03060096 CITY OF CUPERTWO ^a'''� canna w;s>�a; r ' �',
BUILDING DIVISION PE To
��CONTRALGTQI2
BUILDING ADDRESS: PERMIT N"03060096
0.03 0 6 0 0 9 6
-INER'S NAME: PEftM T'NA712/2 0 0 3
PHONE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED I amCONTRACTOR'S DECLARATION Job Descri, �NALE® -
e! tttkkkWWR"' I hertDy afOrm Ner I am littnutl antler provisions of Chepur Y(commencing
with Section 7")of Division 3 of Nc Huai nuaand Profession,Codaand my lice.is
n ldmllto..and efine'' BATHRM UPGRADE
2�ZLicense ClMr Lim.
O Da¢ Cml.Wm u 1I
ARCHI7i DECLARATION 1�oY Oa� 2003
I unrsa
dend my plans shall ho mud a public recnrN NOV
tyU
b0 Licensed Professional
b OWNER-BUILDERDECLARATIONBUILDING
�a I I hereby mam .(Siem than 1 em exempt from am Contractor's License Law for the
3 a2 followinguires a (anti t 7 motto,Business and ate,Professionsdeli Code:Any city or roomy
$ Which requires s Pomba reconstruct,after,improve,h Permit t ri e a sig ed awcmre
my
prior its issuance,Former,toms theapplicantfor sucCounsrmitmcense Lw(Ch statement
g Natomenclgwit Pursuant to the provisions of the Canwness and Professions
(Chapter Sq.Ft.Floor Area Q8Vj�1�10❑
$ 'a,he exempt
with Section7")ndthi Division of the Businexmpton.Any
Code)or V
Net he b exempt therefrom roti the basis for the allegrA exemption.Any violation of
• Section 7031.5 by any applicant for a pe.I,subjects Ne applicant in.civil pemhy of 3 A6N 4YD414et 0 0 Occupancy Type
nor more Nen five hundred doth.Myst).
❑I,uowncr of the propeny,mmy employees with wagmu Ne'v solecompiarm on, f
will do the work,and firm structure is not intended ora@red forsale(Sec.7W,Business —
and Professions Code:The Contractor',License Law doe,not apply to an owner of d IHSpeCtIODS
RS
propeny who buildsorimprom thereon,and who doeseuch workhim,elforNrough his 102 — PIE
own employees,provided that such improwmcnts,re not intended croRemd formic.If, 103 — UFER
however.the building or improvement Is sold within one year of mmplation,the owner.
builder will haw Ne burden of proving Nat he did not Wild or improve for purpose of 104 — REBAR
ales)' 105 - ANCHOR BOLTS
fit 1.m owner of the property,me uela dvely contracting with licensed contractors to
convect the project(Sec.7044,Business and Professions Cade:)The Contrmmes U. 106 — SEWER & WATER
cense Law does not apply to an owner of property who Wilds or improv Norton,and 202 - UNDERFLOOR PLUMBING
who contacts for such projects with a contractor(s)located intimated in the Contractor',
License Law. 203 - UNDERFLOOR MECHANICAL
❑lam marrinunde eh ,B R P C for this mason 204 - UNDERFLOOR FRAME
ORKER'SC PENSATION DECLARATI
205 - UNDERFLOOR INSULATION
/ 301 - ROUGH PLUMBING
1 herby
to
y rally of perjury one of Ne following decWlions:
D llovemdwlll onuin a Cenificam Consent of Conseno se6losure for workar'a Cooper- 302 — 'TUB & OR SHOWER
action,u provide, r by Section 3700 of the Labor Code,for the Performance of this 3 03 - ROUGH MECHANICAL
murk ler which this permit is ismed. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Waf es Compensation laturance,as required by Section
3700 of the labor Cade,for Ne peRarmance of the work for which this permit la Issued. 305 — FRAME
My Worker',Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
Carrie policy No.: 307 - INSULATION '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(This action need not Wcomplesed ifshe permit is formic Wndred dollars(SIM) 309 - EXTERIOR LATH
or bass') 310 - INTERIOR LATH
1 unify that in the poor.ane.of die work for which Nis permit is issued.I shall not 311 - SCRATCH COAT
employany person in my connection u to become subject o that Workeri nsa
Competion
Laws of California.Dam 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT:If,after..king this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation previsions of the labor Cede,you must
' ,Z, forthwiNcomplywithsuchprovisionsorthisPermitshallhodcocdBrvoked. 502 — FINAL PLUMBING ENERGY
Z 0 CONSTRUCrION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
4 T hereby came that Vert is a construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY
as > don work for which this permit is found(Sec.3W7,Cit.C.)
Underi 505 - FINAL ELECTRICAL
n1 Q Nmnc
� Z <naer,Aad ss 506 GAS TEST
J O I renify that 1 haw mad this application and sum that this show information is 507 - FINAL PLUMBING
IL F correct.I agree to comply with all city and county ordinances and sato laws relating in
pU building conswctinn,and hereby authmrite represconadvca of this city to enter upon the FIN MECHAN CAL
ahove-mentioned pmPerty for inspection Purposes.
(We)agree m saw,indemnify and keep homeless the City of Cupertino against 0 9 F I /
.Hi rq
Enid[idea judgments,earn and expenses which may in my way accmc against said City NG //
UZ in canuqucnce of me gaming of Ni,permit.
^' APPLICANT UNDE ANDS AyVD WILL COMPLY WITH
/ALL
nNON--POINT Issued by:5 C WORKS Date
SOU CE L 1\t,.IIQ\-- / Y I��I 0>
V Re-roofs
nawrcYlApplianUCo actor!{ RDOUSMATERIALS DISCLOSUREType of Roof
cant orfutum building aeeupmtsmm or handle hazardom mamdal
asdefinedmpcourt Municipal Code,Chapter 9.12,and the HeaWi and Safety
case. E]Yes
No All roofs shall be inspected prior to any roofing material being installed.
Will Nc applicant or future Wilding occupant use eyuipmmt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air emmeninams as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes �No
1 have mad the hamNnus materials requirements under Charter&95 of than Califon,
oiaNext th&Safety Cock,Seetioat 25505,15533 and 25534.1 understood dui Wilding
docs not eunemly have a tenant thata
mat
y rpeatm roily ily the occoman or On
fcyvi max rest met do, �i,smmaofaccraneouid'"Pym. Signature of Applicant Date
0a more ode age D re All roof coverings to be Class "B" or better
21763 ReyocrYt Court
c�PeY-t��,a, cq 9so, l� B
• �Q C3�fitnroovti On Ist `Ioa
3"~I 5'- 10 1 /2
9 TER
i SHOWER
4
12 20
BY
TOILET
T CUE T •BATHAPPROVED
N1 iORDA CE ITH THE CITY 06
MO A DINAKCFA
!. SINK OAl
OVE -'dTh ; of p' s and specifications MUS .
1 be k m .,a lob at all times and it is ung
/ - lav fl ` make any changes or, alterationti
"n sl i c without written permission front
in Dept., City of Cupertino.
'"•` t ping of this plan and specification
o 1 L .OT be held to permit or to be an
2'-4" hpproval of the violation of any provisions
p anv City Ordinance or. State LavL
•
21763 R45KC,,t Couvt-
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ti�Aor Ca gsolf'I
y�l�ste� �'3A1[IYcnwr d,A
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1�TI is aft of plans -," , s ecitications MUST;
• ; aat o1i the jc at all times and it is ung
N=i ii 1 to make any changes or, alterations
,q s_::. _',t written
�mamg uept., City of
I k mi ""a.f this plan and specification; fl L5 l� LS ll l!1 r
z 3t dd iold to permit oc to be an
—' i lar tho violation of any pro : _jo
a 12 200a
i
By
•
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CqrY OF CUPERTINO v o o q6
CITY OF PERMIT APPLICATION FORM 3
•CUPEkTINO
APN # r , O Date: 6 /2/03
Building Address: 217&5 may t 014 r r C u e r t)LA o , CC, 9 S o l Ll
Owner's Name: SUYe"d ra Lale_ �A Phone#: 40,g 2SS ( } og
Nli}rq Le��L
Contractor: Etivi'SiON Rui 1cl4 License #:
Contact: Cupertino Business License#:
B i ling Permit Info:
*I &ect Pumb M ch
Job ription:
esidential o c,
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: / Occupancy Gro p:
r
Type of Constructio :
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER OtherAppliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to IM 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 <= IOOOA 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
22137.
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ATY OF CUPERTINO i
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BM2qEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily 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
13PCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg 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 eOfFixtures 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 din MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMEDCT 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 I ELECTRICAL
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity. Fee ED Fee Description Fee Group
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 Plumbin Permit Issuance PLUMBING
PPLI Plumbin Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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