04030215 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON 'It�icRIrr `oMr"CtONs'
BUILDING ADDRESS: CONDITIONED AIR PERMITNo04030215
10385 S TANTATJ MIR,
1 OWNER'S NAME: PERMIT ISSUE DATE
LANA DVORKIN SANITARY NO. �24 /2CONTROL NO.
ONE:
(408) 291- 220
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
y O O LICENSED CON FRACR)R'S DECLARATION
raby Rlrm that 1 am licensed tank' roviuona n(Chaprar 9 kommencing Job DCSCIlpt100
with Secu Oof Diviaian Sof the Buai dPro(esainna Code,and mylicanse is
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^� infull forte Re / ��
z � o ren 1 m _ c 1 � < ADD ON A C 'N
3~� ARCHITECTS ATI
ON
�i y. ✓ 1 understand my Ptons shall he used ublic meet& p p 20
0
It Licensed Professional O
<I OWNER-BUILDER DECLARATION
ca 0 I hmaso aRrm that 11. eumpt from the Gonioma License Lew for the ^•vPW
0 o following mason.(Sidon 71131.3.Business and vex,de ins Cods:Any oily as county
whichitsissuance,
requires a permit ac construct,alley.improve,demolish,m nasi' ed structure
psiwNitsisswne0.rsurequires pro inion ofnt fer uchpilor's eaFile,Law statement
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that he is licensed pursuant m Ne provisions of the the Business
License Law(ChapterCode)or Sq. Ft.Floor Area Valuation
(commencing isthectlan7adth Divisionou3 M theeged excerption.
andon.Myons Code)of
r3$ Nm he u exempt Nertfrom and the bmia(m Ne alleged cumpdon.My violation of
Section 7031.5 by a"applicant for a permit aubjecu Ne applicant to a civil penalty of 78' e10 0 anC Occu e
not more leen five hundred dollars($500). Occupancy `J P
❑I,u owner of the pmMny,or my employee with wages u Nei,sole compenutlon,
will do the work and Ne atmnure is not intended urunered forsale(Sec.7044,Burins
and Prafeseiatu Cols:The Conusetor'a Liense Law does not apply to an owner of Required Inspections
propeny w ho builds or improves thereon,and who do such work himself or through his
own employees,provided Nat such improwments mus nal intended mattered Russia.If.
however,Ne building or improvement is sold within one yam of completion.Ne owner-
builder will have the burden of proving Net he did not build or imprays for purpose of
sale.).
❑1.as owner of de property,am exclusively contracting with licensed ennuacers to
construct the project(Sec.7044,Business and Professions Cade:)The Conners Li-
cense Law doe not apply to an owner of property who builds at improve thereon,tad
who contracts for such pmjecs with a condiments)licensed pursuant to the Cantmetoes
License Law.
❑1 am exempt under Sec. .B&PC for this reunn
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Ne following declarations:
I haw and will munW n a Canifrca sof Consent me sel6insure for Worker's Campen.
motion,u Provided for by Section 37M of the labor Code,for the performance of Ne
work far which this Permit is issued.
❑I be
and will maintain Worker's Compenu0on Insurmw,u required by section
3700 of the Labor Cade,for the performance of the work for which this permit is laud.
My Workefs�C(n'mpensaMdan ins-u1p'nm nnicr end Policy number am:
Canis 40,5 Policy No.:I,-!'l FD
CERTIFICATE OF EXE MT MWORKERS'
COMPENSATION IN ANCE
Time action need not as completed if the permit is for one hundred dollars($1160
or toss.)
1 certify Net in the performance of Ne work for which this permit is issued.Isbell not
employ any account in any muner so ss e bocamssubject to the Workara''Comp inse0on
Laws of Califoonie.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject in Ne Worker's Compensation provisions of Ne Labor Code,you must
Qz w N
forthwith comply with much previsions is Permit shall lee deemed ranked.
„z,r ti CONSTRUCTION LENDING AGENCY
F+ I hereby strum that then is a construction lending agency for the performance of
ai.�-i the work fur which this permit is issued(Sm.3(197.Civ.C.)
IULender's Name
B
7 z Lcnd,em Address
U I certify that I have mad this application and muss that Ne above information is
G4 E correct 1 agree m comply wit all city and county oNm
inces and smile lawn relating to
D V building construction,and hereby authorise represenmtins of this city to enter upon Ne
4Tl shove-mcmiuned property for inspection purposes.
LL (We)agree m ave,indemnify and keep harmless the City of Cupertino against
on liabilities,judgments.costs and expenses which may In say way same against mid City
U Z; in consequence of Ne granting of this permit
APPLICANT UNDERSTANDS AOMPLY WITH ALL NON-POINT Issued by: Date
SOU RC¢tR�GULATIONS.
�``Ir IV-15 A- - �� �^��� Re-roofs
$ arc of ApphcenV IImcmr Det
HA RDOUS MATERIALS DISCL RE Type of Roof
N ILL
Will the applicant or future building occupant store or hemile hemocous materi i
u defined by the Committee Municipal Code,Chapter 9.12,and the Health and Safety
ode.Smedon 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
r7 Y. ON.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hauNnus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
council
Oyes ON.
I have mad the hamahms nmen.is raquimmcnts under Chap sti.95 of Ne Califor-
nia Health&Safely Cade,Secdwu 25X15,25533 and 25534.1 undersmind Nmlfthe building
docs no curten0y how a tenant Nat it Y my roapona,islay w notify occupem of Ne
req mi ich mast M at Mo..aa arm ism of Rica S' nature of Applicant Date
Owner ar auNon'radagen Date V� 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 Department
JOB ADDRE 103�� C\ p� PERMIT# G O 2 b rl
OWNER'S N J (Dv Qk) ` A PHONE X40 oP-R 1—L2Z20
GENERAL CONTRACTOR: On Y 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
y Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
y24
/ ontractor Si tore Date
i
CITY OF CUPERTINO
FURNACE/AC 7
CUPEkTINO PERMIT APPLICATION FORM
APN# 7 p O Z Date:
Building Address:
3 Gr��Ctu
Owner's Name: II '''•C Phone#:
Gc T)V Of V � $$.�7 • 057
ontra tor: Phone: License#:
a� 44s1 (Qa -cam
Co tact: Phone: Cu ertino Business License#:
33
Building Pe it Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ Is' floor El 2nd floor
• Adhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningA royal Required ❑
Cost of Project: Type of Construction: Occupancy group:
cr so .._i
Strapped ❑ On Platform ❑ Bonded El Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy =BUILDING
LDING
BREMFURN Relocation of FurnaceHANICAL
BREMACOVER A/C Unit> 10,000 cfrnHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfHANICAL
BREMRECEPT Rec tl, Switch& OutletsCTRICAL _
BSEISMICRE Seismic Fee Res
BSEISMICOM I Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
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