04040027 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT -S ON`I'k&C"�'f1Xt=TNT'C? 'IATIU e
BUILDING ADDRESS: PERMIT'904040027
OS60 RAMPART A17
OWNER'S NAME: PERMIT ISSUE DATE
ANNA LIN
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y00 LICENSED CONTRACTOR'S DECLARATION Job Descri t3
1 hereby affirm that l am licensed under provision of Chapter 9(commencing P nam
n wiNSectiop7"� )ofDivleion3o(dte BusinyeaM Profceaiom Code.end mylicenu is �UNALE®
N in mBfercelBQeffett. ' Lk✓g UPGRADE ELECT PANEL (200A)
S cl 4 Licenu CGtemalC" f/
Dem\ C"nremr CONTRACTOR: AMIR ELECTRIC APR 10 2004
�i ��Wdderamnd my plans shall be used elt Ilc reeouda
3w Licensed Pmfesslonal BI DING
O OWNER-BUILDER DECLARATION BUILDING 68�J a�
1 hereby afirm that I am exempt from the Contractor's License Law for the
p following rcnon.(Section 7031.5,Business and Pmfssaion Code:Any City"county
E 2 i which requires a Permit In commac4 ellen improve,demolish,m repair any structure
prior to also requires issuance,arequires rhe applicant(orsuch permit to rile a signed statement
_iy
i- G the,he is licensedpursuent1.theprovisionoftheContrecmr'sLicenulaw(Chapter9 Sq.Ft. Floor Area Valuati($15 0 0
$C$ (commencing with Section 7")of Division 3 of the Business and Professions Code)or
3.. East he is exempt therefrom and the basis for the alleged exmp0on.Any violation of
Section 7031.5 by any applicant for a Pewit subjects the applicant to a civil penalty of APN Number anel Occu ' p e
nut marc men five hundred della.(S500k P y 'J P
01,as owner ofthe property,or my employees with wages a their sole compensation, 36925005 . 00
.tilde than ork,and the smuclua isnotiotended eroffered forsale(Sec.7044,Business '
and Professions Code:The Contractors License taw does WE apply in an owner of Required Inspections
property who bu ilea ser improves thereon.and who does such work himself or through his
awn employees,provided that such improvementsare natimmuded"offered forsale.If.
however,Ne building or improvement isuid within ooe year of eampledon.the owner.
builder will have the burden of proving that he did no,Wild or improve for purpose of
sale.).
❑h as mvoer of the property,am exclusively convecting with licensed ronmactoa to
construct the Project(Sec.7044,Business and Professions Code:)The Conuacbr'a Li-
cense law dean not apply to an owner of property who Wilda or improves thereon.and,
who contracts for each projects wish a contractors)licensed passant to the Comactor's
Licence Law.
1 afn exempt under Sec. ,B&P C for this reason '
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 herby arm under penalty of perjury one often following declarations:
I have and will maintain a Certificate of Ccaunt mulfinum far Worker'sCompcn-
nation,as provided for by Section 3700 of she Labor Code,for she performance of she
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance.as required by Section
3700 of the Vbar Code,for the performance of the work for which thin permit is issued
My Worker Cam on Insurance carrier and Policy number am:
�6a& Polity Ne.. _
CERTIFICATE OF EXEMPTION FR PRKERS'
Co COMPENSATION INSURANCE
ts section need notbecompleted if she pewit is forme hundred dollen($100)
nr Ices.)
I Certify that in the perfnwance of me.,it far which this permit is issued.I shall not
employ any person in any mapOCLs omc}ub'S to tW War n
Lawn of Calif u (lam/
APPlicanr SO IYL $ 19
t 2
NOT1C APPLICANT.If,aftermakingmu Cemns of of Exemption,you should
Wcomescompy it Worh pro Coons or
is Provisions of me Ichor Cade,you mon
,JO foMwiN comply with such provisions or shin permitshall Wdeemed revolved.
i► CONSTRUCTION LENDING AGENCY
f~ I hereby affirm that there is a canwcdon lending agency for the perfuwmx or
Rt, ti tie wurle for which this permit is issued(Sec.3097,Civ.C.)
MH.1 Q Lender's Name
z
Larder's Address
U Q 1 certify me,l have mad this application and sum mal the above Information is
IL P comet,regime to comply with all city and county ordinances and awe laws relating to
0 building construction,and hereby authorize reprrsentatives of this city in enter upon the
r
above-mentioned(Weagree
propertysave,
for impaction kap hs.
(We)ague to cove,indemnify and keep hawlcss she Che of Cupertino against
pFy Z inconsequence
o sequenc or
Caela and expenses which may in any way accNC agamalaald City /{
f,`L A APPLICANT
of UNDERSTANDS
this permit. (/
APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT Issued by: Dat
rULATIONS.y
D d Re-roofs
AmIteam/Comoscmr Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
the applicant or future building"cupmlamre orbandlc hazardous material
y the CupeAno Municipal Code,Chapter 9.12,and the Health and safely
n us33(a)7 All roofs shall be inspected prior to any roofing material being installed.
a �Ncthe applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
m air contaminants ss defined by the Bay Arca Air Quality Management all new materials for inspection.
C]Yes AN.
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor.
.is Hcallh&SaetyCode,Sectors 35505.25 3and25534.1undeamndthatifthe Wilding
does not Connelly have a tenant,the it is mapomibility,to Wary the occupant or the
mqZ7 whim must he in t pail r to i c ora canictue of occupancy, Signature of Applicant Date
owner as aamoriaed agent DowAll roof coverings to be Class"B"or better
Community Development
*00F
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRES /O 6 0 f Cc/yt1-9Cc.1- OCP. PERMIT#�
U 7 1^7 if1 D
OWNER'S N /l2 PHONE # p
GENERAL CONTRACTOR: IFAX #
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
Excavation
Fencing
Flooring: Carpeting
C Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rgrk
Tile
N4Contractor Signature Date
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO if
APN# Date:
,�,.� Gy
6 �ay
Buildin dress: M lipg Addres (if different from building address):
Owner's e: W ho 6 -clef D 3
Contractor: / CTlV G Lic se#:
Contact: (Q Phone: Cupertino BusinessLicense#:
Fax: al?G 35 /9
ilding ermit Info:
Bld Elect ® Plumb ❑ Mech ❑
Job5cinription: U/p -bl i /00 A10/2
Residential �o (/ Commercial ❑
Sq.Ft. Floo a: $/Sq.Ft.:
Cost of roject: r�n� Occupancy Group:
Type of Please check this box if the project is a
second-story addition: ❑
uanti Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE BldgPermits . 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 > IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energv BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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�
CITY OF CUPERTINO
CUPE
111TY, NO PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BNUCONTME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTBAE 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 Instalt/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
Nor BPWSVCS Main Water Service PLUMBING
BREINSPECT Reins ection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm 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
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 Si s, Maz t ELECTRICAL
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ZTMC
CITY OF CUPERTINO
CUPf�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
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 Swinuning 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
17 EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot I PLUMBING
ZADDCHG Address Chane BUILDING
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