mato no expenses which may In any only ammo against said City r2,5045�;��D
U z in consequence of tho granting tof this Peit.
APPLICANT UNERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by: 67Date
SOURCE ULA O O J�
r Re-roofs
Sign pph aUCEAusm r Date
HAL RD to
S ATERIALS DISCLOSURE Type of Roof
Will the applihnt or(utua Iding occupant uore or Mndk harArdoh material
h dcfned by the Cupertino Muni o I COO.Chapter 9.12,and the Health and Safety
Code, C3 es zss3zto7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu
Will the applicant or Cut.. nding Occupant he equipment at devices which .If a roof is installed without first obtaining an inspection,I agree to remove
l hazardous air conmorman fmcd by the Bay Area Air overtly Management all new materials for inspection.
Disuict7
❑Yes v
1 haw mad the Wood us materials mquimmenu under Chapter 6.95 or dm Califur
no Real"Safety Cook,S=etiwu 25505,35533 arul 25534.1 undcntonE that irdte building '
Jape not cumenJy an a tananl.Nat it r my nespomilhoity m notify the occupant of the
requiremcou v, ch rbc priormi,aamancwprhtearaapacy. Signature of Applicant Date
oLn ran nthannca as=rat am 6 All roof coverings to be Class"B"or better
CITY OFCUPERTINO
BUILDING DIVISION PERIAP
BUILDING ADDRESS: CLIFF W COUEY CONSTRUCTION PERMITNcb4020161
R'S NAME: PERMIT ISSUE DA713
GUPT
PHONE: SANITARY NO. CONTROL NO.
408 252-
ARCHTIRCT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
] 0 0 0 0
al O Zp LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm Nu 1 am licamed under provisions or Chapter 9(commencing P
with S«lion7M))ofDivision3of Ne Business Pfofesslnns Co .andmylicenceis
GH inrnnrn Aenaert«L UPGRADE CEI LINE & ELECT BRANCH CIRCUITS
J Z License class Ir'.s
2, p Dale Carl.=,
7W ARCHITECTS DECLARATION
< I..&.ad my plea still be used u public record
U
O Licensed Pmfceaionel
OWNER-BUILDER DECLARATION
�a S I hereby a(Rrm on 1 1, exempt(rum the ConlnnCo License Lin,o for the
p 0 which requires
.perm(Secit
R(J t.3,Business andren. seas demolish.lc:Any city atcounty
rutime
$iso which mqulra s pmmh m coaw0.a@c improve, tirm repair any swcurc
i pdormits iasuence,alw requires the appllamfor, such .tire filo signed statement
�< e u lr«
licensed pursuant to tic provisions of the ConloiWanan LAW Sq.Ft. Floor Area Valuation
Ina h
(commencing with Stenon 7000)of Division J of the Business and Professions Code)or
6" $ Ihu he Is c fermi Bv+efrom and the basis fm the alleged exemption.My violalfon of
Section 7031.3 by arty applicant for a parch subjects the applicam to a civil Penally of .3 I1�e10 0 Occupancy Type
not more than five hundred dollars($500).
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offend ror tale($«.IDI+,Business Required Inspections
and Prosecutors Code:The Convenor's Llame law cast not apply i an Owner or - - q P
property who buildsortmprosse thereon,and whodoessech work himselforthrough his -
own employ..provided Nat such improvements ase not intended cronered forsele.if.
however,the building or improvement is sold within one year of completiam the of
builder will have the burden Of proving Net he did non build or barrow for purpose of
ailed. ■ {�r�nu
❑1,ru construct tis er of the property.am nclusi and confessions with IiceveCantnctors u 1YALelm
earnLthe project(Seo ION,wner of and property
who
ds or Improver
Contractor's Li- .��11
<cnae Lew dose not apply u an own«Of property who builds or improves thereon,and -
whoeontnctsforsuchprojectswithacontessa )Ilunsed pursuant to the Comeaemr's MAY 2004
10371of
a Uw. 1 L
m tee under. ,B&PCf'Ihi moon
r WORKER MP ATIOND A N A.L BUILDING
1 hereby M.under Penalty o perjury,oro of lowing declaration
aw and will maintain a Cenifiate of Coaent 1.self-btsurc for Workels Compen.
.tee Provided for by Section 7100 Of the Labor Code.(m the performa«c of the -
for which this Permit is issued.
an tad will maintain Workers Compensation Istsurance,as required by Section
the labor Code,(or the perfmmana Ofthe work for which Nis permit 1,Issued.
orker's Compensation Insurance carrier and Policy number am:
Carriu: Policy No.:
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
math cation need not becompteted lithe Permit is,rose.Worked dollars(5100)
or las.)
I anify that n�I plea m umc of the work for which this Permit is Issued,I shall net
employanyperin in en arnncr asm become abject to lM Workeri Composition
Laws of Celifornt6. m
Ni'fTO APPOCAN11.If.after nuig Or Cenirncam or Exemption,you should
became subject w Ne Wohefs Com. . provisions of the Labor Code,you muse
0 Q forthwith comply with such provisions or u permit shall ban
Ise demand mwked.
z CONSTRUCTION LENDING AGENCY
(..r► IhcrtbyaM.Jbat Ness iso esufmninn lendingegency for the perfuemamc or -
ai ti the work for which this permit is issued(See 3091,Cih,C.)
W Lender's Name
D.
D.2 lender's Address
U Q 1 cenify that 1 ban lead this rip,ication and sum that the anon information u '
IT.F correct.1 agree in comply with all city and county oJinanees and sure laws mining in
O V building coauuction,and Wrobysuthadm rcpreaentatives of Nis city in enter upon the
[T] aMve-mentioned Pori for Impaction purposes
(We)agree to saw,indemnity and keep harmless the City of Cupertino
TA waagainst
r.� IhbilideLJudgments,costsand expenses which may In any y segue agulnsla
sid City
u ineonegcence Or Negnnlingaf Nis Permit.
APPLICANT UN ERSTA SAND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE ULA O - O(�
2 Re-roofs
Sig. Fri..UCO =tor Date
HAZAROD S ATERIALS DISCLOSURE Type of Roof
WIII tic+pplicanmrfmurc sending occupant store or handle ha'rallous material
defined by the Cupe ino Moor u (Coda.Chapter 9.13,and the Halth end Safety
• te.Section 25532f.)? All roofs shall be inspected prior to any roofing material being installed.
[:]Y..
Will the applicant or ml..b ddl.g occupant use equipment or dc.ieu which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air comment....
eftncd by the Bay Arca Air Quality Management all new materials for inspection.
District?
0 year mz
I hon read theism tlusmaurlalsmquiremcntsun�r Chapur6,95ofthc Califor-
nia Hwlth&Sdmy Cod0.Sectioa253113,73577 and25534.1 undcrsund W ifthc Wilding
does rot currently an•enema that It u my responsibility u notify dte aecupem or the
requirtmatsw be prior m issuance of.endnote or Occupancy. . Signature of Applicant Date
2G
Own ro uthamcd egem All roof coverings to be Class"B" or better
Da¢
( - TY OF CUPERTINO D �zo,.-20,1,b'
,.-20,1,6
W �rroF PERMIT APPLICATION FORM
UPEkTINO
APN#3 03 U Date: Z �Z6- 0
Buildi Address /y VC Mailing Address (if different from building address):
Owner's Nannie: � Phone #:
Contr tor:License #:
C-1 C owe �hs �ru �� �
Contact: Phone:qe6' y)2 Z°R Cupertino Business License#:
C C.oue Fax:
Building Permit Info:
Bld I� Ele t Plumb ❑ Mech El
Job Descriptiory J
Residential Ila o me is
Sq.Ft. Floor Area: tj
Cost of Project: /q L O 50 Occupan Group: �
e of Construction: Please c eck this box if the project is a
second-story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE" Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
RBOILER4 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
BMITIGATC I Comm. Housing Mit. Fee BUILDING
1 of 3
RTY OF CUPERTINO
SUPEfZ;TINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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 rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm. MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace> I 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
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
2 of 3
. ftITY OF CUPERTINO�
C ICATION FORM
CUPERTINO PERMIT APPI,
uanti Fee ID Fee Description Fee Grou
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation S stems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL S ecial Inspection BUILDING
BSWIM Swimmin Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Tem ora Bld Permit BUILDING
BTEMPSVCS TemD Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MP
ERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG PlumbingFees foot PLUMBING
ZADDCHG I Address Chane BUILDING
3 of 3
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CITY OF CUPERTINO
BUILDING DEPARTMENT
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