05020103 CITY OF CUPERTINO .
BUILDING DIVISION PERMIT GUN YI2AC �QRINOTtMATIgI
BUILDING ADDRESS: CITY OF CUPERTINO PERMITN'b5O2O1O3
OWNER'S NAME: PERMIT ISSUE DATE
CITY OF CUPERTINO COMMUNITY CENTER _D2./1S/2nnr;
ONE: SANITARY NO, CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
2 o 6 LICENSED CONTRACTORS DECLARATION O O
ly 1 hereby afllmt WI I am licensed under previsions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of IM Business and Profesaluns Cade,and my license is
in full forte and effect.
5g Lm.maaaA ue.g IN FLOOR ELECT. OUTLETS
t11F1--- Date Com,Amr CITY PROPERTITY/NO .FEES
�Se ARCHITECTS DECLARATION
y I understand my plana shall W used as public meet&
tad Licensed Profaskmal
^
OWNER-BUILDER DECLARATION
i x 1 hereby affirm that I am Commit,from thc Contranal,License Law for me
IN following reason.(Section]0313.Bud.and Promssxns Cade:My city a,county
+� which r.quima•permit to Concoct,alar.hnprow,demolish,or repair any structure
prior m its Issuance,also requires alta applicenl for such pmnnil 0 Ne a dgnulauamem
Out he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation $0
$ (commencing with Section 7000)of Division 3 of Ox Business and Profession,Could)or
Out Im t,exempt tlrsefromed the basis fm NM
e alleged eaempdon. y violation of
Section I411.5 by any applicant for a permit subject,the applicant to a civil penalty of APN Number Occupancy e
not mom than five hundred dollars(M). P y'T•y!P
01.A Owner of the property,or my employees with wags A thebhale cooperation, 32654049 . 00
will do that,work and the amtuua is not intended or offend fur ask(Sec.IOM,Business
and Prefeu ans Code:The Commences Lmense Law rima Out apply m an owner of Required Inspections
property who bull&or improve[thereon,and who docs such work Mmmlf car through his
Own employees,provided that well Impmwmenu arc not Intended araRered for Ak.It.
bubble,,the building car immdwmml u hath within are wee of mmove for the owner-
builder w10 haw tin burhm of proving that k did can build a improve for purpose of
tomo
❑L u Owner of the property,am exclusively connecting with licensed contractors to
cunswe,the project(Sec.n0. of andProfessionwho bu Code:)The
wis me
mh U. /
ante law dos at appy je an owns of property who bulkis or imprews Comore,and 1/
Lwho le"w nets for such prefects viNaeonuacmm(Olicenxhpuavantm the Can,nnola wt/
Lkenm law.
❑lam exempt under see ,BBPC fm this won
Dore, Data J�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under totally of perjmy oro of the following declarations:
I have and will main Wn a Collimate m
ate of Consent sel6losum fm WorkeYaCompen-
Edon,as provided fm by Section 3700 of the Labor Code,fm Ne perfmmanm of Ne
work for which this permit is issued.
❑I have and will maintain Workees Compensation Insurance,as required by Section
3100 of the Lab¢Code,for One performance of the wart for which this permit is intauf
My Worker's Compensation Insurance carrier and Policy number am:
Cartier, Policy No.: ..
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This motion need not hecomplemd time permit Is ferane hundred dollars(SI00)
or kit)
1 certify Na,in Ne performance of me work for which this Permit u Issued,l shall not
employ any person in any manner an as be become subject to Ra Wmi en'Compensation
LAWS of CtllforaiL Data
Applicant
NOTICE TO APPLICANT:If.after making this CeniOaa of Exemption,you should
become subject to the WoheYa Compensation previsions of the labor Cock,you mat
O 0 forthwith comply with such provialons m this PeEO limit be deemed mvekmd.
CONSTRUCTION LENDING AGENCY
win
F kfar which
Lillionchthi that Nem uatmmac.30 lending agency for the performance of
ai theLe work far which N4 permit b issued(Sec.]097.Civ.CJ
Y Q
Leaders Nam.
�z lends,'[Add.
U Q 1 certify that I haw mad this application and sum that the above information ts
If.(^ cement.I agree to comply with all city and county animuces and aux law,misting to
0 kr.'! building construction.and hereby authorize mprexoatiM of this city to enter upon me
y t27 aMw-mentioned property fm inspection purposes.
[-, a (Wc)agme In saw,indemnify and keep harmless the City of Cupertino against
GCn Ilabiliia,Judgments,cats and expenses which may in my way seems against Aid City
V 7 In conseguenee of Nm grmung of This permit.
F7 APPLICANT U NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE N D W I LLfj/-M_�
Signature O Ppbamtconhxmr Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building eccupmamm mNndle haardous material
A de0ned by Ran Cupenina Municipal Code.Chapter 9.12.and the Health and Safety
0m-do. Elltiony"25532(4)? All roofs shall be inspected prior to any roofing material being installed.
Yon No
Will the applicant o ftl roam building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ll hmardom air contaminants as denied by the Bay Ama Air Quality Management all new materials for Inspection.
Mantel?
❑Yes
Ad
1havemad the hu m`maarialsmquimnunuunderChapar6.95ofthe Califor-
ria HAlth&SafetyCodc.Sccdons 266(1x.25533 and 25534.1 undersand thmlf the building
doesno,curmn0 haw a seems Na,it u mY mspansihility a notify Ra occupant n(dta
agmmm ie bl:.Ctpgiormw.�.ncmrrmm.toamp..y. Signature of Applicant Date
n aulhorfmdegent - Data All roof coverings to be Class "B"or better
CITY OF CUPERTINO
CUPE(�TINO PERMIT APPLICATION FORM S
N# 2 / S ti Date: 91 -
_ 1 _ 0S
BuildingAddress: T Mailing Address (if different from building address):
101555 STe11, �
Owner's Name: Phone#:
C1T aF'Cu�efi,nD 777 - 321
Contractor: S e W License#:
Contact: Phone:t/a g 77732-72- Cupertino Business License#:
C 6r l C, Fax:
Building Permit Info:
Bldg ❑ Elect 00 Plumb ❑ Mech ❑
Job Description: - J N r"D JZ --L:.-C7-AI Ciy-c- 0 �rrl
Residential ❑ i hST4 Ie TC , IN 'PloDy Commercial
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
tt��yy� ,j
secon -story additionsE3IR '
ro'ect Size: Sttandard I l Large ❑ Major❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other,Appliances MECHANICAL
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
BELECI000 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
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'CITY OF CUPERTINO
CUPEI�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMTTIGATC Comm.Housing Mit. Fee BUILDING
BNUCOM M 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 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 cf n 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
BREWMAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BRENBMC 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
Ak BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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. CITY OF CUPERTINO
cuPE�riNo PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Ligbting 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
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