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04090277 CITY OF CUPERTINO..',I :a^ �%,• '>u� -Tyai�-sem • BUILDING DIVISION PERMITPOA •}RACTO Il � Y� �� w "'-s• .. .' BUILDING ADDRESS: - PERMIT NO. 04090277 OWNER'S NAME: - _. PERMIT ISSUE DAM. NE: - - SANITARY Q§VOL NO. ARCHITECT/ENGINEER: - BUILDING PERMIT INFO ELECT PLUMB MUCH l� 'LOp LICENSED CONTRACTOR'S DECLARATION - - -JObDeSCrI n "' 1 hereby affirm Nat I am bmnmd under provisions of Chapter 9(commencing - p Digwith Section 7").f Division 3 of the Business and Professions Code,and my lic_evc is _ a• in full I.,..Clan.force and mifeM a UPGRADE ELECT. "PANEL DEC ,�o Dem Liccontractor l 2004 U I understand my plans shat ..it a PuDECLARATION M ..aids ? - I G 0 Fn Licensed hominy anal ---• BUIL L® - t3 OWNER-BUILDER DECLARATION Com en - - - o I nmedu affirm that 11. exempt from the Conlmctoad :Any c Lew for the _ .. ❑O following maean.(secuun 7 o r'tr Business and improve. de o demolish. Cole:Any city or county $(L which requires a permit to construct.elteq impmw.demolish,m repair any structure that he_Z� triton iuisssedpuruarequires provisions the Co Permit mimnse Law(tammcm p ao (smarmarS mJ pursuant loth)ofDismnanf the Common's Licemclaw(Chode)to Sq.FI.Floor Area . . ValUa n '- E RR E (cat he is xempth Section 70nd the basis far of the alleged exempt on.Any Code)of NN io is 31.5 b Ihetefrom and the bears for be cts th tl a Beano to Any violation of Section 7than ley any applicant(m a permit subjects the applicant b a civil penalty of 3�tpnheTO 0 Occupancy Type ' not marc than rise hundred dollars(E500). 01,as owner of the property,Lir my employees with wages as their sole compensation, will do the work.and the structure is not mounted or offered for sale(Sec 70th.Business and Professions Cude:.Tbe Commuter's Limnse taw does not apply b an owner of Required IOSpeCt10DS .. - property who bulldsorimprovm Namon,andwho diessuchwork himselforthrough his own employees.provided that such lmprowmenu arc notin¢nded or offered forsale.If. - - - however.the building or improvement is sold within one year ofcompletion,the owner- - builder will have the burden of proving that he did not build Lir improve for purpose of mleJ. Irk 1,as owner of the propeny,am exclusively contnedng with licensed contractors to construct the projea(Sec.7044,Business and Professions Cade:)The Conmctor's Li. come Law does not apply 0 an owner of property who builds or improves thereon,and - whecontfaclsfor such projects nits.canoectorta)licensed pumuant to the Com 0d, License law. •- ,._ ..,. .. z .. _ rv,« -_ .-__ ❑I and exempt under Sec B a:P CC for Nie msson Own e/A 0 r l L 2 f$ 03— Doe Yg_910 4 - •/� WORKER'S COMPENSATION Dficui 1 hereby a1Brm under penalty of perjury one of the following declarations: - Ihew and will maintain a Certificate of Consent to self"imum for Workdex Compen- - sation,a provided for by Section 3700 of the labor Code,for the pantomimed of the - work for which this permit is isidem. - - ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 37110 of the tabor Code.fur the performance of Ne work for which this permit is issued. - My Worker's Compensation Insurance carrier and Policy number arc: ... Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE (This section need not be completed if the permit latrines hundred dollars(EI W) or less.) - I certify that in the performance of Ne work for which this permit is issued.I shall not employ any parson in any mannerso as to become subject to the Workers'Compensation - Laws of California.Date _ Applicant NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should become subject to the Worker's Compensation provisions of the labor Code,you most z forthwith comply with such Provisions or this Permit shall M deemed invoked. z CONSTRUCTION LENDING AGENCY Iherehy aflon that then I..conatroctme lending agency for the perfurmanxuf - C1i the work for which this pennil is issued(Sec.3097,Civ.C.) GA Lender's Name i z Lmdm3Addre6s V Q 1 mnify that I have read this application and state that the above Information is D. H correct.1 agree to comply with all city and county aminanc'es and slate laws relating to �C) building construction,and hereby authorim representatives of this city to enter upon the cul above-mentioned propcny,for inspection purposes. y (We)agree to ave•indemnify and keep harmless the City of Cupertino against C,) liabilities,judgments,costs and expenses which may in anyway scene against mid City f�Z in consequence of the Stenting of this permit. - ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE U ATIO q� ��A�� Re-roofs si ro o A icaHAZARDO Type of Roof HAZARDOUS MATERIALS DISCLOSURE WIII the aCardapplicant Lir future building occupant,Cliqmm Brand the Health Lia material az ticfined by the Cupertino Municipal Code,Chepmr 9.12,eM the Ncalth and Safety code.Section 25532(.)+ ! All roofs shall be inspected prior to any roofing material being installed. Y. Will the applicant or future building occurrent um equipmml an devices'which -If a roof is installed without first obtaining an inspection,I agree to remove mit haterdous air contaminants m defined by the Bay Am.Air Quality Management all new materials for inspection. Distrin7 / ❑Yes I have mad the hmardnus moonrise requirements under Chapter 6.95 of the Califor. niaHeilth&Smmy Code,Soco.25505,25533and35534.1 undemandthmifthe building Jas net cunemly have a sena Jut it u my responsihility b notify did occupant of the requircomms which mu ba apoor to issuanm of a Ccmfcab of occupancy. Signature of Applicant Date O ., mhanactl rnt Da _ 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 ADD SS: PERMI #, C) 4 OWNER'S N / ( Lm PHW # GENERAL CONTRACTOR: L 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 L : ,4 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 Owner/ ct Signature Da �^ CITY OF CUPERTINO o q Z CUPEI�TINO PERMIT APPLICATION FORM APN# Date: 3 .S 090079' 9 0 0 Building Address: Mailing Address (if different from building address): ��^, O !0 13 sc oT;e,(J y 9'foi Owner's Name: Phone#: O 1 L. Contractor: License#: C ; 6. ,-T X EI«,rt-r-C- 0b1 8rQ Contact: Phone: qog-4o&1-4 110 Cupertino Business License#: c Pe,r Fax: Building Permit Info: Bld ❑ Elect I Plumb ❑ Mech ❑ Job Description: lo0m„�To X00.1— o Residential C9� ({ r c �lc �, e o x Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: g Occupancy Group: \ Type of Constructi n: Please check this box i the project is a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to IM 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 -72 /S 1 of 3 X193. 78 ' CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM uanti Fee 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 BOVERTIME 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 Stonn/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 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 CUPEItTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips 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 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 r 3 of 3