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03100148 CITY OF CUPEW11NO a Bu.nwc DrvlsloN OIUI' ON:T . I Vyly BUILDING ADDRESS: SAN JOSE PLUMBING PERMITNO.03100148 OWNER'S NAME: 1732 HILLSDALE AVE PERMIT ISSUE DATE NE: (408) 296-1820 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO SLOG ELECT PLUMB MECH 0 0 0 0 loo LICENSED CONTRACTOR'S DECLARATION I 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description wit Section]lKN))af pivisionJ of NC BusinessanJ rofcssinro Code,entl my license is „ i mumlass ecL _ REPIPE & NEW SEWER & REPLAE WATER HEATER a cense Class Lic.p a t- ate �+ - —o cccs T cion ARCHITECTS DECLAI A WU 1 understand my plans shall he used es pablic noon s ii y Licensed Professional s OWNER-BUILDER DECLARATION 3<f 1 hereby affirm that 1 am exempt from the Contractor's License Law for the .a0 following mason.(Section 7031.5,Business and Professions Code:Any city or county 2 which requires a permit ha cnnsvun,site,improve,demolish,or mpai'any shucmm prior to its issuance,also m4mms the applicant for such permit to file a signed statement sr< that he is licensed pursuant in the previsions(if the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation - 2t$ (commencing with Section 7")of Division J of the Business and Professions Code)or 3 Out he is exempl Rumfrom and Be,basis far the alleged exemption.Any violation of 37529039 . 00 Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more Nan five hundred dollars(SSIXB. P Y YP ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the swmure is not intended or offered far sale(See.7044.Business and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections proPeny who builds or improves thereon,and who does such work himself orthrough his own employees,provided that such improvements are not intended or offered forsale.If, however,Ute building or improvement is sold within one year of completion,Ne owner- -I_, builder will have Be burden of Proving that he did nut build or improve I., urp..of ■C li I'�A LE D sale.). - q004�f ❑1,as ownerconstruct of Ne properly,am exclusively contracting with licensed contractors to MAY 2 4 2 construct the project(Sec.7044.Business and Professions Code:)The Contractors Li- cerise Law does not apply to an owner of properly who builds or improves thereon,and who contracts for such pmjects with a contractor(s)licensed pursuant to the Contrecmfa License La exew. BUILDING El crept antler See. .B,k PCfnr this moon Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penally of Pe jury one of die following declarations: I have and will maintain a Certificate of Consent to self-insure for Worker'a Compcn- action,as provided for by Section 3]00 of the labor Code,for to Performance of the work for which this permit is issued. ❑1 have entl will irmin Warker's Compensation Insurance,As requited by Section 3 Wof NC Lebo ode.for the performance atom work for which this permit is issued. y Workee in it ti Insurance carrier and Policynu t a) Cartier. No.: r/ a 3 In 7 0 9 a CE I I EX5dFTMNFROM WORKERS' COMPENSATION INSURANCE (Th0 sectimn need not he complemd if Ric permit is foronc hundred dollars($100) or It .) I comfy Nat in the performance of the work for which this permit is issued,I shell not employ any person in any manner an as to become subject to the Workers'Compensallon - Laws of California.Dam Applicant NOTICE TO APPLICANT:Ir.after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you mum O forthwith comply with such provisions or this Permit shall be deemed mvoked. Z .�~.. CONSTRUCTION LENDING AGENCY I thereby affirm that Umre is a conaRuaion lending agency for the performance of Ys r�-r the work for which this permit is issued(Site.3097,Civ.C.) Z10 Lender's Name �,Z Lender's Address JO 1 certify that 1 have read this application and since that the above information is y P correct.1 agree to comply with all city and county ordinances and state laws relating to �U building construction,and hereby amounts,representatives of this city to enter open the Na above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino againat V) liabilities,judgments.costs and expenses which may in any way see=against said City J 7 APPL,CAcNn7ccofDERrnmingDSthis AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale •7 S URCF� G� Signature"f AA'pplmaut/C"ntracum Date Re-roofs / HAZARDOUS MATERIALS DISCLOSURE Type of Roof ( Z `� — 03 Will the applicant ur future building Occupant store or handle havardous material as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety Code,Section 25532(.)? All roofs shall be inspected prior to an roofing material being ON. Will the applicant or(inure building occupant use equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. cartel, Fl yea ON. I have mad the heromnus materials myuircm ma under Chap A,6.95af the Califon ma Health&Safmycotic,Simmons 25505,25533an 534.lundersmntl lhm ifthe building docs not currently how a tenant,dim itis my maga., u nntilY the occupant.1 0. req""�m L hhi`hm"atx nc-� Pan Si nS tureofApplicant Date All roof coverings to be Class"B"or better Owner or amhorind agent pare G` CITY OF CUPERTINO o3 b d �f 8 CUP TYOF O PERMIT APPLICATION FORM APN# 73' 22 3 p Date ,-,- O Build in ddres : J WO / 7 V O er's Name Phone#4_ 2Q /' G 6ZO License#/'/� `/ v BOO J Contact: Z_10 ? y0,;20 , / Cupertino Business License#: Building Permit-Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Job Description: Z c✓ Residential Commercial ❑ Sq.Ft. Floor Area,: 7 $/Sq.Ft.: Cost of Proj c? Occupancy Group: CJ O Type of Cgns c 'on: i Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILER1 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 BMITIGATC Comm. Housing Mit. Fee BUILDING tof3 / 0 �` � -- CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING 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 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BRE SIC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2 of 3 (a . r` CITY OF CUPERTINO CITY F PERMIT APPLICATION FORM ' CUPEI�TINO Quantity. Fee ID Fee Description Fee Grou • BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rcpt], Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Sigris Add Branch ELECTRICAD ' 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 PPERNHTFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fees foot PLUMBING ZADDCHG Address Chane BUILDING i 3 of 3