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05050070 CITY OF CUPERTINO dew xrasm.'«a-;+ « "N^+s�' BUILDING DIVISION PERMIT MCOlTRACTIgRIN '.OR1�TAT Na . BUILDING ADDRESS: PERMIT NO. TL ELECTRIC 05050070 N R AM PERMIT ISSUE DATE Ah ONE: SANITARY OL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 300 LICENSED CONTRACTOR'S DECLARATION Job Desc ' tion +� 1 hemby affirm that 1 am licensed under provision of Chapter 9(commencing withllSecdomto.70MR of Diviaion3ofthe Business uM Profoaions Code.and myliceneb �I■INALED Li full Toro and h'!I010 & License Comm ADD PANEL (2 0 0AMP) e J Date Contractor E ARCHr1ECTS DEC LARATIO )/ ;p(U lundenondmypWualWlheuredupublic.ads �oo� jK Licensed Preim.1one1 OWNER-BUILDER DECLARATION ju I hereby affirm that I am exempt from the Contractors License LAW for On Ka fallowing memo.(Section 71313.Business and Pmfmsioos Cale:Any city or county 9 which requires a permit to connect.after.Improve,demolish.or repair any mature BUILDIN arm., �ZS° prior m its issuncc.alsu requires the applicant for such permit o file a signed otstemcm He Nat he is licensed moment In the provisions of the Cmnmmo9 License Low(Chapmr 9 Sq,Ft.Floor Area aua 0 yF� (commencing with Section 70()f))of Division 3 of the Business and Profession Coca)or I� Nat he is m emp therefrom and Me bub fm the alleged exemption.My violation of Section 7031.5 by any applicant fora permit subjects The applicant to a civil penalty of Type not more On five hundred dollars($500). 3�Sr00Occupancy ❑1,As marver of the property,ar my employvca with wage As their sole compenadon, will do the work.and the strumae Is not intended As offered for sole(Sec.7044,Business Required Inspections And Prokas om Cmdm The Contractors Limmos Law don e ns not apply 0 an owner of q P property who builds or improves thereon,end who Eos ouch work himol f or thmugb his own employed,provided that such improvements we not intended oaffned for sale.if. however,Ne building or improvement bold within an yen of compilation.Me owner. builder will haw On,burden of proving No he did not build or Improve for purpose of sale.). Q 1,As owner of the property am exclusively contracting with licensed cenrocl9rs te constmer the project(Sec.7014,Business and Profession Cade:)The Contractors U. came Law docs not apply b an owner of property who Wilds or impnws thereon,and, who contracts for such projects with a contractor(s)licensed persum,in the Comrnm's Lie'.low. ❑1 am exempt under Sec. .B h P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION 1 thereby aifino ndef penalty of perjury ore of the following decimations: 1 haw entl will mandedo aCeNBcate of Cement to self4rumm for WarmesCompen- m ton,As provided for by Section 3700 of On Labs Code.for the performance of the work for which Nis Permit is WumL ❑1 ban and will maintain Workers Compensation Insurance,As required by Section 3700 of the labor Code.for the performance of the work for which IMi$poral Is Issued. My Workers Compuotion Insunno carrier and Policy number are: Carrier.MMN flgr,a w,rA Tvms .Polity No.:B 19 1419 7 I CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE (This section reed ombecompleted If the permil is fwamhundrud dollars($100) or less.) I certify that in the performance of the work for which this prich is issued.I"I not employ anypersen in any commerce nem become subject in to Workers'Cmmpmnaton Laws of Calilho i..Dow Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject At the Worker's Compecamma provisions of the IAbm Code,you muss .J O foMwith comply with such provision or this permit shall be domed revoked. ' „zm y CONSTRUCTION LENDING AGENCY [..m I Wmby groom thoudemamnstr donkndingape fmdxperfom of Me work for Which this Permit b Wucd(Sec.3097,Cih,C.) W A Le ndufs Nurse a z lender's Address U O I certify that 1 haw read this a"Iscatinto and cute the Me above infomuuun k ty^ correct.I agree m comply with all city and county ordinances me suss law relating m O SV' building commuctimn,and hereby authotm repmeentatim of this city to enur upon the W almve•menuonud proprty,for inspection Purposes Ly, (we)agmo to ow,Indemnify and keep harmless the City of Cuperinm against II,I IiabilWetJudgmens,cmts and sapiens which may in my way wane against said City of Moo U F4 I.APPLICANT cUN EgonungoS ANDWILLWILL COMPLY WITH ALL NO POINT Issued by: Date S E L ONS- Re-roofs Sign1rarelrArpicanVComncmr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant Yore ohandie haommus ma add M defined by the Cupenion Municipal Code.Chapter 9.12.and the Healthand Safety mac,sedan zss3z(.)T []Vas All roofs shall be inspected prior to any roofing material being installed. �u Wilt the applicant or future building occupant sec equipment air devices which If a roof IS installed without first obtaining an inspection,I agree IO remove it haoNous air cOmminams,ss defined by the Bay Arca Air Quality Management all new materials for inspection. tricG ❑Yat �e I bow mad the harsndommatodAisrequimC7 mcnu undcrupter6.95 ofthe Califor. nb HHeal"SafctyCode,Sccuun 75505.25533 And 2553/.l undersand thin tithe building b Idoes not curunmly haw a imam Met it 4 my responsibility sex of ponsibility modify the ofthe require khm beret ' rtoiouaneofaCatRcamof Signature of Applicant Date Owner orauthorizedagnot Dole All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue aClOF Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 UPEkTINO Building De artment JOB ADDRESS: PERMIT# 1905-0 'AV'Q, OSCN7 0 OWNER'S NAME: PHONE # 7..5;;A5- GENERAL CONTRACTOR FAX# 3 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical L LrZb1 b 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 `J Owner/Contractor Signature Date aloCITY OF CUPERTINOCUPEITINO PERMIT APPLICATION FORM 4, 7 v N# 316 06 Date: s3 Os' Building Address: Mailing Addre (if different from building address): Q50 k.. , Own 's Name-'A ame: Phone :s-714 7/ - G 3 7 S SSO - Contractor: License#: TL 701D tCa u0 Contact: Phone: 415"- Cupertino Business License#: O A- Fax: Building Permit Info Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: / � Residential ElAcUl✓I OUSQ PrAh Z I o1Coa ommercial Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: SBO C�9 Type of Construction: Please check this box if the project is a - second-story addition: ❑ ro'ect Size: Standard ❑ Large ❑ 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 Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING lof3 �� CITY OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM 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 BOVERTINIE 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 BREMAIRHAN A/C Units<= 10,000 cfrn 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 BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heatin MECHANICAL BREMRESAPP Remodel Res A liance ELECTRICAL 2of3 CITY OF CUPERTINO CUPEfZ;TINO 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 Inspection BUILDING Bsvlgm Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM -Ternporary 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 PlumbingPermit 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 • 3 of 3