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04040110 CITY OF CUPEWI'INO nmLnrnc urvlslon PERMIT ^CONTRACTOR INFORMATION : BUILDING ADDRESS: - PER MIT NOD 4040110 OWNER'S NAME: PERMIT ISSUE OATH STEWART WU ONE: SANITARY NO. CONTROL NO. ARCIIIIEC(ENGINEER: BUILDING PERMIT INFO F. UMB MECH bar, LICENSED CONTRACTOR'S DCCLARAI'ION If I agiff ILA=lmlglO I hereby affirm that 1 ant licensed under provisions of Chapter 9(commencing Job Description with Section 7")of Division 3 ofthc Buaincseand Professions Codc.and mylicenuis Lqmfull force and effect. CLEAN-UP FIRE DAMAGE OCT fl- 1004 Z License Class Lic.M n t-� Dale Contractor ARC({ITHCTS DECLARATION BUILDING 6i 1 vndersrend my plans shall W used M public records Licensed Professional g OWNER-BUILDER DECLARATION I 1 hereby affirm that am exempt from the Contractors License Law for the 00 follnwing reason.(Section 71131.5,Business and Professions Code:Anycky of county m which requires a permit In construct,niter,improve,demolish,or repair any structure , poor In its issuance,alsorequiresnceapplicant fenuch Permian file a si,red,mmment that at ivlicensed pursuant tnthe Provisions nrthe ContinuaraLicense Law(Chapter 9 Sq. Ft.Floor Area Valuation yh (cum ma¢ing with Section 7")of Division 3 of the Business and Professions Com)or y chat W is exempt flirtations and Use,basic for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 5\'M9,Q161 cr0 0 Occupancy Type not more than five hundred dollars(5500). P y YP ❑1,As owner of the property,or my employees with wages as their sole compensation, will do the work,and me structure is not intended or offered for sale(Sec.7044,Business And Professions Cade:The Contractor's License Law doea not apply to An owner of Required Inspections property who builds or improves thereon,end who daessuch work himself or through his own employees,provided that such Improvements arc not inanded oroffered for side.It, however,the building or improvement Is sold within one year of completion,due owner- builder will have the human of proving chat he did not Wild or improve for purpose of sale.). El I,43 owner of the property,am exclusively contracting with licensed convectors to consumer the project(Sec.7044,Business and Professions Cade:)The CmiUmtor'a Li. . cense law dors not apply to an owner of property who Wilds or improves to mon,and who contracts for such projects wi rh a contraetor(s)licensed pursuant to the Contractor's License Law. ❑lame rrrfft0 tf ac. ,B&PCf,this,... . Owner Data WORKER'S UMPE SA ION DECLARADa 1 hereby affirm under Penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent e self-boom for Worker's Compete Mth n,As provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,m required by Section 3700 of be Labor Code,for the performance of the work for which this Permit is Issued. ' My Workers CmmPeruation Insurance carrier and Policy number art: Cartier, Policy Nu.: CERTIFICATE OF EXEh1P ION FROM WORKERS' COMPENSATION INSURANCE . This amount need not W mmplcied if the Permit is for one hundred dollars($IN)) . or mss.) I certify that in che performance of the work for which this Permit is issued.I shall net employ any person in any manner so u BS become subject to the Workeri Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:If,after making this Certifiable of Exemption.YOU shouW become subject 10 the Worker's Compensation provisions of the Labor Code,you must .JO forthwith comply with such provisions orchis Permit hall W deemed revoked. z r" CONSTRUCTION LENDING AGENCY (-+�+ I hereby affirm chat there is a mrsmation lending agency for the rarfurntmee of the work for which this Permit is issued(Sm.30617,Civ.C.) W A Lender's Name z Lender',Address . U C 1 acnify Nat 1 have read this application and sum(hal the above information is Fcorrect.1 agree to comply with all city and county ordinances and state laws relating to 0 building constmelion,and hereby amhorim representativres of this city to enter upon the _ ction W abovome judgm Property fond x ma which may (We)agree to save,oriental ry and keep harmless the City of Cupertino against UZliabilities,khro menu,cramondeapcnses which they in any way eccmc against said City Uz inconsequcncc of the Sooting of PurrrrrrrttttttyyRyyR'titttt. s^' APPLICA�N J}NT ' DP.rR' STAND COMPLY WITH AL4�N-�NT Issued by: Dale SOU`�TIONS. G >bD ea m Cent Datd a-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or rtdure building occupant store or handle hbasduus material as defined by the Cupertino Muriel pal,Code.Chapter 9.11,and the Health and Safety ,dWcede,sOrienzss3z(.)+ Ycs �I N` /u All roofs shall be inspected prior to any roofing material being installed. future the applicant or futurere Wilding occupant use mquipmentor devices which If a roof is installed without first obtaining an inspection, I agree to remove it hasamous air contaminants as defined by the Bay Area Air Quality Management all new materials TOC inspection. ❑Ycs AC]NU 1 have mad the hammous materials mquimments under Chapter 6.95 of the Califnr iia Hwlth&Safety Circle,Sections 25505,15533 And 15534.1 undersand in.if the Wilding does not currently have a¢tent air y sexpomihility m notify IN,acorn,cif the rcyuimme tWma, oIn iku.zT1aCcnirumef aton�cy./ � Signature of Applicant Date _ Dllc All roof coverings to be Class"B"or better oow ter( D¢ g Community Development aC101 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 UPERTINO Buildin De artment JOB ADDRES PERMIT # Q 0 �, r4a4�tA. kt C SD !�fa OWNER'S NAME: PHONE # —moo GENERAL CONTRACTOR: 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 l Fencing IV t 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 Own erf C c r Signature Date d CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEk�TINO IIRPN# / O o o Z Date: Building Address: Mailing Address (i ifferent fm buil ing address): DO IC P Owner's Name, � � Phon #: Contractor: License#: AAA 719S�, Contac: , Pho e: Cupertino Business License#: J/ Fa -�)N-68 Building Per{ut Info: Bid C1 Jea1 Elec Job escription: N Residential ❑ l��JJ el Q0.vl Eve 11^ Eom cial ❑ Sq.Ft. Floor Area: I $/Sq.Ft.: Cost of Project: Occupancy Grou 051 k Type of Construction: Please check fiks box if 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> 1.75M 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 BMITIGATC I Comm. Housing Mit. Fee BUILDING qW 1 of 3 2 D� ' CITY OF CUPERTINO d . CITY OF PERMIT APPLICATION FORM CUPEkTINO ' uanti 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 BPCESSPOOL Cesspool PLUMBING UZ 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 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 BREMAIRIIAN 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> I 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 Sips, Marquee ELECTRICAL 2 of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO uanti Fee ID Fee Descri tion Fee Group BREMTHEATR Theatrical LiahtinR Fix ELECTRICAL BREMVENFAN Vent Fan Sin le Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Slie6fiq Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL S ecialIns ection BUILDING Bsyvqml Swimmin Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electricals foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicalsq. oot MECHANICAL MPERNIITFEE Mech Permit Issuance MECHANICAL PPERNIITFEE Plumbing Permit Issue PLUMBING PPLBG Plumhina Fee czn foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3