04060169 ' ITY OF CUPERTINO �r k;• 14 z= "'' Ft 'r .`
BUILDING DIVISION PERMIT CON
F":ILDING ADDRESS: PERMIT NO0 4 0 6 0 16 9
10295 MIRA VISTA AV
OW NER'S NAME: PERMIT I SUM DATE
LESLIE FOWLER 4
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONDUCTOR'S DECLARATION
fly 1 bareby.ffi.that I am licensed ander provW.a of Cesium,9 m.mmenriag Job Description
M Sec ion 7IXN8 of Division 3 oftha Businmmd PmfcW(ins Code,end my Iiccw is
0flif andafr �fS1SSS� ELECT SERVICE UPGRADE
Dam Co.' �H r e �wfm CONTRACTOR: DLH GENERAL CONTRACTING
ARCHITECT'S D C llRATION I EXP
1 and my plans shall W used hilt retards3CG Liccuctl Pndrssional
OWNER BUILDER DECLARATION
ico I I hcrosm.(firm Nal 1 em exempt from tha Contactors License Lew for the
OG which regrias..(Steffan constr,Budmsssad improve.
deduce Cade:Anycin tacounty a$r which xquims•permitra enres On,alar.imlrove,dcermitt me a iany twnuro iED
''�i i•" O tr W its issuance,also...,to rex tho isum applicant for.uam C h pennil m(imuLa signed statement b 5 0 0
t^< momenie licensed puauenundW provisloa of the ComrecWr's License Law(Chaper9 Sq.Ft. Floor Area Valuat$)
$ that he Or n6 with Smtltn and
the
D utf r th lite Batlleserapt on.Any aCale)or
^ dui W b essmpt thea(rom and the but fm the alleged essmpdm.Any violation If
Secdon 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy e
Out marcmanfive hundred d.R.($Xi]). 35702037 . 00 P YTYP
❑1.as owner of the property.or my employs with"gas as Och sole compensation,
will do the wort,and theawcturo is at intended or offered far We(Sac.7044,Business Required Inspections
and Professions Code:The Coruscates Lt..Law does not apply to an owner of q p
property who Wilds orimproves thereon.and who doessuchwmk himselfor through his
own employackpaevided tWasmh improvements are ml intended m offered had W.IL
however,the building or improvement is sold within am Year of completion,the Owner.
Wilder will have the human of proving that he did net Wild or improve for purpose of
tele.).
Q 1,as owner of the property am exclusively conuu9ng with Heartened cenuacmrs W
c.awct the project(Sec.7044,Business and Prolusions Code:)The Contractors U.
cents law does not apply to an owner of property who Wilds or improv theater.and
who contracts for such projects with a conumnorm)licensed pursuant to the Contractors
License Taw.
lunesemptunder See ,B&PCfor Nbmuan
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the fallowing decimations:
I love and will main Wn aceNRate of Consent W self-Insure far Workers Campc..
ation,as provided far by Section 3700 of the labor Code.Or the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as roquimd by Section
3700.(the Labor Cade.fm the perfmanstme of les work for which this permit is mused.
My Workees Compensation Insurance tamer and Policy number am:
Cyai S'1]fIC t3/,v0 Policy No.: 6�
s/ CERnFICATEOFE%EMPI70N RKERS'
COMPENSATION INSURANCE
(This sectio nmd nut becampit aJ tithe permit Is far ane hundatimAlaa(SIg)
or leu)
1 certify that in Ne performance of the work for which this permit is issued,l shall not
employ any person in any mannose Is to become subject o the Workers Compensation .
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificam of Exemption.you should
become subject W the Worker's Compensation provisions of Ne labor Code,you must
rJZ forthwith comply with such provisions Or this permit shall be dcmcel coked.
Z� CONSTRUCTION LENDING AGENCY
[•+ 1 hereby affirm Oat there is a consumconn]ending agency for the Performance of
0.> the work for whichthis Permit 1,annual ss (sus 304,cite.c.) C /
0.O leaders Nuna
z Lendcrb Address
V Q I comfy that I have rad this application ant rata Nn Ne above information Is
Is, ^. comet.1 agree W comply with all city and county ordinances and sum laws misting to
p rV" Wilding convection,and hereby suthorim representatives of this city a enter Ulan We
(.61 aMw-rammianed property for inspection purposes. s,
(We)agree to an,indemnify and kap harmleu the City of Cupertino against /
c4'q liabilities,judgments.costs and e.peues which may in any way amus against said City
t.7 Z to consequence of the granting of this Permit.
APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
rCEREGG N0l Re-roofs
ApplicanUConlnetor D a
HAZARDOUS MATERIALS DISCLOSURE Type of Roofthe applicant m future building occupant at..or Wnlc lawm.a material
the Cupertino MuniciWI Code.Chapter 9.12,and da Health and Safetyn 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
twthe applicant or future building occupant sac equipment or devicas which If a roof is installed without first obtaining an inspection,I agree to remove
us air conumian6 u nod by the Bay Axa Air Quality Management all new materials for inspection.
❑Yes
I he.xad the ha smaus materials rcquiremenu ardor Chapter 6.95 of the Califor•
nia Ruth&SaRtyCodc,Sections 25505.25533 and 25534.1 understand thus ifdc Wilding
does net c.ally haw a tenant.that it is my res'nes hility W sooty the occupant n
metal aswh net et usuanatfacenlOaWof a cr. ignature of Applicant Date
i.04 �( o
nor or ulhoriscd agent Data All roof coverings to be Class"B"or better _
CITY OF CUPERTINO
CUPEI�TINO PERMIT APPLICATION FORM cs�
N# 3s� o v 6-37
37 Date: G �i
Building Address: Mailing Address (if different from building address):
10 ,95' MIQAc vISThRa
Owner's Name: Phone#:
LESLt - Fb rr-62 -log — SSS' C Z2o
Contractor: License #:
1:;LH 6rs-1 ce j k73A=T-i.0 6— S r 5'S$"S'
Contact: Phone: 14,4 q Cupertino Business License#:
IDAVWD Fax:C-SD-949-0897'
Building Permit Info:
Bldg ❑ Elect � Plumb ❑ Mech ❑
Job Description: Senuice UP 6R .Or-
Residential &r Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Constructi Please check this bbsiLth6roject is a
second-story addition: ❑
roject Size: Standard ❑ 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
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:► - CITY OF CUPERTINO
cuPERr1No 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
BOVERTIN E Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
MIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Cbeck 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
Imp 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 clin 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 Furnace > 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
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si CITY OF CUPERTINO
a or
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
BRENIVENFAN 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 Temoorary ME 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
PPERNUTFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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