05030326 CITY OF CUPERTINO s 'x � :.�w•a: F * + '�'d EN W,
• BUILDING DIVISION PERMITCOR�S.GTUR INFIt1kCA'�IIIQIV
BU ILDING ADDRESS: SUMMIT BUILDING CONSTRUCTI 699"'05030326
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY 0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG
O ELECT PLO t�
�0M LICENSED CONTRACTOR'S DECLARATION Job Description
YyyyUyuP���i 1 banby affirm that 1 are I xermand under Provisions of Chapter 9(commencing
tZ VihS=don7000)of DivlLM3ofLMBY9l m PIofcsd COOL', myIILCM1CY
in full fort^aM attar O
''ger Lm an Datar FIRE DAMAGE-REPLACE 3 CEILPNG�JOIST
AacxlTEcrsDEcu REPLACE ELECTRIC WIRE ���"��
a; 1 undenunJ my ptau ahml he used u public recons qp^ /.:��
3 555 //1�' f`.0:�
.a tea Lkenacd Professional �j /
OWNER-BUILDER mDECLARATION .S
a9 1 hereby reaso .(Sere o n I am exempt fare the Contractor's Co :My c Law far the , (/`vl Ovs
O O following reason.(Section]1131.!,BualNu and improve.
Professions Coda:My city or erectly
$� which reyulra•permit m cmmuc4 colla.improve.demnlhh,or repair my avucmm p-
t- 'y^ prior W its iaeame.Alan mquires Ne aPPOcant for such permit to file a signed statement ``,rtery
�< thetheullconudpunumtmthiameisiouaf Me Conlncmri U..Law(chapter 9 Sq.Ft.Floor Area O I Valuat�000
$ (commonan{with Section 7000)9 Division 3 of led Buslmumd Professions Cook).1 Ii�!
dust he is exempt therefrom and the beau For the alleged exemption.My violation of t�
Section 7031.5 by any applicant fa a permit subjects use applicant to A civil penalty or APN Number Occupancy Type
not mom dun fin hundred dol Ws(5300).
❑1,u namcr efthe property,N my employca with ngp u Weir mfe cmnpeaamon, 35913001 . 00
will do Ne work And thesmaum as m imended"ofered far safe(Sec.7044.Budnass
And Pmfauhms CMM:The ComammA Liam law don nut Apply W M owrer of Required Inspections
property who builds or ire provN thereon.coed who docs such work himself or Iluough his
onemployma,provided unlatch improwmeun sec notlmended oranered to sale.if.
honwt,the building or improvement is mid within oat year of completion.the Owner.
builder will tun the hard.of proving that he did not build or improve for purpose of
calm.).
[:)1,As owner of the property am acludvely coMmdns with liceued anweWrs to
construct the project(Sec.7004,Baines and Professions Cade:)The Cmtracmra U.
com law does not apply W an owner of property who bulbus or improves thereon,and
who convects for such projects with aconvacmr(s)IlaNed pursuant W use C.vaaora
License Law.
0 Ian so mpt under Sec. .B&P C fm Ws macron
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby aRmn under penalty of perjury ane of the fallowing declaruionur -
I have and will mainuin ACeNfiate of Consent m calf-insure fa WorkersComp<n-
utlon,u Provided far by Section 37M of Me Labor Cade,far the Performance of to
yyw�Lork for which this Permit is in ted.
IM I ban and will maintain Worker's Campeunlon Insurance,ss required by Section
3700 of the Labor Cede for Ne performance of the work for which this permit is issued.
My Werke ,CompeuNon Tpytpna nrtia antl Pmiry number v
Grtien Policy No.:
E FIC OF EXFMP110N FROM WORD RS'
COMPENSATION INSURANCE
(Thu=cu.new mtbecomplemd Hthe Permit Isforom hundraddo0sn(SIM)
N teas)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in my mmur an As At became subject to the Workers'Compensation
Laws of Celifomia.Data
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the labor Code,you must
.JO forthwith comply with such provision or thin permiuhbl he deemed revoked.
z CONSTRUCTION LENDING AGENCY
y
[—i I hereby affirm that den Is a construction lending agency forte Performance of
l2:� Ne work far which this permit u issued(Sec 3099.Cin G
W Q I nice,Name
z Landers Addman
U O 1«nify MAL 1 Nn and Nin Applulmn and situ tett the Man informdim IS
D.F correct 1 at=to comply with W city and county oralmaxes and sum Ian relating to
OU building construction,and hereby mthadm mpreunlNns of this city to enter upon Me
W Ahme-mentionw property for inspection purpNes
(We)agree W un.indemnify And kap bAnnlw the City of Cupcnina Against
w.o rrA IlabilWea,judgments,cuts and tantrums which may In my my arra against mid City
U 7 in consequence of Ne Snming of this permit.
rte• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE �/�//�
S.grant a p;TE o tncmr ' Dau Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant ams or handle ha]an1oN material
As defined by de Cupertino Municipal Code,Chapter 9.12.and use Health and Safety
Cada,Section 25532U)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes we
Will We applicant or future building occupant use equipment or dcviaa which If a roof is installed without first obtaining an inspection,I agree to remove
It N comm,air comanamnla as defined by tax Bay Area Air Quality Management all new materials for inspection.
inrict7
❑Yes <No
I have caw M hsvandeas materiels requlmmenu under Chapter 6.95 of the Cslifor.
nix Hcelu&Safety Cade,Scwau 25505,M533 and 25534.1 ma en and that ifMW building
does not currently have a Wa nt,Net it u my reamnslhiltly,W notify the occupant of Ne
requimmcnu which must M met prior m issummay aCcnincaw of Oc y.,/ ignature of Applicant Date .
Owner or aulhodmd agent Dote All roof coverings to be Class"Bo or better
• Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
'•
Building De artment
JOB AD�DSS: L-Aj PERMIT# ��3b 7 \
OWNER'S NAME: i acGU Eo PHONE # — d Z
GENERAL CONTRACTOR FAX#
I am not using any subcontractors"--7'O'-.;-' 3/ O
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
J Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
'AI CITY OF CUPERTINO
CUPEfZTINO PERMIT APPLICATION FORM S 103 a (v
APN# 3 _ 3 _.d 0 Date:
3
Building Address: Mailing Address (if different from building address):
z0 40 U- e) e G u e 'moo t&(-
Owner's Name: Phone#:
Contractor: ocA] License#:
S ,awm 3� �_S' 'aAj 8
Contact: Phone:4cV) �/S=NS` Cupertino Business Licens :
w- Fax:
Building Permit Info:
Bldg Elect ® Plumb ❑ Mech ❑
Job Description: C'e' 2 X 6 =/2y :Mr + O 1
Residential LTJ ���� Q 150A7t?W C:ri' :N Co ercial. ❑,�'�c� ge/ev
Sq.Ft. Floor Area: ��a — $ q. t. Wa�
_AV
Cost of Project: ,00) 0 mp 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
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM 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
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CITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPERTINO
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 rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
Ak BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent 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
BREMFDtT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFUBNOV 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
IMF
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CITY OF CUPERTINO
CUPERTINO
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 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
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