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05030210 CITY OF CUPERTINO BUILDING DIVISION PERMIT OITRA.CT,URINFORMA'PON '- ,� au1LDINC ADDRESS: CERTIFIED ELECTRIC INC PFxMrrN 05030210 OWNER'S NAME: PERMIT ISSUE DATE ONE: SANITARY C OL NO.XTD4 ARCHr1EC IENGiNEER: BUILDING PERMIT INFO BLDG O PLUOMB 0 Ypp LICENSED CONRACIOR'SDECLARATION JobDescri tion r� I Mreby affirm Net 1 am Became e under provriou of Chapter 9(Commencing P ��)I�� with Section 7W0)ofDividow 3 of the Bowness W Prohculau CV ndm lice eco /' ZFFi �asaeroeudercF_f0 r ECT. SERVICE (100 AMP) //'�� r ARCHITG DECLARATON 01? t �i I understand my piano"I he used as Public ranrda �/ 7 O✓ License Profesvoul OQ u 56 OWNER-BUILDER F 0$Z 0tf<idA OWNEcDECLARATION ECLARATION gp�x I hereby office Nm I sun exempt f Ne Low for IM following mama.(Southern 703 1.5,Sulam and lemm,Code:Any city or county which require,•Permit tm rnnume.Blwa.non.camads or repair any anacro O O/ J , prior b its ssus cow cquims LiteApplicant forsuch Permit to file a lignedMontrealenl thethehlleewdpussanlfoupmvisimafNContrmhLumseaw(ChaPte9 Sq.Ft. Floor Area Valu tbn� , $ that Mis asemiNSatlon7B001 of basison3 alleged exe talon.My viCode)or - Wf io r ems b theefrom and dse aper int the Jude, exemption.Any violation or not m7031.5 con Ewnndredaiw.(isW).hwbjeaa uu.ppliantm.dvil pen,Rr tr 39VV3Tdnbe00 Occupancy TI pe ❑I,u owner of ft property,or my employee with wages so,their sole wmpenutlon. T72`J`ll will do the work.and the structure is not inuncad or offered for sale(Sm.7044,But. Required Inspections ' and Pro lmius Code:The Contractees License Law dna tut apply to an owner of q P propertywho builds orimproves thereon.andwhe doessuch work Mmself(r Waugh his own employee,provided dmf such improvements art not Intended ntorccrnd furswe IC however,the building or improvement Is mid widen one year ofmmpletion,the owner builder will have the qudan of proving the he did ant build or improve fee purpose of sole.). ❑I,u owner of the Property am ecluvvely contracting with licensed canmmen to construct the pmjm(Sec.7014.Business and Professions Code:)The Canmcter's Li. cense Law does not apply to an owner of property who build,or improve etereon,sod, who concocts for such pmlecm with a eonwcfor(s)licensed pursuant u the Convacfaes Luertse Law. ❑1 am emmpt under Sec. .B h P C far Nis meson Owner Dow WORKER'S COMPENSATION DECLARATION - 1 hereby air=under penalty of perjury now,of the following declmuimu: I have and will maintain a Certificate or Cement to elf-luum far WarkeYsCooper. uran.u provided for by Section 3700 of the labor Code.for the performance of the work for which this permit Is issued. t1 have and will maintain Worker',Campen m on Iwtrsnce,U requited by Section 700 of die labor Code,far the performance of Use wort far which this permit is Issued. My Worker',Com-pgsuadon Lowrance carrier and Policy number a¢: Cartier. 5 - '- d-- Policy N.1,(110 2-1"-CI`9 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Crew cctian need sot Mmmpleud If W panni,Is intent,hundred dollars(5100) per leu) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in my mannerso u to become subject to the Workers'Compenandan LawsefCWfomta.Dau Applicant NOTICE TO APPLICANT:If.attar making this Certificate of Exemption.you should haeme subject he the Workees Compensation provision of the labs Cade,you muss 0z forthwith comply with such provitlou or this permit mail W domed rtvokeA r'-" CONSTRUCTION LENDING AGENCY I ncmby sRrm dust there Is a construction lending agency far the performance or C the work for which this permit b Issued(Sec.3097.Civ.C.) W�0 Lendces Name a z Lcndeh Address J,',� 1 madly dust I have mad thiupplication and auto that the above inrmmNan 1. , ILI 1-•� cormm.I agree to comply with all city and county callowness and mu law muting he p SV' Wildingmunrttion.and hereby authodm mprcommaies of this city to enter upon du W above-mentioned properly hent iepecuion purprues G (Wt,)agree u save,indemnify and kap harrnkss the City of Cupertino agaiw fA Iiebilide,ludgmenU.coatiande whichm yin anyway scout agwnat said City til 7 in eonseque fdu6 g PemneL' e A APPLIC UN S HAL NON-POINT Issued by: Date SO `' Re-roofs Signuurt of Appli HVAC,.nA DOUS MATERIALS DISCLOSURE eau Type of Roof Will dse applicant er future building oaupentuom or handle hazardous material u deflud by the Cuperdm Municipal Code.Chapter 9.12.and the Health and Safety Cde,Section M32(a)7 All roofs shall be inspected prior to any roofing material being installed. DYa [gNo• Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove It hazardous aireonuminmta u defend by the Bay Area Air Quality Management all new materials for inspection. Imict7 ❑ we Yes c d I have mad the hxzardots materials requircencou under Chapter 6.95 of the Califon Came. Huduh lSafety Coca,Savor ca 25505.25533 and 25531.1 unntutd Nc du ifbuilding does not comedy hew•tenant duan it u my mapouibllity u notify due occupant of W :- requlrementswhichon poor to in oh CetiOcate oracupan 5, �� Signature of Applicant Date Owner or ani t Dow! All roof coverings to be Class"B"or better Community Development 0 Torre Avenue J CCupertino CA 95014 h" Telephone(408)777-3228 � CITY OF Fax(408)777-3333 UPEkTINO Building Department JOB ADDRESS: ,CI,{0 v ,� _ PERMIT # 0-5�b 3- 2V OWNER'S NAME: PHONE # jlkoo S 2/ - /4/9 S GENERAL CONTRACTOR: �Q FAX # I am not using any subcontractors: 11 Signature Date Please check applicable subcontractors and complete the following 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 � • er/Contractor Signa a Date CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM qPkPN# .3 S `1 —) •3 — 001 Date: Building Address: Zd b D Mailing Address (if different from building address): Owner's Name: Phone #: Contractor: Drnc- License#: -7cf9d 8' 47 Contact: Phon :$ SZ/-NCupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Descriptio • /a�tFn/ o0 Residential D Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: 3.2- ov Occupancy Group: S / • Type of Construction: Please check this box if the project is a second-story addition: ❑ 1qrPro•ect Size: Standard ❑ Laze ❑ Major❑ 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 - Eneigy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING � d3J l of 3 6 7, 0 0 _` CITY OF CUPERTINO CUPIwo I�TINO PERMIT APPLICATION FORM QuantityFee 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 BREMAMHAN 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 > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC N isc 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 I Remodel Res Appliance ELECTRICAL 2 of 3 �� : CITY OF CUPERTINO CUP ERTINO 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 BSWIM Swimming Pool BUILDING BTEMP Tem ora 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 3of3