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05030240 CITY OF CUPERTINOBUILDING DIVISION PERMIT CO1V'TRACTURTNF•URMA= 1010 BUILDING ADDRESS: PERMIT NO. 05030240 OWNER'S NAME: FERMITI59UEDAT6 ONE: SANITARY OL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO ye BO EIPCI' PLO MECH O LICENSED CONTRACTOR'S DECLARATION lob Description r� I Wmby affirm Nal I am licensed under provish ns of Chapter 9(commencing a�1 with Section TOO)of Division 3 of the Busduas and Profeulmts Code,and my license is =�i iLic.oa�ndenem. LI R ELECT SERVICE (2O0AMP) te� am Com eror ARCHITECTS DECLARATION �S 1 mlde rami my plans'hall W used as public records 3 Z to Licensed Professional _ th OWNER-BUILDER D6 Ce Contractor's _ a 1 hereby.Diem that 1 1. exempt from tiro CaninactCo License Law for the D which me mason. emit 1 703 1.5, t,Business and Proimprove. demolish, e Ions Code:Any city or county $Pi which mqui s a a permit re mires eL alter,W for such demalla t nr rtpalr any museumnem b,Itn pnorbits iasuuKo.aau requires tiro applicant for wch permitmfi4asignW wmnem < matlalicensms,u edpntmtimprovlaiouafftcontruWrilJceuelaw(cl rp 9 Sq.Ft.Floor Area Valua[on bo $ (commencing with Section 70th)of Division 3 ofthe Businev and Professions Cents)at that W Is exempt therefrom and tine basis for the Alleged enamptiau My violation of Section 7831.5 by any applicant for a permit anbjcm the applmant to a civil penalty of not mom than Bw hundred donor($5110). 3 9 'b qrO O Occupancy Type ❑1,u owner ufthe pmpeny,m my mpioycea with wages u Weir role compenudon, will da the work,and the smmlu t ism,immdM m offered for We(Sec.7044,Business And Pmfeuians Code:The Camtracter'i Licenne law does not apply An an owner or Required Inspections propenywho build'verimprom themon,and whodau'uch some himself mUuough his ownemployeu,provided Wal such improwmmts art notimended malfued fm sale.IL howem,the building or Improvement isrold within oro year mmmple ion,that owner. butlde "vnB low We burden of proving that he did not Wild or improve far purpose of "_- 1,as owner of the property am exclusively contracting MM licensed comlraemn to � Q eanatmct the pmject(Sec.7044,Business and Professions Code:)The ConMtor's U- 4,�0 come Law docs not apply m an ownerof property who W Ilds ver improm Moment.sed who contracts for such projects with a conusemr(q licensed pumumt in We Communes 2/ License Layi 1 un ea�idpt undo Sec. &P C for this reawn ,. yQ �noS O❑wns Date WORKEWCOMPENSATION DECLARATION r 1 hereby affirm under penalty of perjury an of the fallowing deelarsda e: OU �a� I inward will maintsinACenlfteateofConumteulf-insum for Workers Compen- W� , 131W.fMA tion,u provided for by Satan 3700 of We Labor Code,for the performance of the h for which this permit is issued. 1 Mw and will maintain Waster's Compensation Iwmce,as required by Semon Vbor Code,for the performanceofthe work fm which this permit is issued. y Worker's Campcasation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need nothocomplemd If the permit Is furore hundred dollars($]M) or lea.) 1 o nify that in the performance of the work for which this permit is issued,l shall nm employmypmuMm mannermasmb,Mt mthe Workeri Compewtion Laws of Califemlaw a NOTICE TO APPLICANT-If,after may¢this Ccni0cete of Exemption,you should became subject m the Waher''Compo on provWons of the falmr Code.you mus, .,O forthwith comply with tech provisions mthia permit W deemed mwked. CONSfRUCf1ON LENDING AGENCY [tiff (hereby M.that them lsaeonumcdnn lending Agency,for tie performance,of tY.> the work for which this permit is issued(Sec.3097,Cl,C.) QLeedeh Name 0.7 Z Lenders Addmaa . U 0 1 certify that I low read this application sed sum that MC above information 6 DL tortea l agree in comply with all city and county ordinances and sus¢laws relating in p Wilding construction,and hereby authadm representatives of this city to enter upon the 4k1 above-mentioned property for Impaction purpmem Ly,pts (We)agree to save.Indemnify and keep NmJess the City of Cupertino Against liabilities,judgments.costs and expeuu which may in my wry accrue Against aid City In consequence of the V APPLICANT UNDERSTANDS Aof IS Permit.WILL COMPLY WITH ALL NON-POINT Issued by: Date SOU ULATIONS. Re-roofs Signature ofAPpliemtlCantn r DataHAZAR US MATERIALS DISCLOSURE Type of Roof Will the applicant or fuwre building mcupanumm or hanldlc hnudous material As darned by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety cause,seeYu der I5532(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑ ❑No Will We applicant or future Wilding Occupant mo equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove it hanrdnu air eemmainmts As defnmd by the Bay Arte Air Quality Management all new materials for inspection. IsuicR ❑Yu ❑Nu I have read We hutNnus materialsrequirements under Chapmr 6.95 of the Califor. nia Health&Safety Codc,Scmos,25505.25p3yal 73534.1 understood!thatiftite Wilding time mol cuAim':, s m onslhilitym notify the mcupant of the require. uan •rdnaateaf y Signature of Applicant Date wDam All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 aClOF Fax(408)777-3333 OUPEkTINO Building Department JOB ADDRESS: PERMrr # oS03 OZ V OWNER'S NAME: PHONE # GENERAL CONTRACTOR: V U FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: WL 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 Owne Contractor Signature Date (1 CITY OF CUPERTINO CUPEI,TINO PERMIT APPLICATION FORM APN# Date: z1;L-1 Building Address: �G k Mailing Address (if different from building address): /03.74) I?�1/ Owner'§/�rrarae: Phone#: t e� V /(/..v rn.e c/ x-53 9-3 (� y Contractor:,eeo � % Contact:`/f License#: / // Phone:,_7S v5 6 y Cupertino Business License#: 6 Fax: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description- /00 � Y yy��q � -200 /S�r /05 Residential F Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: o Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 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 hid/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 -�4 z�P7 1 of 3 CITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM uauti 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 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 cfm MECHANICAL BREMAIRI-IAN TUC 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 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 Ap liance ELECTRICAL 2of3 CITY OF CUPERTINO CUPEft,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 Insection BUILDING BSWM 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 PlanningLon Range Residential PLANNING ZADDCHG Address Chane BUILDING 3 of 3