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05040138�a �z CITY OF CUPERTINO "'t^z : ��, '' �' _ -° rt,' - - V� -, UG -T 3 N- BUILDINGDIVISION PERMIT 1' ik,IRkORMA- BUILDING ADDRESS: )221 M(`rTF.TTAbj RD CALIFORNIA POWER AND LIGHT """".05040138 OWNER'S NAME: PERMIT ISSUE DATE NE: SANITARY OL NO. ARC HITEC'MUNGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH l� 0 LICENSEDCONTRACTOR'SDECLARATION Lm Job Description under', I hereby affirm that I am under provisions of Chapter 9 (commencing that I P with Stenon TMM) ftheBd J of Ne Business aM Professions Code. mtl my license is ecDivision in LicenseClassClasrm s d Affect. Lk.0 ADD GFCI RECEPTACLE (1) Dam Cimbramm,CITY PROPERTY/NO PERMIT FEES ARCHITECTS DECLARATION I understand my plans shall he used as public mcofds Licensed Professional OWNER -BUILDER DECLARATION I Wmhy affirm that I em exempt from Ne Canoacme. License Law for the Following reason. (Section 7031.5, Business end Pmfcasione Code: Any city or county which requires a Permit to construct, alter, improve, demolish, or repair any structure prior in its issuance. Also requlrea llM applicant rot such Permit in rile a signed Statement that he is licensed pursuant o the provisions of the Contmeon'S Licenm Law (Chapter 9 Sq. FL Floor Area Valuation 1 (commencing with Section 7") of Division 3 of the Business and Profcandons Code) in that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the Applicant to a civil penalty of APN Number ane Occas e �'P not marc than r hundred d.11...($50(y.P Y 1, as owner of theproperty.arm em l0 Y employees Co4. 35706011.00 will Podedo the work. end A: The Cure la not intendedorLaw do for sale(Sec.to an Bulinus the or owageaasalei(Sec. Business and ov Cade: The C law don not apply to rt owner of U e eCt10I5 s diercofs ndwho ray who ch who dassudt wink himulfor through his eery who Wilds Own employees. that Improvements Own provided suchimprovementsarcnot inteMedoro@rtdforsale.howeve,- � � EP the Wiprovided pr year of comolefor theose Wilder awthgorImprovementisoldwithinore of Wilder will hew the burden of proving mat he tlitl not Wild or improv for purpose of la.) ttS..a,tt1, as owner of the property am exclusively contracting with licensed mmemss to ay. ro �J / �^ • /�io� construct the project (Sec. 7064, Business and Professions Code:) The Contractor's Li. cense law docs not apply m an owner of property who Wildspor improves thereon, and whocontactsLacox for twit projects with a romrmm(q licensed pursuant to the Conmaofs License Law. BUI�� ING ❑ I am exempt under Sec. . B A, PIC for this moon �� /�.��,, OwneriV V3A-. n(/yxl pYt Dam 4 -Ile -(05 WORKER'S COMPENSATION DECLARATION 1 hereby affirm under Penalty of perjury, one of the following declarations: 1 have and will m.oull. a CeniRcam of came. to ul6lnsurt for Workee.Campen- mion, u provided for by Section 37MI of de L Wf Code, for the pedmmattce of the work for which this permit is issued. I have and will maiinain W.11me. Compensation Inunnce, . mooned by Section 3700 of Ne laborCode, for the performance.( the work for which this permit is issued. My Workers Compensation Insurance Cartier and Policy number am: Cartier. Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' , COMPENSATION INSURANCE (This section need not W completed If the Permit Is tarots, hundred dollars (SIM) or less.) 1 certify that in the pefGsnnanee of the work for which this permit is issued. l shall not employ any person in anymenner.w lira ileo 9le subJecuo the Workers Compensation YYI�J. S I.awsof Califoroia. m - Applicam I 'YV1 . V) NOTICE TO APP A1,1T. If, after making this Certificate of Exemption, you Mould Wcome subject m c Waiter's Compc.ation provisions of the IaMr Code, you mum Forthwith comply with such provisions or this Permit shall W deemed mmked. CONSTRUCTION LENDING AGENCY 1 hereby arcrm don there is a construction lending ageng I'nr the imormonam a of the work for which this permit Is issued (Sec. 3097, Civ. C.) Lender's Name Lender', Add.. I Canty that I have read this application and sum that the aW w information is correct. 1 agree m comply with all city and county o.inames and toxic laws mlating to building Conawction. and hemby aothorim representatives o(1114 city to cover upon the above-mentioned!for inspection /I (We) agree m sere. indemnify and keep harmless the City of Cupenino against ' nt, C., Which an. expown judgment, costs and expenses which may In any way accrue ageinn said City 91toDate inconil in consequence of the graining of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: SOURCERE y ATION . Re -roofs 0 D- 1�2ate Signature of P Dem --HA ARDO ---HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or forum Wilding Occupant.Chpnorc of handle ha�ous material Ax defined by the Cupeninn Municipal Cuda Chapter 9.12, and the Ncahh and Safety Code, Section 255320)? \ Ail -_.. e.. .,1_11 s._:_ Uan NNu Will the applicant or future Wilding occupant tau equiPmut or devices which h.vardous air Contaminants as 4Rned by tM Bay Area Air Quality Management kl? ❑Yes �Nn 1 have man the hmardous materials reyuircmenu under Chapter 6.95 of the Califor. nia Health A Safely Code, Securms 25515.25537 and 25534.1 undcrsuM that ifthc Wilding don not eunently haw a tenant. Nat Ir u my responsibility in mu fY the ..111Ot of the .. .—I. a.rssr. s. snpcucu Pt too to ally IuuIIIIg material being Installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 CITY OF Fax (408) 777-3333 �UPEf�TINO Building Department L JOB ADDRESS: 44 Ra.nth C�p Cl✓iiv o 22221 MLCie il�r� Vzct c.4 f,5vi4- PERMrr # c) 0)-3e y OWNER'S NAME: Cik of C u e4-,iny'- .> PHONE # 403 »(0 3X35 GENERAL CONTRACTOR: C^ PUwe*---t- to t^t FAX # I am not using any subcontractors: 2.610G Signature Date Please check applicable subcontractors and complete the followine information: rrn• nzN-d�l-� U Owner/Contractor Signature 4H- V-v(kn1b,1(5 ctub Lepd 4-12510 5; Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing x Electrical CA- 4'u vrn- -t- Excavation Excavation Fencing Flooring: Carpeting Linoleum / Wood 1 Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile rrn• nzN-d�l-� U Owner/Contractor Signature 4H- V-v(kn1b,1(5 ctub Lepd 4-12510 5; Date L r % CITY Or CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM sem' c f 3 APN # 3S� b Date: A-12- 510 E Building Address: Mailing Address (if different from building address): '2221 J0CLIc11CAP� (2uw�cd/ sa14 Owner's Name: Phone #: (i1-`- t� F C C i/�%h v o L40'3' -Y-) Zp - 3 9 35 Contractor: I C4KA r{ OY In 1 OL W- + Li t^ + License #: '7 2 O to Ss 4 ConittacPhone: -7-7(,• 355-35 Cupertino Business License#: Fax: 7 ZO % 8 ¢ Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: o,CJf i cwt-twvwl, Residential ❑ Adel GFt- 1 r -e -t.2 te,c Lk Commercial.-._ viov va r, ( 6Ik4 Sq.Ft. Floor Area: $/Sq.Ft.: Srt Cost of Project: G O D Occupancy Group: Construction Tax 4H p4nch Type of Construction: Please check this box if the project is a %EDo C12CVlT 62ihitFn Pat GCFT 0JTLfT- second -story addition: ❑ Project Size: Standard, Laze ❑ Major ❑ 71 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 C A 1 of 3 G CITY O CUPER,TINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 Fee ID Fee Description Fee Group SoQuantity l BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL 13NUCOMMM 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 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/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 BREMAI)PLI A Bance Install MECHANICAL BREMBUSWAY Remodel Buswa s ELECTRICAL BREMFIXT Li htin 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 I Remodel Res Appliance I ELECTRICAL 2 of 3 I...v.� CUPEkTINO CITY OF CUPERTINO 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 Insection 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 PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3of3 1 J