04080184 CITY OF CUPERTINO
a BUILDING DIVISION PERMIT CO � '
Ru1LDING ADDRESS: DONALD FONG ELECTRIC PERMIT NO,04080184
OWNER'S NAME: PERMIT ISSUE DATE
12
ONE: SANITARY N 0 OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
ep BO EO PLO MEOCH
Y00 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Net 1 am licensed under provisions of Chapter 9(commencing Job Descriptio
n� with section 7")ofDiAsi.o 3 of the Resines and Professions Cod, rd my license is NALtE®
in full form and ect.ffe
5'y� rte 4 License Lic.N MINOR ELECT. WIRING/NEW LIT
mss-, Dem Convector
eq ARCHITECTS DECLARATION
y. I understand my plans shall W used as public record SEP
/ I� 200
D
iC
Licensed Professional
SE
OWNER-BUILDER DECLARATION BUIL
1 heresy.sort on I am exempt Imre the Contractors Cc License Lew for the
F. o followingmason.Permit
TII3sru Business and improve,
demolish.
Cod:Any oily or county
which requires a permit m queen that atm[i t for sex demolish.or c a sir any structure
,j- that hoits issuance.
ensedpalso myarat o the tWvisio of for mchpaimi's Reese aw(Chmment
< (commencinnscdpurnSection7 7")of
3ofMe the usines'andP LicenseLawapter 9Sq.Ft. Floor Area Valuation
y�O Me,he its(commencing a oureion land theIesDivisionr of al eged Business and on.Myrna Code)of
$ Net he u exempt therefrom and van burs it the alleged exemption.to Any l Penson of ABN
II.a,,
not.. dere five
any applicant fora permit subjects Nc applicant to a civil Penalty of 3 AOH moots 0 0 OCCU anC e
not ream Nan fiw hundred dollars($5001. P Y EYP
❑1,as owner of the property,many employees with wages an their role compenudon,
will do Ne work,and theswctom is maim ended oroffered forsale(Sm.7W.Bunnexs
and Professions Code:The Contractors License Law clues not apply to an owner of Required Inspections
property who huildsorimprows Nereem,andwho doessuchworkhimulfor through his
own employers,provided Nat such improvements em not intended oroRemd forule,if.
however.Ne Building or improvement Is sold within one year of mmplcdon.the owmr-
buimer will have to burden of proving Net W did not build in improve for purpose of
male.).
f1,as owner of W property,am exclusively contracting wish licensed convectors to
nawm the project(Sec.7094,Business and Professions Code:)The Conuactors U.
c nse law does not apply to an owner of property who Wild or improves thereon,and
whocmnmacls or such pro' wit a convactor(s)licensed pursuant to dm Contractors
License Law
❑1 am axe p entire Se B&P or Nia recon
Our r wz
W1Rf R'S COMPENSATION DECLARATIOTIO
1 hereby aRhraundr Neely of perjury one of the following declumons:
I haw and will maintain.Certificate.(Consand toself-insure for WarkoesComper-
sation.his provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insum m.u required by Section
3700 of Ne Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not tecomplclod lithe permit is fm one hundred doll.($10()
or leu.)
I comfy that in to performance of to work for which this permit is issued.I shall not
employ any person in any mannerse as in became subject m the Workers Compenudan
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Uhm Code,you must
.,O
E forthwith comply with such provision or NWemrevo
is permit shalldeed ked.
`� CONSTRUCTION LENDING AGENCY
[—ice l hereby affirm that Vert is a construction lending agency lot the performance of
the work for which this permit is issued(See.3097,Civ.C.)
Til Q Lenders Name
z Under's Address
V 0 I mnify that 1 haw mad this application and sham that the above information is
W F cornet.I agree to comply with all city and county ordinances and Aute laws mining to
p v building convection,and hereby authorise repmsentadvca of this city to color upon the
>0 U ahow-mentioned property for inpmorin Purposes
(We)agree in saw,indemnify and keep harmless the City of Cupertino against
rF"iy IiebilTtiex 'uclgmenm.eo u and expenses which may In anyway accrue against maid City
(„)z in don quhna'I ands of Nis permit.
APP CANT lIN ANDS AND WILL COMPLY WITH AL NON-POINT Issued by: Date
SO CE�t_EGUL NS. �j o /
U 6 Re-roofs
.,
"HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant or future building acupent store or handle lomandousalth ad
u ds.Sec io Ne Cupertino Muni al Code.Chapmr 9.12,mcl the Hce1N and Safety
oae.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
[3 Y. u
Will the applicant or future building occupant uta equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hmamous air contaminants in defined by the Bay Arca Air Quality Management all new materials for inspection.
lDistrictl
❑Yes
I have neaddiamour materials requirements under Chapter 6.95ofNeCalifer-
Heal &Safct aB Sections25505,25533 un25534.1 understand Notifthc building
ans n commit hes tenant,due it is my responsibility m notify Ric,acupent of Ne
qui mcsawhich Wmet Poor toisevanceofaCeniOcamof0. ser. Signature of Applicant Date
w era ,o., s=ret ate 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
UPEI,TINO
Building Department
JOB ADDRESS: PERMIT#
iD5 QKCS A-ve. PE-Rrtnlo eA - fSpl d Og 0f 00
OWNER'S NAME: T,R. FlC NAN&CA(V I K. kA t, D4 PHONE # 408 -ate 3 --a8
GENERAL CONTRACTOR: aht.® Fb N L CT2 t FAX # L 0 a • R b Q- b G&0
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 DONAL-6 �PoN e- e�
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
caner/ ct r Signature Date
%oza , CITY OF CUPERTINO 0 q o ? d t
CUPEkTINO PERMIT APPLICATION FORM
N # I Date: 6 -
Building Address: Mailing Address (if different(from b ilding address):
165 ,21 5TokC.S A-ve cuPER-r1uo _ 615701
Owner's QName: Phone#:
T-K . �\ ACHAxjl+2A-N k12T1 KAtj-bkb-G 40 as3- 084.3
Contractor: License #:
WNA C-DW C4ELECT K
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect u/ Plumb ❑ Mech ❑
Job Description: WA,.v ¢ t"yv WL W-i-+iK6
Residential EK row Commercial El
Sq.Ft. Floor Area: 0 $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this b if tlie' ject is a
second-story addition:
Project Size: Standard ❑ Large ❑ Major ❑
Quantity. Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu . MECHANICAL
BBOILER2 Boiler> I OOK 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> IOOOA ELECTRICAL
BELE 200 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOM 4P New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING it
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
MIXTURE Pb1g 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 x
x
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo 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
BRE COVER A/C Unit> 10,000 cfm MECHANICAL
B 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
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WITO
CITY OF CUPERTINO PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmd] 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 Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
SPECIAL Special Insection 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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