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03090186 g CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTnR INFORMATIONNN ', a ELI BUILDING PERMITND03090186 0c:-1 Tj PnRTATAll OW NER'S NAME: PERMIT ISSUE DATE T AN ONE: SANITARY N0, CONTROL NO. ARCHITEC Ii NGINEER: BU PERMIT INFO BLDG ELECT PLUMB MECH lOo LICENSED CONTRACTOR'S DECLARATION �u Nochy 7000)hrmtharI amon3 licensedMcBuindcrpmvisiornonsChapter CoN. 9(commencing Job DescrlpllQa��NALE® with Section]OlN))of Division 3 of Nc Business and Professions CoJc.end my license is F � i rice ciae�°a cereal. L1eN ELECTRICAL SERVICE UPGRADE �^ Dam Cun DECLARATION ARCHITECTS DECL ARATION OCTV L_ C0 Q 2003 pp I K 1 understand my plana shall W used as public records 5yu Licensed Poor usianel BUILDING 3 OWNER BUILDER mDECLARATION Cn O I hereby affirm that 11. exempt from the Canto Co :Any c Law for tbe v p o following remora.(Section]IDIA, t.alter, and improve, dernu Calc:Any city or county 5 which its has a permit re construct.alar,improve,h permit t or repair any statement PmOrtOhathei uccesed pursuant ayuirea the forsuch micensrile ae ned aw(suimmcm < the Sq.F[. Floor Area Valuation E Q (eat he Is (commencing with Semfmm rkyOland the basisofrM Neeged ascription. Any vi Calc)or Nn he u exempt therefrom and dm buts for the alleged eumption.Any violation of 3163 0099 . 00 Section 7031.5 by eery applicant for a permit subjects the applicant to acivil penally of APN Number Occupancy T not mom Nan five hundred dollars(SSW), —' - - - -- Pane Y YPe -- - 0 1,m owner of the propany,or my employees with wages u their tele compensation, will do the work,and Ne awctum is not intended or offemd for sale(Sec.]04d,Business — XUUU OM' and Professions Code:The Commetors License Law docs not apply to an owner of 5 01 - FINAL E CTR n NERGY property who bui Ida or improves thereon,and who does such work himself or through his ownemployeu,provided Matsuch improvements Manor intended ora(fered(orule.It. 505 — FINAL ELECTRICAL however,the building or improvement issold within ON year ofcomPintion,the owner. - builder will ham the burden of proving that he did not Wild or improve for purpose of sale.). ❑ 1.as owner of the property.am reclusively convecting with licensed convectors to .- —- consume,the project(Sec.]DW,Business and Professions Code:)The Contractor's U. cntse Law does not apply to an owner of property who Wilda or improv demon,and, who contracts for such projects with a conuxmmil licensed pursuant o IW Contractors cense Law. 1 stn(�crept antler. ,BDate h PC for his..on alxK s 3 WORKER'S COMPENSATION DE ION FN Ihereby.perm under penally of perjury ore of =Mowing declarations: p^ I have and will mainuin a Cenifcane of Content m ml(.insumfor Workers Compcn- V smion,as provided for Ey Section 37M of the Labor Code,for Ne performance of to , work for which this permit is issued. - ❑1 have and will maintain Workers Compenamion Insurance,u required by Section 3]00 of the Labor Code,for the Acro mora of Ne work far which this permit is issued. My Workers Compmtsab on Iuu once,carrier and Policy number are; Cartier: Policy No.: _ CERTIFICATE OF EXEMP ION FROM WORKERS' COMPENSATION INSURANCE (Thisxe,ion need not W completed if the permit is forte hunddd dollars(SIM) loss.) I certify that in the performance of the work for which his Permit is issued,l shall not employ any porton in any manner so u to become subject to the Workers'Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:If.after making this Cenificete of Exemption,you Mould become subject to the Workeh Compensation previsions of the Labor Code,you must D forthwith comply with such provisions or this perm it shall he deemed revolmd. zCONSTRUCTION LENDING AGENCY 1 hereby mMr.Nat More is a comtructinn lending Mgancy for the perfmo mea of SS Ne work for which this permit Is issued(See.IDB],Civ.C.) 4 0 Lender's Name 3.3 z lender's Address . ;J 0 1 anify that 1 ham read this application end sum that the shuns information is y F correct.I agree to comply with all city and county ordinances and suite laws relating to V building construction,and hereby authorim representatives of this city to enter upon the G shave-mentioned progeny for inspection purposes. (We)agree to sans,indemnify and keep harmless the City of Cupertino against (n liabilities judgments,costs and capenses which may in any way accrue against mid City :)Z in consequence of Ne gaming of this Permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date S R EGULATION , rs'Y,1�o s( t( Re-roofs ignat o ApplicamuComnclm Delc HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant M(ntua building Occupant store or handle hazardous material u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety cme.5mies zssu(.)'1 All roofs shall be inspected prior to an roofing material beim Ayes KNa p P Y g g installed. 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 hanNnus air contaminants as Joined by Ne Bay Area Air Quality Management all new materials for inspection. mie,? ❑Yu .d71 Nu I have mad Ne homrdous materials requirements under Chapter 6.95 o1 the Califon nia HcalNXSafay Ct ,Seeuou25505,25533md25534.1umkuund Narif Nc Wilding chef not cu only haw a tenm4 Nm it is my responsibility m amity de,ecapmm of Ne agcimm hic,oncen Me nonulss MCcOfaCCogf1 NOfGrryAya /G Signature of Applicant Date Or urauthmizedagent Y�DataAll roof coverings to be Class "B"or better I 1 � FAN CITY OF CUPERTINO r ° PERMIT APPLICATION FORM CUPERTINO WPKPN# p Date: i Building Address: r ; / (f Owner's Name: _ `( Contractor: License#: Contact: x Cupertino Business License#: Building Permit Bldg ❑ lac Plumb Mech ❑ Job Description: Residential ❑ omm cial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Quantity Fee ID 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 1 of3 � 37 Car: CITY OF CUPERTINO CUP TYOF'NO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BMTTIGATR 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 71: 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 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 WaterHeater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 clin' MECHANICAL BREMAIRHAN 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 Fumace> 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 2of3 ( l CITY OF CUPERTINO •• CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group 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 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 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 3of3