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05030128 CITY OF CUPERTINO BUILDING DIVISION PERMIT `C ONTRAC°�TOR£INFORMATIQN . BUILDING ADDRESS: FISHER POWER AND DATA INC "B"""b5030128 OWNER'S NAME: PERMIT ISSUE DATE HENRI BERG 11 ONE: SANITARY NO. CONTROL NO, (650) 325-5768 ARCHITEC XNGiNEER: BURRING PERMIT INFO BLDG ELECT PLUMB MECH m o p LICENSED CONTRACTOR'S DECLARATION O O O O uC I hereby affirm that 1 am Ilcened under provision of Chapter 9(commencing�W r'' @� n Job Description wiN Srtion)of4n of Division Soflhe Buslmssand Profession Code.and mylicenset EI \\ 11 n ^ n in fun fora and cffr 5gz LicensecIa t '1D L .« CGd�o3�l 100 AMP�SUBPANEL. R�EPLACEMENT pp� ARCHIIELTS DECI.A ATION I undcraunJ my plans shall he used u public records ' h<4R /g 2005 o G Licensed Professional ,S OWNER-BUILDER DECLARATION II n .�2 0 1 hereby a(fnm Nos 11. exempt from dm Contuso o License Law far IW /1 11 (1 trZ1,I� a co following reason.(firman 703 1.5,Bnim+•and Profusion Code.Any city W county U IL'1��L� ql (�`/eV� which requires a Permit m con umea,alter,improve,demolish,or repair any structure Zo' Prior In its oxiontat,also requires the applicant for such Permit to file a signed statement s thinmislicensedpursuanttotheprovisionsofdeContractor'sUmnacLaw(Chapter9 Sq.Ft. Floor Area " Valuation s�$ (commencing with Section 7")of Division 3 or she Business and Prafessinn Cndc)ur that M u exempt therefrom and the basis for the alleged exemption.Any violation of Section 703 L5 by any applicant for a permit subjects the applicant o a civil penalty of 3 1jU11I�Q1fm93e10 0 Occupancy Type not mom man five hundred dollars(5500). P Y YP ❑I,uoweroftheproperty,rmyemplo winwaguastM solecompenvuon. will do the work and me structure is not intended oroRemd torsade(Sec.7044.Business Md Profession code:The Contractor's Liana Law does not apply to an Owner of Required Inspections pmpenywha Wildsorimproves thereon,and whodoessuch work himselfor through his own employees.provided that such improvements are not intended or offered forsele.If, however.use building or improvement is sold within tete year of completion,the owner. builder will haw the harden of proving that M did not build in improve fa purpose of sale.). ❑1,as mvner of the property in.exclusively contacting wit licensed cantacmrs in construct the project(Sec.]014.Business and Professions Code:)The Conlucsars Li. cense Paw does not apply to an owner of property who Wilds or improves memon,and who contacts for such projects with a ewussmr(s)licensed pursuam in the Conracloes License law. I am exempt under Sec. .B A,P C for this mason Own Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury aro of me following declarations: 1 haw and will maintain a Certificate of Consent m selGinsua for Worker's Compen- sation,as provided for by Section 3)00 of dte Labor Code.for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as regnisid by Section ] of the labor Code,for me performance of me woh far which this pcmlis tissued. My Worker's Cam pensaatioonwlnsuurrancee carrier and Policy nunu1m/harem: n 1 Cartier— QT, l.OarW.Ja/S Polity Na.L./`[�•t7f0��7__0,4 CERTIFICA OT OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Mit srvm need not W cmnplcwd if she permit is fortune hundred dollars(SIM) or las.) I certify that in the performance of the work fm which this Permit is Wood.I shall raw erdploy any person in any manner so u m become subject I.the Workers'Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:If,after making this Ccmrkate or Exemption,you should become subject to the Worker's CompenlamOn previsions of the labor Code,you meet .Jz r0Mwolt comply with such provision or this permit Mail W deemed mwked. ':O CONSTRUCTION LENDING AGENCY F+ I hereby affirm that mea is a Wommcuon lending aenthe gcy for performance of W> the work for which this permit is issued(Sec.3097,Civ.CJ Igd 0 Lendch Name =z Lender's Address U Q 1 ocifify mu 1 have read this application and state that the about information n D.n F bormiL 1 agree tocomply.and with all city and Cntnly OrdinancesoNd etty 1 mu Rlamng e QU abow-geoioned Propend hereby authoriareoses. sus Ol this city menteruPnn me rue abovoes,judgmnroPeny for inspection Purposes. (We)agree to save.indemnify and keep harmless flux City of Cupcnum againl F Z intiou"from minu.cosasandOfPcusesreft. may in any way accrue against said City t.)Z A consequence or UNDERdo STANDS ANA WILL COMPLY WITH ALL NON-POINT Issued, by: Dat J—J SOURCE REGULATIONS3 / 05 ig re o App icantContan ase Re-roofs HAZARD US MATERIALS DISCLOSURE Type of Roof Will d e applicant err future building occupant store or bandit haraNum material u defined by tic Cupertino Municipal Code,Chapter 9.12,and tin Health and Seely Code. r IYes 25532(x)? All roofs shall be inspected prior to any roofing material being installed. []Yes No If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building Occupant esu equipment or devices which g p Off havardon air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District, ❑YO, 4Nu I have mad Thi buarmms could-lsrcquimmentx undcrChapter 6.95 of the Caliror. nix Hcallhk SafctyCodc,Section 25505,25533 am125534.1undcmand thasifmc Wilding does nos currently haw a tenant,met 4 my responsibilityw notify the occur.,of me myuimmmu which most I or t mance nee.c"m""of Omyl Signature of Applicant Date n m,pthmivcdagrt qte 5 All roof coverings to be Class"B"or better Community Development H � 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY 0, Fax(408) 777-3333 f UPEI�TINO ZBuildin De artment JOB PERMIT #Qc;Lq7Or OWNER'S NAME: O PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followin 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 Own /Contrac or Signature ate Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 iUPEkTINO Building De artmept, s JOB ADDRESS] J^ PERMIT # OWNER'S NAME: gyp' PHO :. #�, } GENERAVC A��CTOIL, \' I' FAX # '— z I am riots u- : gtanylsil contr ctors:`cf In - ' ` -r' t_.t1 L,� ' 1.1 t L �.�� .t(S�ignatu�reJ Date Please cher a hcable subcontractors an complete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork 1 _ a q • Ce ent 4nTclYnr f +� r. N'1 Electrical `A' Fs e ,Tja Excavation Fencing .t' w 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 1 Tile 5A ef Pf � -� �1 Own? /Contrac or Signature ate � '- CITY OF CUPERTINO TY or PERMIT APPLICATION FORM CUPERTINO a5o1 APN# 3/lp 2 5 6 (6 Date: 3 .OS Building Address: Mailing Address (if different from building address): i�lNor#brooK Owner's Ne: Phone #: an 6 e LM- 17�9- 3/� Contractor: License#: er aae - a {ate r . (o0(o3y Contact: Phone: (a-jD q%-,3 Cupertino Business License#: TO or e LL i O Fax:65D- qq - 356 a oZ 7 Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: 100LIM19 SU QnQ licloeMel) if) ResidentiallL1Ca tb Commercial EI Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this box if the project is a �� second-storyaddition: ElPro'ect Size: Standard LJ- Lar e ❑ �Ma �EO] 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 1 of Son CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEKINO Quantity Fee 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 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 Ai BPTRAP Kitchen Trap PLUMBING IMF 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 cfm 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 > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Mise 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 2of3 Q� CITY OF CUPERTINO CUPE(�TINO PERMIT APPLICATION FORM QuantityFee 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 Electfical 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 • 3of3