04100100 CITY OF CUPERTINO
BUILDING DIVISION PERMIT AlCONTRACTOR INFORMATION
BUILDING ADDRESS: CONDITIONED AIR PERMIT N04100100
0430 STOKES AV
OWNER'S NAME: PERMIT ISSUE DATE
al PLYUSH JIN 1701 LITTLE OR 0 4
PH ONE: SANITARY N0, CONTROL N0.
(408) 291-2220
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+x+00 LICENSED CONTRACTOR'S DECLARATION
C 1 hcrehy affirm that I am licensed under provisions of Chapter 9(commencing Job Description
U withilcction Td 6acDiviaion]of NC Bu�'aJs and Pru(cssin-Cnde.and my license is FI /
in full retrT�dud left .J' idW�/33
0 LlK License .1 `�.-%10 Lic.N REPLA & D A C
seg, Dam Convector
qq ty ARCHITECTS DECLARATIO
�i W-i 1 and rsand my plans shall Mused as public records
u
Licensed Pmfcssinnal
OCT ZI 2004
OWNER-BUILDER DECLARATION
E n I masa affirmact thin 1 oro exempt from the Contractor's License Law co the
p O following reason. ration 7 construct,
Business and improve,
dininns Code:Any city or county
E
m which its requires a permit no construe,ahce i t fors.h rental
care a.sig any structure
poor m its issuance.elw requires the applicant for such permit m rile a.OgneJ statement -Nil DING $f;BBQ
that he is l immecd purauantm the provisions ofthe Contractor's License Law(Chapter9 r Aft Valuation
,FG (commencing with Section 7000)it(Division 3 of the Business and Professions Code)or
y that he Is exempt theeram and We basis for We alleged exemption.Any violation of
Section 7031.5 by any appimantfor a permit subjects the applicant to a civil penalty of 32A#A&2r1bdD0 OCCU anC T e
re
not mothan live hundred dollars(5500). P Y YP
❑ 1,as owner of the patient,or my employers with wages as their sole cam pensation,
will do Ne work,and Ne str.etum is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Convener':License Law does not apply to an owner or Required Inspections
property who builds or improves thereon,and who does such work himselfor through his
own employees•provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is mid within one year of completion,the owner,
builder will have the burden of proving that he did not build or improv for purpose of
sale.).
❑1,aser of the property,am exclusively contracting with licensed'conuactors to
construct thepmjen(Sec.7044:Business and Professions Code:)The Contractors Li.
nsc Law does not apply to an owner of property who Wilds or improves thereon,rod.
who contracts for such projects with o comractor(s)licensed p.a.anuo the Contractor's
License Law.
123 m
I aexempt under See. B h P C far this rcmon
Owner Data
WORKER'S COMPENSATION DECLARATION
I herchy of".
under Penalty of perjury one of the following decimations: -
El I haw and will maintain a CcnlEcam of Consent to wir-houre ror Wmksar'sCompen-
nation,as provided for by Section 3700 of the labor Code,for Ne performance of the
work for which this pn'rmll is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Cade,for the performance of Be,work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Rjmer��.1y�,��c�rSY�Ys-a>1 \nG Poliryf9p.:
C` ERTIFICATE OFEMPr10N FR MW�%
COMPENSATION INSURANCE
(Thissection need nm MfomPlemdVthe permit is fn malmodreddalbox(Strap
m ices.)
I cenify that in the performance of the work for which this Permit is issued,I shall not
employ any Person in any manner set as to Mcomc subjccl to The Workers'Compensation ,
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making Nis CeniOcam of Exemption,you should ,
become object be the Worker's Com Nnsation provisions of the Labor Code,you must
.J z forthwith comply with such provisions or this Permit hall M deemed invoked.
z 0
N CONSTRUCTION LENDING AGENCY
(•-'� IMmhyeffrm that there is a construction lendiagagency for theperformanecof
ai 1 the work fur which this permit is issued(Sec.3(H7.Civ.C.)
it]A Leader's Name
CL
z Lender's Address .
V C) 1 certify that 1 have read this application and state that be aurae information is
e,P comm.l agree to comply with all city and county ordinances and state laws relating a. '
0U building construction,and hereby mthorina represenmtiws of Nis city to enter upon the
r 4 above-mentioned properly for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
�" fn liatelitiesjudgments,costs and expenses which may in any way accrue against mid City
of the omfiri,of
U z APPLICANTCUNDERSTAND StAND his rmILL COMPLY WITH ALL NON-POINT Issued'by: Date
tn
U REGU ATIONS.
lU l .0 Re-roofs
wro 0,ApplicanV omramo Data
If
MATERIALS DISCLOSURE Type of Roof
Will am applicam m future building.,.par t store car handle hvarduus material
c0ned by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
e,Senion 25532b.)7 All roofs shall be inspected prior to an roofing material being
❑Yes �N. P P Y g g installed.
Will the applicant or future building occupant use N ironer or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hroodaus air comaminanm m dcfncd by the Day Arca Air Quality Management all new materials for inspection.
D'nricO
❑Yes �Nt
1 havemad theh Saafivamaterlalsrequirementsunderdl,pm lh9Lifth Cldif g
ni.s nalNhSatlyy CWc,sccdnnshat it is myaand25534.1 to mol,the
Wilding
Jr of currently have a tenant.thin 1 is my respsnsihility m nntilj the.cupmt nl'thc
rrNuag wnLLnms� met t t:manaonc,mr,am---/( an,y. at r�eofApplicant Date
/1 ~/�y /� All roof coverings to be Class "B"or better +
Owns rauthori'rcd agcm`� Dam
acloF
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Building Department
JOB AD SS: PE #
10 O S o OL{ 100 \ D C-)
OWNER'S N Etw #
GENERAL CONTRACTOR: FAX
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
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
�✓ Heating \Y
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
� G• • o
O� actor ignatu ate
- CITY OF CUPERTINO
FUR-MACE/AC
SCl-
OF
UPErkTINO PERMIT APPLICATION FORM
APN # Date•
72- 6/ 4� a Z la-l3•
Building Address:
0
450
Owner's ame: Phone
stn 410-1o5Co
Contract n n r Pone: License #:
iG a8 fir 44slroa—
Contact ( ( Phone: Cupertino Business License#:
v(
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mec
Job Des ription: adv Pin
Residential Commercial ❑
For Residential Installations:
Attic ❑
Is' floor 11 2nd floor❑
c . dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structuralEl calcs)
Structural Calculations required for new installation 11
New installation Planning Approval Required Q
Costo Pro.Ler,�: _� Type of Cons n: Occupancy
Strapped ❑ On Platform ❑ B ed Sq.Ft. Floor Area:
New Location Re laceme
Qtn
A Fee ID Fee Description Fee Group
Y Ener BUILDING
URN Relocation of Furnace MECHANICAL
COVER A/C Unit> 10,000 cfin MECHANICAL
IRHAN A/C Units <= 10, 000 cfm MECHANICAL
ECEPT Rec tl, Switch & Outlets ELECTRICAL
ICRE Seismic Fee Res BUILDING
ICOM Seismic Commercial BUILIDNG
TFEE Elec Permit Issuance ELECTRICAL
ITFEE Mech Permit Issuance MECHANICAL
TFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee UILDING
BUSLIC Business License BUILDING