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03030116CITY OF CUPERTINO p�T >§ I "sax" ^�"'�' az _y/'��•�'«- "+ �� e• s'iTOR INFORNIr1T0," BUILDING DIVISION p�1'RMj'� tea,. aa� =a4 . ,r= BUBDINGADDRESS: PERMITNO. JM CONSTRUCTION RA1NBGW BR OWNER'S NAM PERMIT ISS 562 DIVISION ST PHONE: (408)379-9852 SANITARY N OL NO. 1'IECr/ENOINEER: BUILDING PERMIT INFO BLUOELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION lion JobDescription I hereby affirm that 1 am licemand under Provisions of Chapter 9 (mmmencing o with Section 7").f Division 3ofNe Business and INofesalom Code, and my license h In full fume end grfcn. License Class (pp-CK`.T, Lu.I R -t 7'3,Gnr,6 REWIRE/REPIPE/FURNACE/PANEL.{UpPGR$�yA�DE Date CARPENTRY nContractor ARCHEcrS DECLARATION I understand my plant shall Ire used u public records _ JUL 0 8 2003 Licensed Professional OW NEmBUILDER DECLARATION 1 hereby .(fare that 1 exempt from dm Canlractofs nso law for the Code: Any airy or county maxo 1. e: A t IID1.0. Business and Pm. de o demolish. fallowing uuon. Permit re camwG, a3tee Improve, demolish, m repair any educe which requires a BUILDING D G ' 10 «t LIJI to e.also for p)nnit m Olen. Lail statement prior m its issuanlicensed the lW .pions Nc Comnnesta Ucenrexin Cause)9 Sq. Ft. Floor Area Valuation nt to of that the (commenllnmcdpSeuanl 700) of Diviaunf pursuant its Code) or with Section 7000) ofDivisionr of OU Bwinwand on. I that he ,dog that he U esempt Nertfram and Nc bsa4 for tW alugW corruption. My violation of My APN Number OcCupag, ey Type Section 7031.5 by try applicam for a pnuth subjects the applicant be a sir it penalty of not mom Nm rise hundred dollen (5500), ❑ I,uownerofthepmpeny.mmyemplDyeuwiNmMuNeirmleeompenutim. Required Inspections will do the work, and Ne swcture it notirmoded moRemd fertile (Sec. 7044, Business and Profualom Cade: The Conmctofs License Law does not apply in an owner of property who builds orimprovu thereon. and who daessuch wmkhlmulforthroughhh 101 - FOUNDATION ownemployms, provided Naltuch improvements amnutlntendedoroneredforaale.If, however, the building or Improvement It sold within ore year of completion. the owner - 102 — PIERS builder wIB have the burden of peeling that W did net Wild or bri mw for purpose or 10 3 - UFER sale 1. 01. a. Graf the property.am esclutivclyconuacHng wird licemed mntnnon m 104 - REBAR construct the pmlem(See.lou. Business and Profuse. Cade:) The Conunater's u- 105 — ANCHOR BOLTS roue law does not apply an an owner of property who Wilda or Improves damon, and who contracts for such projects with a mnuacur(s) licensed pursuant to the Contractors 106 — SEWER & WATER License slaw' ❑ 1 a)tempt under See. . B & P C for this reason 202 - UNDERFLOOR PLUMBING - UNDERFLOOR MECHANICAL Owner Date203 204 - UNDERFLOOR FRAME WORKER'S COMPENSATION DECLARATION I hereby ammt under penalty of perjury one of the following declaratiorm: 205 — UNDERFLOOR INSULATION Nu "allu-andCcBm of Content to self -Insure for worker's Camper- 301 — ROUGH PLUMBING u provided for by Section 3700 0(the lobar Code, for the performance of Na 302 - TUB & OR SHOWER or which than permit is Issued. haw and will maintain Wmtrfs Compemadon Insurance, as required by Section 303 - ROUGH MECHANICAL 3100 of the Labor Code. for the performance of the work for which this permit is tamed. 304 - ROUGH ELECTRICAL My Wortse, Compewtlon Inserume carrier and Policy numkf.m: 305 - FRAME carrier.\tj PoBryNO.: � RIFIft-F1 ON FROMR 306 - HOLDOWNS COMPENSATION INSURANCE 307 — INSULATION or lessJ�usectlnn nsodootbocanpMted iftha lcrmhufmopm hundrW dollen (f 10(1) 308 - SHEETROCK I certify that In dm performance of the work for which this Permit is luued, l shall But 309 .- EXTERIOR LATH employ any person in any manner an as in become subject n the Workers'Compensation 310 — INTERIOR LATH Laws of California. Date Applicant 311 - SCRATCH COAT NOTICE TO APPLICANT: Ir. )fur making this Certificate of Exemption, you thmld become Subject to the Worker's Compensation provltions of the labor Code, you must 313 - ROOF NAIL ' forthwith comply with such prnviil0umthis permitshall be deemed revoked. 501 — FINAL ELECTRICAL ENERGY i CONSTRUCTION LENDING AGeNcv 502 — FINAL PLUMBING ENERGY 1 rum hereby althat Vert is a construction lending agency forthe performance of ' a. work for which Nupermit 4Issued (Sec.3097,On. C.) 503 - FINAL MECHANICAL ENERGY a Lerder•aName 504 - FINAL BUILDING ENERGY Lcnd)r's Add., e IttNly that lhew read this dol the shorn Information h 505 p___,�— - FINAL ELECTRICAL cityanc countydmte corm. I agree a comply with ail day roil county oNinantts and sou laws rtletlng m506 - GAS TES T building construction, and hereby authorise mpreunutiws of this city to enter upon the for inspection 0 FIN PLUMBF9AL above-mentioned propeny purposes. (We) agree to saw. Indemnify and keep humleu Ne City of Cupertino stations j liabilities judgments, casts and expenses which may In any way accrue agalnm said CityV?A 0 8 F I In combqunce orle e granting of this "soh. 5 APPLICANT ERST AND W L COMPLY WI N N Issued by: Date ALL -POINT' SOURC ATI S Re -roofs 514NAL Type of Roof PUBLIC WORKS _ a Q Sitnuu a plieanVCon= Due HAZARDOUS M ALS DISCLOSURE 111thpplivantmfuwm Wll IccuWnt nommhendlc huallom material as defined by the Cupertino Me 'ci al Code. Chapter 9. 12, and the Health and Safety Code, Section 25532(a)? All roofs shall be inspected to any roofing material being installed. E] Yes u prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future siding occupant use cqulpm'el or devitta which )mil W.Mets els comaminanu dcOncd by the Bay Arta Alr Quality Management all new materials for inspection. let? ❑Yes No I hew read the hnaNuusmaterla requirements under Chapter 695 of the Califon is Healut& Safety Cade. Satiw255 25533 and 25534, I malsooutd and iftM Wilding dote not cv haw ant Nu 'u my ruapouihllity w noVy the ore pant of tW rcqui sen ch et rio les issuastm ofa CcniOcete f cu 2,1 y'Q Si [u (Applicant Date ,All roof coverings to be Class "B" or better Ow a ar. arises gent Dau • I CVTA, Ca1:1 q f+ ��N me loa et i t 8`n• s and it is un low tp� ake ehy �,ar�a3 or alteration;. on same w0gut aY; pe.mission frorc the building D`sp`t:, ;day of 'cupartipo. The StamO p4'y is p,yn and spocificagic SHAH M IEC iile;d. to permit or, to 6e epprms ml m*h Violation of any pro, ii .18w ¢1t4� tprdinancp or Sgata ' r 0 M MITTA,L { '7 t 4 � o 1 R ems( fop r� � i Ct�v5e1 �lo5e�.. S {levee f � C, Elcot•ca� Po� t ;> � N r� •�. v 1 � 0 M MITTA,L { '7 t 4 � o 1 R ems( fop r� � i Ct�v5e1 �lo5e�.. S {levee f � C, Elcot•ca� Po� t 11Soj-) DATE4- ;> � N r� •�. v 1 � SIGNED,_ t H This set of p:ar. a ,;auon>s BUST d �+ timesand i!s un rg lawful to mak a, ,y c ianges or alteOutions P- Q on sar easi9;,}usf wri ten permission3from the budding Dept., Ci y of Cupertino. gthe stamping - I,; Ian and specifications SHALL NOT be held,�6permit ort "_ an s approval of the viola tl�n of any prov%ions of any City Ordinance or State Law, 0 +aa a, 2 003 ,. � _ 0COP I u�� ttLs u� u 0 Q `M VJ' V d "•; v i t w 3 9VE® 3 lie d v "s IN ACCORDANCI ; ITH THE .lTY Ofi t P,,• g[JPERTIN COD 7 Q QJ m u AND IN''.. CESS ° 0 a 11Soj-) DATE4- ;> � N r� •�. v 1 � SIGNED,_ t H This set of p:ar. a ,;auon>s BUST d �+ timesand i!s un rg lawful to mak a, ,y c ianges or alteOutions P- on sar easi9;,}usf wri ten permission3from the budding Dept., Ci y of Cupertino. gthe stamping - I,; Ian and specifications SHALL NOT be held,�6permit ort "_ an s approval of the viola tl�n of any prov%ions of any City Ordinance or State Law, 0 a, N ,. � _ y J ;> � N r� •�. v 1 � t H rA ITY OF CUPERTINO AY OF CUPERTINO • a� o /j� PERMIT APPLICATION FORM `3 N # � Fee Group Date: ZI X03 Other Appliances MECHANICAL BBLDGFEE Bldg Permit sq. foot Building Address: BBOILER1 . Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu Owner's ame:h BBOILER3 Boiler> 500K to'1M Btu Phone #:.3 _ 7Q �� Contractor: Boiler > 1M to 1.75 M Btu MECHANICAL License #:3 CO S.& Q h o MECHANICAL BCONSTAX Construction Tax Contact: 11 J e,�F BCONSTAX Ind/Off/Comm/Quasi Cupertino Business License#' BuildingPermit Info:., Con. Tax for BQ Zone BUILDING Bld I�Q Elect P umb 11� Mec Job Description:, Constax — Resi/Mobile BUILDING Residential ❑ e Car t.,Jr Commercial ❑ Sq.Ft. Floor Area: Elec 600V > 1000A ELECTRICAL $/Sq.Ft.: Elec Svcs 600V <= 200A ELECTRICAL . BENERGY Energy Cost of Project: BENERGYADD Energy Add Multi Occupancy Group: BINVESTIGA Investigation fee BUILDING BMITIGATC Typ of Construction BUILDING 1 S'o r + e e v o � QuantitFee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permit sq. foot BUILDING . BBOILER1 . 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 LI �� 2� I of 3 14 4 CUPEf�TINO PITY' OF CUPERTINO • 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 Multifamil 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 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 Pipe 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 cfm MECHANICAL' BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY 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 IMisc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE ' Pole/Platform Fixture ELECTRICAL CITY OF CUPEf�TINO CITY OF CUPERTINL'i PERMIT. APPLICATION FORM .Quantity ID Fee Description Fee Group -Fee 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 3 of 3