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05100057CITY OF CUPERTINO q ✓ ,;err �a«� §' F'" �' s, BUILDING DIVISION PERMIT r4i�N,T�I�AC$QRraIATIO BUILOINOMDDRESS: PERMIT NO.05100057 10164 PARISH PL OWNER'S NAME: PERMIT ISSUE DATE SUBHARHINI RAHASSAY 5 ONE: SANITARY NO, CONTROL NO. ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG EO PLUMB MECH O LICENSED CONTRACTOR'S DECLARATION lob Description T hereby affum lentT am lim=d under pmNslov of Capmr 9 (mmmmcin{ P with Sectim ]gKfwL 'ansae NC Buaircseerl jin dsra d/Ny licevci, i.ggd tante andtRM. U REPLACE GAS LINE LE® Liceme Class Lk.R Dam Camracser CONTRACTOR: HENRY LLERENA ARCHITECT'S DECLARATION CT I understand my plans Mall he used as public rrenrda af,—i, 1005 Licensed professional OWNER.BUILDER DECLARATION I them He Committees License Law for the BUIp ti's LVV" 1 hemby affirm that am exempt Business Profession Chit: Any or p. 'f " #v'1 following Ratan. (Section 7W 1.5. and city County eh, or ¢pair any structure which requira Permit Musuget. ober, improve. dmalb e to� �43 R C.h prior an its issnnec. also requires the applicant for such permit to fmle a signed statement Ft. Floor Area Valuati$d8'00 that he is licensed pursuant to the provision of He Common's Theme Law (Chapter 9 Sq. (commencing with Section 70001 w Division 3 of He Buainen and Pmfessinu Code) or that he a exempt Marginal, and the bub far He alleged exemption. Any violadan of APN Number Occupancy Type &Man 7031.5 by any applicant for a permit subjMIa the applicant too Civil penally of het more than Ow hundred dollars ($500). 31644032.00 ❑ T,uownerof NepmpenymmyemploycawlHw Sesudxirsolemmpemdan, Required Inspections e fl will do the worst Mad thestmaam b mtinbnded orortered fanatic (SM. 7044, Business and Profession Cale: The contracmrM Liaisn Liaise Law donot apply m an owner of P property who builds her improves Hereon, end who dna suc h work himself ar through his own employcu, provided that such improvements as notlntended aaQo ed for sale. If, , however, the building or improwment is said within aro year of completion, the owner. builder will haw Ne burden of proving that he did not build or improv for purpose of tale.). Q 1, as owner of the property, am excluaiwly contracting with licensed cantracroa m consumer the project (Sec. 7044, Business and Profession Cade:) M Carmichael Li. come Taw don not apply to an or of phap arty.wa Wilds or Improv Neaan. and, who contracts for such projects with a contracter(O licensed pursuant o Ne Contractor's License Law. ❑ I am exempt under Sec. ,B&P C far this mama Owner Data WORKER'S COMPENSATION DECLARATION I hereby alarm under penalty of perjury, ON of to following declare ions: I haw and will maintain. Cmifmcate of Consent go self -imam for WalkeM1Compen- ution, u provided for by Section 3]00 of the labor Code, for Ne performance of the work for which this permit is issued. . ❑ i haw and will maintain Workees Compunction Insurance. u required by Section 3]00 of the Labor Code, for eperfarmmce of Ne work for which His permit is issued. My Worker' notion na carrier and Policy number mg: Cartier: Polity No.: C FICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE rNb radon need not Mcomplmed light permit is faun hun lmd dollars ($1011) or less) I comfy that In the performance of Ne work for which this permit is issnd, l call not - employ any Fusion in any mortgagee as m become subject to He Worbaf Compemauon Laws of California, Dam Applkant NOTICE TO APPLICANT: If. after making this Carillon of Exemption. you Mould become subjen m Ne Workers Camperuchum provision of the labor Cade. you muss - forthwith comply with such provision or this Fermlg Mall W dtunW rewkcd. CONSTRUCTION LENDING AGENCY I hereby omni the Nese Is a construction lending agency for Nt lerfoomseen of he work for which this permit b issued (Suc. 309]. Civ. C.) ' Landers Name Under'sAddress I aMfy Hat I Its. cold Wa application and sum lint the Mow intomadun 1. ' corm l gree to comply with ail city and county aNinerces and some laws mlauin{ m building conduction, and hereby authadm mpresentadws of His city to env upon the l chew-mentiamd property fa Inspection purposes (We) agree m u ,indemnity keep armless dm city at Cupertino mpbtat j Ilsbilidol.juagmems,c tsandexpe which may In any way acme againnuiO City in comogw milli(of a IL APPLI U RSTAND WILL OMPLY WITH ALL NON -Pols —Ts -sued by: Date SOURCE RE ON �l 72 Ze V / Re -roofs Signa FA T muco er Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will dO applicant or future Wilding occupant mom or handle Meadow, material as derrmd by the Cupertino Municipal Code. Chapter 9. 12, and the Health and Safety Can, Section, 3553200+ V 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 ,6p��V Will Nc applice or fuwgo building occupant use equipment her dcvlms which mit ha'urdnm air cont minis u do ncd by dm Bay Area Air Quality Managcmcnt all new materials for inspection. DIM6W ❑Yen I hew gold the uranium all mquimmenu under Chapter 6.95 attire Celifor. iia Hcolth&Sm.tyC .Sued., 5.35533mw15534.lun&.wdNmlrthe Wilding does not curralle h Oman my responsibility m nndfy the Occupant of Nu .got. w he mbau ar.ccmpcaw Getup.peJy.Jl /Goan Signature of Applicant Date All roof coverings to be Class "B" or better ower Ode t IPA CITY OF OUPEkTINO E Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department 4 7. I am not using any subcontractors: --/- AZ Signature Please check applicable subcontractors and complete the following informatiom Date SUBCONTRACTOR 1191TIJ 13 111M h, 121 M W: COIL, I WAJW 4 7. I am not using any subcontractors: --/- AZ Signature Please check applicable subcontractors and complete the following informatiom Date i �. Contractor /C�- /z -2491 Date 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 it i �. Contractor /C�- /z -2491 Date CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM A �L .r/ X5:7 N13/6 #3/6 ^ — �� Fee Group Date: /0 —1L — 2-C tU $— Bgijcji A ress �� /(nJ,,A MECHANICAL Address (if different from building address): bN a6�� )� J i BBOILER2 C n -GIJ� L�4 Boiler> 500K to 1M Btu MECHANICAL L� #� I Co t ct: Phone: Fax: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb . a ❑ Mech❑ Job Description: Residential �-As— jt (jdC �cia ❑ Sq.Ft. Floor Area: BUILDING BCONSTAXBQ q.Ft.: n, Cost 4Pgojer, �j l� BCONSTAXH Hotel and Motel O�Sup g1-:9: Jl L avMl Type Q ozstruction: 1 Constax — Resi/Mobile BUILDING Please check this box if the pr 'ect is a second -story addition: ❑ ro•ect Size: Standard Laze ❑ Major ❑ BELEC1001 Elec 600V > 1000A 0 Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 13BOMERI 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/Conun/ uasi 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 3 3 13 I CITY OF CUPERTINO PERMIT APPLICATION FORM uanti FeeID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING INV BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME. New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTEvIE 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 Re -peat 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 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY .. Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMIvIISC 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 2 of 3 CUPEI,TINO 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 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 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 • 3 of 3