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03050061 CITY OF CUPER't'INO °n BUILDING DIVISION PERMIT �6QQNTRACTOR INFORMATION ,. BUILDING ADDRESS: - PERMIT NOO 3050061 OWNER'S NAME: PERMITISSUE DATE .NE: SANITARY NO. Cj CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �0, LICENSED CONTRACTOR'S DECLARATION 48 I 1 hereby affirm that 1 am licensed under provisions of chapter 9(commencing Job Description z with Secdun7(K0)nf DivixRa3cfNC Businessand Profcsdom Code,and myliccnx;. �® < in full force and effect. >'qz LlcenseClass Le.Is ADD 752 SQ. FT. p Data Contractor DO111q--- ARCHITECT'S DECLARATION I, WI understand my plans shall bo used as public records v/J� l I' 1 V 001 ea Licensed Pmfessinnal OW NER-BUILDER DECLARATION 0 0 1 hereby affirm Not I ore exempt from Ne Comms Co License Law for the 'O"11 ®I� 0 0 following mason.(Section 7031.5.Business and Professions Code:Any c'ny or county ` G <m which requires a permit to construct,alter,improve,demolish,Or repair any structure °zj, priurto its use.ree.alm requires the applicant fmsuch Korriuo filcasigneJ statement < that heisliccnxrsm dpuumltorhepvisimuoftoConuLaw Sq. Ft. Floor Area Valuation els (commencing with Senion 711(10)of Division 3 or the Business and Professions Cott lir jr Nn her is exempt therefrom and the basis for the alleged exemption.Any violation of 35912010 . 00 Section 703 1.5 by any applicant for a permit subjects Ne applicant to a civil Penalty of APN Number Occupancy Type not more man End hundred dollen(5500). P Y YP CD 1,as owner or the property,or my employcu with wages as their sole compensation, will do the work.and the awcwre is not Intended Orolfa.d forsale(See.7044,Business iui — d Ins ections and PrOhosir m Code:The Commctori License law does not apply to an owner of 10 2 - PIERS IERS P pmperty who builds or improves thereon.and who does such work himself or through his ownempOyces,provided thauuch;mpowemenu are mainrended confined for.O.If. 103 — UFER however,Ne building Or improvement is sold within one year of completion,Ne owner. builder will have the burden of proving that he did not Wild or improve for purpose of 104 — REBAR °°le' 105 - ANCHOR BOLTS (�s owner of Ne Property,am exclusivelyinend Professions with licensed comet's m conswn me prnjcet(Sec.7044,Business end Professions Code:)The Cemrx,or'a Li. 106 — SEWER & WATER came law does not apply to an owner of property who Wilds or improves thereon,and, 202 — UNDERFLOOR PLUMBING who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. 203 - UNDERFLOOR MECHANICAL Oram fie ,under See. ,B&PCfor Nisremnn 204 - UNDERFLOOR FRAME Owner i*^�WORKER'S COM SATION DECLAgA7TO.�yN�-��— 205 - UNDERFLOOR INSULATION t I hereby Official under arms y of perjury one of Me meowing declarations: 3 01 - ROUGH PLUMBING . I have and will maintain a Cenifiam of Consent to self-;roues for Worheri Compen- 302 — TUB & OR SHOWER prion,as provided for by Section 3700 of Ne Labor Code,for the perlmmsnc,of the 3 03 - ROUGH MECHANICAL work for which this pconit is issued. ❑1 haw and will maintain Worker's Compensation Imunnce,as required by Section 3 04 - ROUGH ELECTRICAL 3700 Ofthe Labor Code.for the performance of the work for which this permit is issued. 305 — FRAME My Worker's ComPenaulon Imunna carrier and Policy number am: 306 — HOLDOWNS Cartier. Policy Ne: _ CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 - SHEETROCK (This section mad nolhec9mplaxd iftle Permit is for One hundred dollars($100) 309 — EXTERIOR LATH In its,.) 310 - INTERIOR LATH e certify Nat in the n any panne of the work rm which Nis Permit is iesucd,1 shall but Laws. CalifornninanymannersasmhccomcsubjecuetheWorkers'Compcnsetlon 311 — SCRATCH COAT Lawacf California,DemAppici313 - ROOF NAIL NOTICEfter Ncome suOAPPLhe Worker's Compensation this Cellons of the E Labor Code, you 501 — FINAL ELECTRICAL ENERGY become momp y the WOrh ro Compensation provisions of the deemed revoked. Code,you most �z mrmwhncomplywansumPrnvisiomorthis permilmalMdetmtdrewked. 502 - FINAL PLUMBING ENERGY ' z0 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY F 1 hereby Orion Met Mare is a construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY X> Ncwork for which this Permit isissued(gcc.J097,Civ.C.) 505 - FINAL ELECTRICAL W 0 IsndNunc jz Lcnacra ar'xAdam 506 - GAS TEST U O I certify that 1 haw read this application and sum met me above information is 507 - FINAL PLUMBING conte,.I agree to comply with all city and county ordinances and sum ta laws mm ing OU Wilding construction,and hereby amhonm reprmontatiws of this city to enter upon theFIN MECf CAL ahovomemluned Pmpeny for inspection purposes. (We)agree I.saw,indemnify and keep harmless Ne City or Cupcnino.&inO 9 FI F'rn liabilities,judgments,costs and expenses which may inany way we=against said Coalrmit. try 5 in his APPLICANTOUNDERSTANDSof the grand ng of IAND WILL COMPLY WITH ALL NON-POINT Issued by:5 5ONG WORKS Dat SOUR REGULATIO S. - "^^^ Re-roofs store Of Applico t/Coni Dan. HAZ US MATERIALS DISCLOSURE Type of Roof Will the applicant or forum building Occupant store or handle haardous material as defined by the Coleman Municipal Cade,Chapter 9.12,end the Health and Safety otic, El ea,23572(a)? All roofs shall be inspected prior to an roofing material being El Yea, N9 P P Y g g installed. Will me applicant or future Winding Occupant use equipment or devices which. If a roof is installed without first obtaining an inspection,I agree to remove nrmabdous air conbxminan efinc l by Ne Bay Area Air Quality Management - all new materials for Inspection. linin? ❑Yea No 1 have mad the hnallous materials requirements under Chapter 6.95 of the CahrOP nixHcalN&Safety Code.Sections 255115,25533 and 25534.1 understand Nat irthe Wilding dm na tumc hely hew•¢nano.Nn it u my responsihiliry o notify IM accupw of Nc require nu whish mu met prionu;ssuement.Ccrufcate of oc upancy. �'R 03 Signature of Applicant Date er or.umOrnca agtm Dam - All roof coverings to be Class "B" or better CITY OF CUPERTINO • c CUPEI�TINO TM of PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING 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 VT 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 BREN AIRHAN 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> 1 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 2of3 -� CITY OF CUPERTIA +C'TMO PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group1 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 BREMSIGNS Remodel Si az s,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 ! i 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 Issuance PLUMBING PPLBG Plumbing Feesq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3