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03080007e} CITY OF CUPERTINO NATION BUILDING DIVISION PERMIT sCONTRACTORINFO BUILDING ADDRESS: 009c; RAICH WAY PERMIT N6. 3 0 8 0 0 0 7 NER'S NAME: PERMITISSUE DATE DARS HIDAWAY NE: iAl SANITARY NO. CONTROL NO. CHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MEC14 p LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that 1 am licensed under provisions o(Chapmr 9 (commencing Smtion]Oflll)n(pivisionlo(Hc Response and Profcuinm Code, end myliccnu is iwith in full farce and Cff Licera Lm.e '7$ �`3 REPLACE CASTIRON PIPE SEWER —1 FZ a� Dau Contractor ONTRACTOR • ARCHITECTS DECLARATION i I undcrmanJ my phos shall be used as public records U ct 1 Licensed Professional 5 OWNER BULLDER DECLARATION 116 X I hominy affirm that 11. exempt from He Conine Law for the Co e: Any c (Section end Code: Any city at county firdl.imwhich ire cns5,Business which are. demob requires a permit re construct, alter, improve, demolish, or mash any nmeum to prior m s licensed i afro requite the vision sof for such permit m Em uigmd sutemcm as issu hCincingn71)(4)ofDivision3ofthef the nlmCmM1ndProfLiccall IIW(Code)9 Sq. t. IoorArea Valual� O O 0 shut pursuant O Section Division rth the essexe and Code) or $ (cat h alleged on. Any vi Chet he h exempt therefrom said cite bosh for the ellcgM exemption. Any violation of he is exempt said the �5imLa�.!1.1t 3WN2VlIDia=00 Occupancy Type Section]0713 by any applicantfor a permit subjects NC applicauo a civil penalty of not mom Nan Rw hundred dollen (33001. ❑ I, u owner of the properly. or my employees with wagesu Heir sole compensation. gg�� d Ins ections is not intended or offered forc(See.]O, Business will do He work, and theswcart dN and Professions Code; The Can=,.,'.License Lew dee but apply m a owner of 101 - FOUNDATI'OO p property who builds or improves Hereon, and who dos such work himself or through his own smarmy.. provided that such improvement are not intended met for ale. If. 102 - PIERS however. Ne building or improvement is said within am year of completion. the owner - Wilder will have robe burden of proving Hat he did not Wild or narrow for purpose of 103 - UFER ale.). 104 - REBAR C] 1. as owner of He propend, am exclusively conuacling with licensed Contractors to lO5 - ANCHOR BOLTS construct the pmjcct (Sec. 7009, Business and Professions Cade:) The Com actor', Li. . cera law docs not apply toanowner of opens who builds or improves diction. said, lO6 — SEWER & WATER who contracts for such pmjcct wiNaw tiacbr(s) licensed pursuammNe Commeah W. 202 - UNDERFLOOR PLUMBING Inexempt under c. ,B&PC for din, n 203 - UNDERFLOOR MECHANICAL OwnerKER5 TION 204 - UNDERFLOOR FRAME COMPENSATION DECLAR T. 205 - UNDERFLOOR INSULATION amrmunnet penalty ofPerjury amofthe mEowingdeclarslions: 301 - ROUGH PLUMBING Ihew head w0I m.imin aceNBc.m of consent m selainsum for Workers Camped. s on, as provided for by Section 7700 of the labor Code. for Ne performance of the 302 - TUB & OR SHOWER work for which this permit isjuned. 303 - ROUGH MECHANICAL 1 have and will maintain WWkCrs Compensation IIWIrN(e. u Ielulmd by Session 304 - ROUGH ELECTRICAL JTOoof theLaWrCom. far the performenceaf the work Tor which Nil permit is issued. My Worker's Compensation Insurance carrier and Policy number sew: 305 - _ FRAME Cartier. Policy No.: 306 - HOLDOWNS CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 307 - INSULATION moduscctim mood nollccamplead role permilisfaroaehundeaddonaa(SIM) 308 - SHEETROCK "rle6) 309 - EXTERIOR LATH 1 unify Not in the perfurmamC of the work for which thio permit is issued, 1 shall not employ sny peran in any mantra a a become aubjcctio tM Wonc�n'' Compemdon 310 - INTERIOR LATH Laws ser Califamia. Dat 311 - 313 - SCRATCH COAT ROOF NAIL Applicant NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should atiord become h m the Worker's ComPemlion provisions of Ide labra CMC, you mull mrmhwiHmmplywith deemed 501 - FINAL ELECTRICAL ENERGY court such provtirnamthis Permit ahanberevoked, 502 - FINAL PLUMBING ENERGY CONSTRUCTION LENDING AGENCY I hereby affirm that Hem its construction lending agency far the performance of 503 - FINAL MECHANICAL ENERGY > Hawork for which Oil Permit IsWood (Sec.3097,Civ. C.) 504 FINAL BUILDING ENERGY :I L.endch Name - 505 - FINAL ELECTRICAL Lender's Addtet z yI certify Net 1 haw read this application and sate that He above information is 506 - GAS TEST comet. l alone to comply with all city and county ordinaces and stem laws miming m comuoclion, and! hereby alhodarepresentatives Ofdue City 10or pnnHe FINA PLUMBI G ..jbuilding abovo-menlloped pmpeny fat inspection purposes. 0 8 FIN L y (We) egrte to ave, indemnity and keep harmless the Ci Ly of Cupertino aleinsl n liabilities. judgments, cos, adexpemswhich may inany way am= against and City 5 A Z in concciumco of she gaming of His permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:5 NG Date SOURCE REGULATIONS. 11111 _ Re -roofs Type of Roof Sigumum of Applm.nVCm%mCm, Data, HAZARDOUS MATERIALS DISCLOSURE Will He applicant or future Wilding occupant mom or handle haradous material as de0ned by she Cupertino Municipal Code, Chapter 9.11, and she Hea1N and Safety ode, SCclion133J1(e)?\ All roofs shall be inspected prior to any roofing material being installed. ❑ Y. ON If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which it hazardous air caaminau as defined by the Bay Area Air Quality Management all new materials for inspection. moiety ❑Yes 1544� Ihavemad NehvaNa,mot) Stills rtquirement under Chapter 6.95 ofthe Califon nia Hcaldo &Safely Cade, seed 505.25533 and 25570.1 undermad ft ifthe building docs nam emomil w a ten ro(rt. that it is my respomihtlily m no6my the mcupat of the m an mnam mat MrktisaamaraClninaateoJ,Qc-apaay. 3 Signature of Applicant Date L ,� All roof coverings to be Class "B" or better Owneror thmixedagent Dam "S CIT OF CUPEkTINO CITY OF CUPERTINO o3 PERMIT APPLICATION FORM A_ f_ BMITIGATC I Comm. Housing Mit. Fee I BUILVINU 1 of 3 (�, PN # 3 2 / (� 2 3 n C Date: Building Address: Mailing Address (if different from building address): O er's Name: S vt Phone #: O - Contractor: o License #: C-3 8 5 Contact: — Phone: Fax: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Job Description: Residential ❑ Commercial Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: co ucco Occupancy Group: Type of Construction: (Zr G . ?I C Please check this box if the project is a second -story addition: ❑ SL 1-JIS�►•, Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > IOOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> IM 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 <= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING A_ f_ BMITIGATC I Comm. Housing Mit. Fee I BUILVINU 1 of 3 (�, C OF i CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 uanti 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 Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BOVERTIME inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING MIXTURE 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 Repipe 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 Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent 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 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 2 of 3 armyo CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group 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 BSEISMICRE Seismic Commercial Seismic Fee Res BUILDING 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 Issuance PLUMBING PPLBG ` Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3