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04090076 CITY OF CUPERTINO BUILDING DIVISION PERMIT k"CONTRAC"TOWINFORMATION • " - �+v,-' BUILDING ADDRESS: PERMIT ND0 4 0 9 0 0 7 6 OWNER'S NAME: PERMIT ISSUE DAM AM DARRELL K ONE: SANITARY NO. CONTROL NO. 7z�, CHrlECTIPNGINEER: BUILDING PERMIT INFO BLDG BLECT PLUMB MECH 0 M 0 0 LLICENSED CONTRACTOR'S DECLARATION JobDescri tion 1 hereby affirm Wr I am Iimnsedun emviaiane of Chapter 9(commencing P Aull da )af0ivision3of NC Busi end ProfeWuiu Cotle.and mylicenrc isNI 9LE® . ndertec ELECT SERVICE UPGRADE (200nNnad T_ C^ ,e RCHQECTSDEFL�R TION CONTRACTOR: MOLCSAN ELECT. y .l undersand my plana shall he teed as public records SEP /G 2004 3 GGGGod Licensed Proressienal OWNER-BUILDER DECLARATION E0I 1 hereby (firm on I am exempt from tw recons Co License C taw for tw BUILDING ip0 following rcmon.(Secuun]fDl.S,Businm and Profmiam Code:Any oily or county 29 which raquim a pumit to cnmmct.alter,improve,demolish.ar repair any structure =g S prior to its issuance.also requires the applicant for such permit to rile a signed statement !i=0 Net he is licensed pursuant to the provisiotu of the Conamtor's License Law(Chapter 9 Sq.Ft.Floor Area ValuaG10g800 mMmamencingwith Section70DD)nf Division3O(nwgusn=mdPmfmions Cs )or 41- e;§ that he u eumpt therefrom and the bass for the alleged nu mption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy e net mom On me hundred Odlara(5300).C] 5300). 31602069 . 00 P Y EYP C]1,as owner of the pmpcny,or my employees with wages u their sole compeneadon, will do Newark and Ne structure is not intended or effaced for agile(Sec.70M.Business and Prefesdons Code:The Cantneer's Liceme Law dote not apply in an owner of Required Inspections propeny who builds or improves thereon.and who doessuch work himsell or through his own employes,provided Out such improvements tee not intended oro0ered truistic.If, havers(,the building or improvement is sold within rum you of completion,Ne owner builder will have the burden of proving that he did not build or improve for p M=of sale,). ❑1.As owner of Ne property,am exclusively contracting with licensed contractors to Construct Ne project(Sec.7014.Buainm and Profetdom Code:)The Commoner's Li. cense law does not apply man owner of ramperty who builds ter impmm therton.Ind who contracts forsuch projects with a comma oKU licensed pursuant to the Contractor's License Law. ❑Item exempt under Sec. ,B&PC fm Mia an Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under pcsalty of perjury ane of the following M clarafiom: t 1 have and will for aCeniric00 of ft Lab to Code.for far erformsCompur ..ail setion,u provided for M1y Section 3]00 of the labor Cade.for Ne performance of the work r which this permit is issued. 1 have and will maintain Worker's CompevaWance tion Int ,as required by Section )]BD of Oclawr COM.fortheperfmmuaeofdawohforwbichthispermitsiss . My W9fer'aCompensation losurnnce Carrier and Policy numberam: Car✓ee-J 5- T,A APd Policy Ne.: 17_Z ERTIFIC�BPTIONFR WORKERS' COMPENSATION INSHRANCE (This section need non bccomPlewdlinkss permit is forom hundm-0dolim(SIM) Car leu) 1 certify that In the scriu mance of the work for which this Permit is issued,I Mail not employ any person in any manneran AS to become subject o the Workeri Compematlon Laws of California.Date Applicant NOTICE TO APPLICANT:IL after making this Cenilicam of Esemption,you should became subject to dm Worker's Computation previsions of the Labor Code,you muse 0z forthwith comply with such prevision or this permit shall w deemed revoked. z., CONSTRUCTION LENDING AGENCY 1 hereby affirm Nat there is a construction lending agency for the performance of lY> dm work for which ths permit in issued(Sec.3097,Civ.C.) /fes 4 Q Lead CYS z Lendce3Addmss U 0 1 cenify that I have mad this application am stem that the above information is IL E correct 1.gree to comply with ell city and county ordinances and state law$relating to 0 building constunion,and hereby auNorim mpmsenutim or this city to ewer upon ft aabove-mentioned property(m inspection purposes (We)agree le saw,indemnify And keep haulm the City of Cupcnino against 71( n liabilities.Judgments,cmu and expesan which may in my way accrue against said City t„)7 in consequence of the granting of this permit. '7 APPLICANT UNDERSTANDS AND WIILLLLLACOMPLY WITH ALL NON-POINT Issued by: Date j I SOURSE REC� � r-^aYl ✓y— Re-roofs St un of ADDlioHAZA DO DIm HAZARDOUS MATERIALS &SCLOSYRI✓ Type of Roof Will the applicant or furore building occupantt tore or haMlc hvaAous material as dcfincd by the Cupertino Municipal Cons,Chapter 9.12,and Ne Health and Safety Code.Section Y.25532(4)? 1A All roofs shall be inspected prior to any roofing material being installed. Will the applicant of future wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air contaminants As dcfincd by Me Bay Arta Air Quality Management all new materials for inspection. 7n��lffi&Sd�,,C�,�.ZM5,25533.d25534.1.nW istrict? ❑Yes ®' u to ave mad the h®ardousm=Aits mquimment under Chapwrg.95 ofthe 6lifor dtiesifPo wilding ean not Correnti haw a moan.am its my mspontiabI'm notify th amtpamof the quirtmcnuw 'arluiavan crdficateoroccupaney. Signature of Applicant Date wncr ter amhorizcJ agent Data All roof coverings to be Class "B" or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPERTINO Building De artment JOB AD SS:/n�g PERMIT #� OWNER'S N rv,�l PHONE # _ Z _ Cil GENERAL CQ TOR: Zc a ,7 v t L FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followin information: SUBCONTRACTOR 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 Tank Sheet Metal Sheet Rock Tile ✓yaiqr/Contractor Signature Date CITY OF CUPERTINO o CUPERTINO PERMIT APPLICATION FORM 6 PKPN# / O 26 Date: (5 -� Building Address: Mailing Address (if different from building address): Owner's Name: I Phone #: 5) - Contractor: License#: zw e, C Contact: Phone:468_5ze?-) Cupertino Business License#: cST -.S4 ,J Fax: Building Permit Info: / BldgEl Elect IR Plumb ❑ Mech ❑ Job DescriptiL : z Sv�tResidential Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: so Occupancy Gr up: Type of Construction: I Please check this box if the project is a —/ second-storyEladdition: Pro'ect Size: Standard LTJ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 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 z7 7 1 of 3 CITY OF CUPERTINO CUPEI� I PERMIT APPLICATION FORM QuantityFee 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 BOVERTEVIE 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 PINTERCEP 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 Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL BRENLkMiAN 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 2 of 3 CITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL BREMSIGNS Remodel Sips, 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 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 Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3