04030009 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ;�,1�� .1iAkCTRINFQsIATIO[� ;
BUILDING ADDRESS: PERMITNO04030009 4030009
OWNER'S NAME: PERMIT ISSUE DATE
Ift KULDEEP KARLCUR JNE: SANITARY NO. CONTROL N0,
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
?.top LICENSED CONTRACTOR'S DECLARATION O O O O
1 hereby affirm Nat I am licensed under previsions of Chapter 9(commencing Job Description
with Smtion 7pk)0f Divieion3o(the Ousiresa dProfceguns Code,end mylkenmh FINALED
inraumro}nag a 7`97 CONVERT TO GAS COOK TOP
yyZ Uaae Cls— Lk.N
a camr.aC! CONTRACTOR: MCCANN PLUMBING
rq- As0.11h used DN MAR 0 3 2004
1 undcruanJ my plane shall he used
as pis records
�no
3 w Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
1 herohy a(ftm Nes I em exempt from the C profession
is License Law far the
00 which a moan.(Saito 7(131.5, 1,Business and bereave.
demolish.
Code:Any city sa or caumy
s Inc! which requires•permit m pum;the
L alter.applicant
for w demolish,nr repair say tatamm
priortoiuomuamPerson Personal
the thrvisio sof for mchpermit lofie asigned atsmment
�< that h,islkcnaith section
70001 a Division 3 dm Contractor's Prorand.(Chapter9 Sq.Ft. Floor Area Valuatio9900
$C� (commene ng stempt hereform and ar basis for
Of des,s Businwmt on.Anyons Codin)laden of
a s
that he u,temps Nertfmm and gx bub Ter Ne Jleged exemption.Any vlolauan of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy e
nos more than 0w hundred dmigs(5500), p y�p
0 1,as owner of the property,or my ernployw with wages as Welt able compevadon. 35701090 . 00
will do the work and Ute seueure is out intended err efrcred for sate(Sm.7044,Business ,
and Profession,Cade:The Comrae^rs Liam,Law dots not apply to an am=or Required Inspections
pmpeny who bei Ids m ice proves We reon.and who done ouch wok hlmul f^r through his
awn employes,provided Wasauch improvements ere not intended oroRered forsale.If,
however,We building or improvement Is mid within am year of unmpledon.We awmr-
builder .will have dm harden of proving that W did not bW1d or Improve for purpose of
isle.).
0 1,u oamr of 0x property,am exclusively contracting with licensed ungenerous to
construct she project(Sec.7004,Business and Professions Code:)The Contractors Ll-
came Law does not apply to an owner of property who builds or Improve desmon,ad,
^co"U=for such projects with a cormacmr(O licensed pursuant m the Conemsor's
me ate.
am mempt under Sec. .B&P C(or this swan '
tens, Date
WORKERS COMPENSATION DECLARATION
1 hereby affi^^under mainly of perjury am of the following declarations: -
1 have and will maintain a Cenifcate of Cement m ml6imum for Worker's Coming.
nation.an provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,an required by Section
7700 of the labor Code,for the pedom name 0f the work for which this permit is Issued.
My Workers Compensation Insutma carom and Polity number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
PENSATION INSURANCE
(This Batt do., completed Veto permit b for am hundred dallsss(SIM)
or Iw.)
I certify th nth perfn me of the work for which thisscrmit u issued.I shall not
employe many anmrab suemgfE�brzsia(Tic wor'¢rs'COmpetwgon
Laws a It .Da
PIP I t
APPLICANT:I[ager mekina this Cguricare of EmmpOnn,you should
e a jest in the Workeia Compensation Provisions of the Labor Code,yea mum
.J O foI I comply with smh provision or Nis permit shall M ncemed revoked.
z CONSTRUCTION LENDING AGENCY
(+� I bereby alarm Wu there i.•cmtsanctim leading agemy f.rthe perfurmmcem' '
> the work fur which Wb permit u issued(Sec.3M,Civ.C.)
�5 Landers Name
Z)zLaeder's Address
U O 1 codify that 1 have read this application and state that the shave information is
SV^^. in cort1 agree to comply with all city and county ordinances and suite laws relating to
O buildingconswcli ,m byaulhoammpraamudivesofWiacity menter upon We
12.1 shove-menti. p pertyf inspection purpaabs.
GL (W ogre eve odemnify and Imp harmlw the City of Cupertino against
CA Ilebiltti .lung u,c ande.pensu which may to anywayacrneagaim said City /
Uz in con quem fNming of this permit.
•-' APP ICA UNDO STANDS AND WILL COMPLY WITH ALL NON-POI Issued by: Date
S RCE GUL ON
Re-roofs
rt of ApplimH
HAZARDOUS
De
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wigy the Clamor Municipal
Coe.Chapter
and the He and
do"a"by the Cupertino Municiptl Cade.Chapter 9.11.and the Health and Sefery
ode.ScacYtens 25571(0)? All roofs shall be inspected prior to any roofing material being installed.
Will We appticanl Ore.,uilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It b..doua air ronzMmani u defied by the Bay Amo Air Quality Managnmcm all new materials for inspection.
Wcu
ms materials rmuirtmentsunderChamorb.95oftheCalifor-
,Smtions 255.5,15533md25534.1unWr dthuifthe Wilding
wninns.NesitismymspansibilitymnotifyWeacupmtofthc
mug he met pdorm issuance arm cenifcam of Occupancy. _ Signature of Applicant Date
�` at
Data All roof coverings to be Class"B" or better
r or auth sed,sent
Community Development
j 3 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI OF Fax(408)777-3333
UPEkTINO
Building De cutment
JOB ADDRE : PERMIT# D 00
?Z703; X14kN- GV— CtD-5
OWNER'S N w� i r / PHONE #
GENERAL CONTRACTO FAX#
I am not using any subcontra o s:
Signature pate
Please check applicable subcontra ors and com Tete the followinginformation:
SUBCONTRACT BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic T
S ee M.1-91
Sh t R ck
T' e
Owner/Contractor Signature Date
r! CITY OF CUPERTINO �-
CITY OF PERMIT APPLICATION FORM
CUPERTtNO `
N# Date:
S oiogo 1 /-e
Building Address: Mailing Address (if dif(rent from building address):
a dL
Owner's Name: Phone#:
a -3 JDg
Contractor: License #:
GL�nn Ply / 667&J
Contact: Phone: 7,8' ,37 Cupertino Business License#:
3-Am Fax: 782-3it3
Building Permit Info:
d Elect ❑ P114 b Mech ❑
Jo ption: e ovL To/)
Residential 6,vS Commercial ❑
Sq.Ft. Floor $/Sq.Ft.:
Cost of root: �B Occupancy Group:
Type o ion: Please check this box if the project is a
second-story addition: ❑
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> 1.75MBtu 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
I of
CITY OF CUPERTINO
CUP TYOF PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME -Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
tP BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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
BPVEN'T 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 clip 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 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
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
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Ouantity Fee ID Fee Descri tion Fee Group
BREMTHEATR Theatrical Li htin Fix ELECTRICAL
BREMVENFAN Vent Fan Sin le Duct MECHANICAL
BREMVENSYS Ventilation S stems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM SwimmingPool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Tem Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electricals foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical s . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Feee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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