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04030177' CITY OF CUPERTINO +-t?9,zaa'st4u�•a rg "'`vt�`'"" �.t ``"`,', ._ OIVTRACTOR INFORMAT 0'..` _ /— • BUILDING DIVISION PERMIT . � BUILDING ADDRESS: PRECISION REMODELING PERMIT NO. 04030177' OWNER'S NAME: NAZART PART 4.22 T AVE PERMIT ISSUE DATE ONE: -RT -A. -ND SANITARY OL NO. ARCHITECT/ENGINEER: BUIIDINO PERMff INFO BLDG ELECT PLUMB MECH 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description p I hereby affirm Net 1 am licensed under previsions of Chapter 9 (commencing with Section 7010) 1ofDivielon 3.1' the Business and Professions Code. and my Ikon, it fulleca �d g METER/BRANCH BOX CHANGE Li Deck113 AR CHIT F. CTS DE LLA A 1 undcrsunJ my lana shall be used as public record Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm Nal 1 em exempt from the Contractor's License Lew for the , following reason.(Satiun 7031.5, Business and Professions Code: Any city nr county which requires s permit to emuuuc4 also. improv, demnluh, m MPatf any to ueum ,dor in its Wuarke. atm mquires the aPplum, for such permit m file a sigrod sukment Leman Law Sq. Ft. Floor Area Valuau n dralkisliansedpurmenuothe pmvisiowofMae Crandocr'atChtPlcr9 (commencing with Section 7000) of Division 3 of the Dust. and Pmfeoiane Code)., that he Is exempt Nemfsom and Ne buts for the alleged exemption. My vlolatlon of G9 L^d l 3 .AAat.AT..�3.erQ 0 Occupancy Type Section 7031.5 by any applicant for a permit subjects the applkanua a evil penalty of nut mon than Rw, hundred dollen (g50o). .Y ❑ I• u awnu of the pmperty, m my employee with urges u their mle mmpenudon, Required Inspections will da thewrk. and Neswnure u not inkMed oroRcred forule(Su.7011, Buslneu and Professions Code: The convenors Lixwe Law does not apply to an owner of property who build or im prows therecn. and wh , does such work himsel f of through hu n employee, preAded Nat such improvements are not intended moRerW for sale If. however. Ne building or improwmmt is mid within One Sear of Completion. Ne owner - builder will haw Ne burden of pmving that kdid our build or improv for purpose of ukd./ C 1, as owner of the property, am exclusively contracting with licensed contractors to construct Code:) The Contractor'son,rad not (Sec. 70M. Business and fessionswho of prepody who build or impmws comm and come Taw does not apply m an ny Wiles La des who contracts for projects with acwuantortt) Ilonsed punwm m Ne ConumloM1 witha License Taw. ❑lam emmpt undo See .B &PCfor Nis recon Owner Das WORKER'S COMPENSATION DECLARATION 1 hereby of on under penalty of perjury one or Ne following declarations: I haw and will maintain sCeNfcak of Consent to self-inms for WorkeYSComp m- ution. as provided for by Section 37M of the labra Code. for the performance of Ne wart for which this permit is issued Q 1 haw and will maintain Worker's Compensation insurance. as Rqulnd by Section 37(X1 Of Nc labor Code. for Ne performance of the woh far which this PCort issued. My Worker's Compensation Insurance artier and Policy number art: Cattier•. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu section need not hccornpteted lime patent; Is fmonehundrtAdollan DHKM or lea) I certify Net in Ne performance of Ne work for which this permit u issued. I shall not employ any purees in my rum rmssu onto m�bj'�cuo elk Workcor Compesadon Laws of California. Desc _" ApPllcant /� -- N APP A 1 akmy Certificate of Exemption, you ahoust Labor become subject to Ne hcr'r Compensation provisions of Ne labor Cnd, you moat come subject n pr fodowlth comply with such provisions or Nis permit that) ed domed rewkcd. ON LENDIN0 AGENCY CONSTRUCTION Is le a • ronsctinn lending agency fords perfurmana of 1 hereby Rrm that then, w ' Ne wok for which Nu permit is weed (Sec. 3097, Civ. C.) Lender's Name Lenders Addrtss I codify that I haw mad Misapplication and sum Net Ne allow Information is ' conal. I agree to comply with all city and county ordinances and sum laws relating in building cowwclion, and hereby euNorim repmunutiws of this city to enter upon me shove -mentioned pmperty for ins s000n purposes (WF) agro on saw, indemnify and keep h urnkn the City of Cupertino aGinst i liabilities.judgments. ewer and expenses which may In my waymcna, against cid City in consequence of Ne granting of Nis permit. ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE RULATIO Re -roofs Type of Roof A/ A i 3i�9 pfr Signanor(PAyboll✓retires Data I HAZARDOUS MATERIALS DISCLOSURE Will the applicant or rutted, building Occupant sum orlundlc ha acolous masdal as dafned by the Cupertino Municipal Code. Chapter 9.13. and the Hinds and Safety code. Secdan 35533(.)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes 1:1No If a roof is installed without first obtaining an inspection, I agree to remove Will Nc applicant or future building occupant use equipment or devices which mit handsome, air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection. Diwiol ❑Yea I hrvc read IM Wrudoussmmaterials requirements underchmpter 6.95 of Mae Califor- nia Hodo, k SafetyCod. Sections 25505.25533 and 33534.1 undersand that ifthe Wilding does trot currently new • tenant Net it u my msponandity to notify Me omumn, or ilk regain whim xmalism'Wismamearscenlfiamafo=mucy. Signature of Applicant Date All roof coverings to be Class "B" or better own n Date L Community Development 10300 Torre Avenue 1 1 %* Cupertino CA 95014 Telephone (408) 777-3228 CITY OF Fax (408) 777-3333 �UPEkTINO Building Department I am not using any subcontractors: Signature Date Please check avvlicable subcontractors ancomplete the followine information: JOB ADRESS: D l 0 t-3 O e n n /-c 441'r- - 4 'r-- PERMIT � �03 �/ 77 SUBCONTRACTOR BUSINESS NAME OWNEWS OWNEWS NAME: a// / PHONE # p Cabinets & Millwork GENERAL CONTRACTOR: FAX #ct 17 y- eqq I am not using any subcontractors: Signature Date Please check avvlicable subcontractors ancomplete the followine information: —��Owner/Contractor Signature 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 AM Tile —��Owner/Contractor Signature Date i . CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM D ' 3 c>/ 7 % 16JAPN# /2Zv 22/ Date:2 /41 O e/ Building Address: Mailing Address 'f different from building address): Owner's Name:M5,, O W � l � G � / Phone #: q� y / 0 Contractor: IF�� License #: , Contact: Phone:( Fax: Building Permit Info: Bldg ❑ Elect Aad Cupertino Business License#: Plumb ❑ Mech ❑ Job Description: Residential 4 MAB l Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: 70OD Occupancy Group: Type of Construction: `-- Please check this box if the project is a second -story addition: ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 1 OOK 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 <= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA 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 1W 1 of 3 --* a�ff7� io 0 27 CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2of3 Quantity Fee ID Fee Description Fee Gr BNUCOMME New Comm Electric LECTRICAL BNUCOMMM New Comm Mechanical MEC CAL 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 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 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL W. BREMSIGNS Remodel Signs Marquee ELECTRICAL 2of3 CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group 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 ZADDCHG Address Chane BUILDING 3 of 3