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CITY OF CIIPTR'fINO PERMIT "LI� �TOPR'`FQRM[Ahq,
BUILDING DIVISION -
..x" .ar ul :kik.�
BUILDING ADDRESS: MAY CONSTRUCTION INC PERMITNO040I0I15
422 N PGRTAL AV
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
u 0 Zp LICENSED CONTRACTOR'S DECLARATION - O O O
d F 1 hcrcby arfum that I am licensed under provisions of Chapter 9(commencing .lob Description
-ZE with Scai 7004)of Division Sof the Rusinc.. d Professions Co de,and my license is
jMZmm�m my.d act. _ter ELECT PANEL CHANGE FINALED
Lice mC� Lie.
n ❑ Dae Cun DELL
ee q�3ay RCHITECTS DELL N
g I understand my plans shall he used as pub a records '
o 1 Licensed Professional
JAN 30 2004
,� OWNER-BUILDER DECLARATION
<Y 1 hereby.(Sere that 1 tare exempt s an the Cssions o License Law or the
i o Off,
whallich
reason.a Permit
to c131.S,Business and improve.
de Professions Code:Any ca y m County - BUILDING
which its requires issuance,permit re quires t e alley,improve,h ermit t air repair any avucom
. iy that hor nitsensealsant 10 the theapp
sofcant for sucCompactor's icensle ae Law(Chapter
O (commencing wJpumuanl to the at DivionsnrthceBusinssnd Professions
Code)
Sq. Ft. Floor Area - Valuation
E$ (commencing with Senien]gts)ail'Divisien3nf the Business and Pmfcasiena GOC)ur
that he is exempt therefrom and One buds for the alleged exemption.Any vitiation of
Section 7031.5 by any applicant for a permit subjects Ne applicant a civil penally of 3IE'fP213'bfi14gr0O Occupancy e
not mom than five hundred dollars($500). M3 GN7 C T* P y TYP
❑1,as owner of the property,or my employees with wages ss their sole compensation,
will do Ne work,and the altucture is not intended or offered for sale(Sec.7W.Business
and Professions Code:The Conum tar's Limmic,law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
Own employees,provided that such improvemenm arc not intended or offered for sale.IL
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that M did not build or improve for purpose of
sale J.
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.]044,Business and Professions Cade:)The Coneai U. .
came law docs not apply to an Owner of pmpcny who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sea ,B&P C for this rcazon
Owner Data
WORKER'S COMPENSATIONDECLARATION - -
I hereby affirm under penaby of perjury One of the following declarations:
1 have and will mainmin accnidcae ofcm acnt an wpho are for Worker's Compen-
7307,D)
ion,as provided for by Section 37W Of the labor Code,for me perromonce of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
of the labor Code,for the performance of the work for which this permit is issued.
Wo key'sCnm amtion Insurance caber and Poll num r are,�+�aaniRy Poli Nodl e
CERTIFICATE OF EXEMPTION FR WOR ER '
COMPENSATION INSURANCE .
(This section need not he,ima,i edifthe permit is farmmhmumed dollars($100)
or leu)
I cenify that in the perrmm once of she work for which this permit is ismed.I shall not
- employ any person in any manner so as to become subject to the Worker6Compensadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should -
become subject to the Worker's Compensation previsions of the Labor Code,you must
.J ,Z forthwith comply with such pmvis ons or this permit shall be deemed mashed. _
,z_t O CONSTRUCTION LENDING AGENCY
N
[—t work
whaffemmeat miti isoed(Sec.3097.Cv, aFeuylor Ne perfurmenceof
FL
are work fur which this permit is issued(Sec.3(Y9].Civ.CJ
aQ Lender's Nene
D z Lender's Address
V O 1 cenify mal I bare read this application and some that the above information is
LL.H correct.1 agree to comply with all city and county ordinances and also,laws relating to
O V building Construction,and hereby imhorim representatives Of oris city to enter upon me
Uahoveumcmioned pmperty for marcedon purposes.
W (We)agree to save,indemnify and keep harmless the City of Capetian against
W Iiabili0es,judgments,costs said expenses which may in any way acerae against said City
V z in consequence of the granting of this omit.
f-� APPLICA U ERSTANDS W COMPLY WITH ALL N N.POI T Issued by: Dale
SO C
Re-roofs
graure of Applicant/ Omracer Dm
HAZARDOUS MATERIALS DISCLOS Type Of Roof
Will the applicant or future building occupant stere or handle ham dous malmial
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Inia
WC.$aches 25533(x)? All roofs shall be inspected prior to any roofing material being installed,
yes 1aI Nu
Will the epplicam air fumrc beading w,npam are equipmam pr d,vmea which 1 If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminanu as defined by the Bay Area Air Quality Management all new materials for inspection.
atric'?
❑Ycs QNNo
1 have mad the hamNrms materials requirements under Chapter6.95 of the Califer,
Hcullh&Safely Code,Sections 255)5,25533 and 25534.1 undertand thelifive building
not c nil have a to an, tis responsihilily te nodly the upam Of theuire a a m ort smmm� :,Cardfcae of ocSignature of Applicant Date
ner n thmied agent All roof coverings to be Class "B" or better
11�SNA
CITY OF CUPERTINO i
CUPEI�r PERMIT APPLICATION FORM v `'
APN# Date:
Building Address:
/D �D 4
Owner's Name: Phone#:
TIAJA !7E a: i S 06 3
Contractor: License #:
, 755a - / 9
Contact:GREG Cupertino Business License#:
M%
B ilding Permit Info:
lect Plumb ❑ Mech ❑
L escription:
Residential JZ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group: r
Type of ConstructioAML : XNL674 ad106 a 5 7 6 4 �— E
QuantityFee ID �7 Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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 Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit, Fee BUILDING
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amp
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
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
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
AIL BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Stonn/Rain Water PLUMBING
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
13RFINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BRENLkMiAN 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> 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
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Set CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rrhdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, 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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
BMISCELL Building Mise Fees BUILDING
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