05060074 CITY OF CUPERTINOV,
Ovlu�'
W,
BUILDING DIVISION PERMIT ft"CUDRINN WMAT1,9
BUILDING ADDRESS: PERMIT N995060074
I
Mi21921 MCCLELLAN RD
NER'S NAME: PERMIT ISSUE DATE
FATEKH VERGASOV 06/13/2005
ONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BOLDO ELECT PLUMB MECH
0 6 LICENSED CONTRACTOR'S DECLARATION
I hereby m1flom that I son licensed cedar provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of due Business and Professions Code,and my license is
in full Termagant CRCCL ELECT. SERVIJG
PIOCATE &
OQDow-Cmrseemor UPGRADE TO PI OR: J.W. ELECTRIC, I
ARCHITECTS DECLARATION
I understand my plans dull W tand As public records
Licensed Professional
1 hereby...OWNER-BUILDER DECLARATION
Thu I am exempt from tho Comaxtor's Liam Law for the 205
j:00 following reason.(Section 7031.5.Business and Professions Code:My city or county
which requires a Permit to candsmuct,near.Improve,demolish,ar repair any someone
prior to its issuance,also requires the applicant forsuch Permit to rile a signed stmomen,
ggthatilocislicensood p�an,taffiepmvi3iomoftheContmwr'iLicenwUw(Chapwr9 Sq.Ft.W%Fft Valva S 0_O
(commricingwith Section TOM)dDivision 3 of than,Business andon.
tial an is Antonio therefrom and The basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant far a parml,subjencas the Applicant to a civil Penalty of APN Number Occupanc
.I y Type
..than hundred dollars(M). 35714011 . 00
[]1,nowncraftlar property,army employees with wagcon theirsolecampenuardlon,
will at,the wark,and the nsuUert b not Inbound m offered for We(Sec.7044,Businhs
And fticandons Cods:The Cmummatr',Lice=Law dons Act Apply to In Owner of Required Inspections
Property who builds w impasses,incomes,And who does such work himselfor through his
awn employees,provided thalmsch impmrwmemu sue not Intended modifired for age.if.
however,the Wilding or improvement is sold within one year ofcompledon.the Owner.
builder will have the burden of proving that M did not Wild or Improve far purpose of
"In.).
0 1,a owner of the property,am exclusively conuouring with licensed ronuamam In
comments the project(Sec.7044.Bunflocas son Profousions Code:)The Coamectors Li.
cancer Law does not apply to an owner of Property who build,or improves themor.and,
who contracts for such projects with a con"clor(s)licensed pursuant to the Contractor's
Licens,Law.
I am exempt undo sec B&P C for this moan
nes Dam OV
WORKERS COMPENSATION DECLARATION
The y afErm senior penalty of priory am of the following ciedimations:
1haw and will main al.aCertificamcdC.rom.lueself-inse.f.W.Alace.C.ropm,
sation.As provided for by Section 31M of the Labor Congo.low the performance of mass,
work for which this permit is issued.
1 how And will maintain Worker's Compensation Insurance,As required by Section
W of the Labor Code,for the performance of the works for which this permit is issued.
My Worlsee,Compennumbom Imancrex,carrier and Policy number me:
Cartier.C Car
arr .Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sesdion rend not wcorropleted if the permit is forum hundred!dollar($10)
lexa)
I Unity 0.11.the morarmance of 1.Work far which this Permit is banned,I mail not
conployanyInumni"Any 'a ;!jean eWo,kcr,9;dom,
LA.ofC.Iffmadia.Dow
Applicant
NOTICE TO APPLICANT:It.After making this Cc or Examines.you shmild
Inumance subject to 0 Ftam the LAW,Cone,you muss ,
Nall
OZ formimth comply withmail Im dicomed revoked.
0
CONSTRUCTION LENDING AGENCY
I hereby&film that them Is a comirsection lending agency for the Performance of
the work ror which do$Permit is issued(Sec.3097.CN.Q
Lenders Narrace
Leaders Add.
U Q I certify that I ban mad this application and&out that the show Inforinnathon is
Vy Comm I agns:in comply with all city and county ordinances And mew Is"relating in
0 rU^ building connotation,and hereby authodar reparommmm of this city to enter upon the
lbow-mentioned PTqm1Y Tax inspection PAAPANAL
M (We).,ree to now,mmomity and keep homeless the City of Cupertino against
Ini4bilimcs,jodgmcnis,coms and expansion which may in my way accrue age in,mid City
:n consequ me of the Snoring Of this permit.
In
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date
SOU his.,
Re-roofs
Sign atfir AplicavillComamor Own
Type
HAZARDOUS MATERIALS DISCLOSURE pe of Roof
the applicant or future building occupant mom or handle hamodows maunind
a defined by the Cupentre,Municipal Code,Chalon,9.12.and the Haman and Safety
Section 25532(s)?
clyd. )(110 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building me.opens M equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haradcous air contaminants u dolincal by ft Bay Area Air Quadity,Management all new materials for inspection.
District?
I'A
0 Yes 'AN.
I have mad the hazzatioulmoucrials requirements under Chapter6.95ofulm Calif n,
.is Health&Safety Code,SOCUM25505,23533 and 23334,1 understand Lhatifthe building
dese,not curtendy law A count,that it 6 my responsibility an nonfly tas
he sistant of the
mal,
requirement,wkch a"be met pmor or Wootton 012 ccraricate of Occupancy. Signature of Applicant Date
13-0
All roof coverings to be Class "B"or better
Owns 40duffionzad agent Dow
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
coo Fac(408)777-3333
�UPE(�TINO
Building De artment
JOB ADDRESS: 2- 192-1 /tiG Cl- a4-7 XQ' PERMIT#
C(/i°45r7A✓0 O/ 506600 �
OWNER'S NAME:,4 7,!�- e V R G SDV PHONE #
GENERAL CONTRACTOR: s ' FAX#
I am not using any subcontractors:
Signature- Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
�rro PERMIT APPLICATION FORM
CUPEkTINO
APN# 3 r7 i�� Date: 0
(D 6•— (3 '
Building Address: Mailing Address (if different from building address):
--
21q2-1 11C-
Owner's
7GOwner's Name: Phone#:
G�r`KH r6—9 G,q 5-0✓
Contractor: e License#: yS� 7 C� 0
Contact: Phone: S/0 J /—(07/ Cupertino Business License#:
Fax: ri 0 s38 Lf y 7J9
Building Permit Info:
Bldg ❑ Elect 151 Plumb ❑ Mech ❑
Job Description: S,2 v/0 - 26-C c9 CA 7-1 ON T9a/ 269 0 !J 0 b
Residential ACommercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: / j Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee gBUILDING
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t r
CITY OF CUPERTINO
CUP
fE(�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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
MIXTURE 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 din MECHANICAL
BREMAMIAN A/C Units<= 10,000 din MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFD{T Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> 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
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CITY OF CUPERTINO
CUPER,TINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee 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 Temp 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
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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