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05040139CITY OF CUPERTINO "� Gl,'[2,TNFp1tM BUILDING DIVISION PERMITO1V)y �"flylV n, BUILDING ADDRESS: PERMIT NO. MINALED 05040139 i9GRRE AVE W R' AM : PERMIT ISSUE DAM 7A NE: Al SANITARY Al OL NO. ARCHITECTISNOINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description o provisions of Chapter 9 (commencing 1 Waffirm reby arm Ihal 1 am licensed under pr P with Section 707n)) of Division 3.f die Bust. and Peore.skn Code, and my license in I. lLicense Classed effort. Lk.e REPLACE COOLING TOWER Dan- Contractor ARCHTECYSECLARATION CONTRACTOR:WKW Iundentandmypi... Nall mused as public records NO PERMIT FEES FOR CITY JOB Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that i am uempt from the Conlmct&, License Law for the following mason. (Secdon 7031.5, Business and Professions Code: Any city or county which mqubes a permitm ei mseract, alter, improve, demolish. or repair any atmetore prior ro ins iauane, al.0 mquirta the applicant forsuch Permit a rile asigned Statement that he is licensed Forman,intW provision of the Consonant's IJmnse Law(CNper 9 Sq. Ft. Floor Area Valuation (commencing with Section 0110 7) of Division 3 of the Bulinus and Pmrucions Code) or that he is exempt therehom and the bask for the alleged exemption. Any vlol.don of APN Number Occas ane e P Y P Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mart thm five hundred dollars ($500). ❑ 1, as owner ofthe property, or my employees with wages as their into compensation, 3693103300 Required Inspections wiudo the work. and lheaauclu. is not ntended oronened forna(Sec. 7044, Business Law does not apply an owner of and Profea.lon. Code: The Character, License m . q P propenywho builds or Improved tierean.andwho does auchwork himselfer through his own employees, provided that such Improvements art not intended oroRened for ale. If. however, the building or Improvement is sold within arc year of completion, the easier. Wilder will have she burden of proving that he did rot build or improve for purpose of Sale.), ❑ 1. as owner of the progeny, am exclusively contracting with licensed contractor, to consumer the project (Sec. 7044, Business and Prolusion, Coda:) The CmoactmY U. cone law dean not pply to an owner of property who Wilda or Improves thereon, and, who contracts for Such projects with a contractor(s) licensed pursuant to the Contractor's License Law. 0 l am exempt under Sea ,B k P C for this reran Owner cars WORKER'S COMPENSATION DECLARATION I hereby afnrm under penny of perjury oro of the following dalva0ou: 1 hive and will malmain a Ceriifieste mcmarnt to air-Ilium for Worker's Comport- .'on. provided provided for by Section 3700 of the labor Code, for the performance of lite work for which this permit is isswd. 0 1 have ad will maintain Workels Compression Insurance, u required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ' My Wodees Cnmpmadmluu.nmtardau Polirynumberart: . Carrkr. Poliry No.: _ CERTIFICATE OF EXFAIPDON FROM WORKERS' COMPENSATION INSURANCE (This arena, need not Mcompleted if the permit IS for an hundred della. I$ Halt or less.) I certify diet In she performance of the work for which this permit IS issued. l SIW I not eroplay, m)' prison In any manef an u to Weame abject to be Workris' Compenatlon Law. of California. Data Applicant NOTICE TO APPLICANT: If. after making this Cenlficate or Exemption, you Should become abject to IM Workefs Compensation provisions of tiro Lahor Cost, you must forthwith comply with such provisions or this Fermit.hall W deemed revoked, CONSTRUCTION LENDING AGENCY I hereby affirm that then is a construction kMin{agency far the Perform.. of the wodc for which this pefmR IS Issued (See. 3097, Civ. C.) Lender's Name LendfS Address I ceirdify gra 1 haw and some thSt the sWw Information to thisapplicationand court Wilda. I agree to comply with all city and county ordinances and Sas laws existing to with t and hereby authodm nOwa of diiwilymanmr upon the Wildabove-mentioned ahovm property for inspectindemnify (We) agree to give keepproposes. (We) agree to ssw, indemnify and kap humka Ih City CLpenitm s. es sc scenic id City may in anyway acme againA said City Raconsequence f fteosinend of this permit. PLIrAnce of thegratin{of this permit. V Issued by: L VJ APPLIGANj U�jj11DERSTANDS AND WILL COMPLY WITH ALL NON-POINT A SOyR�C RATIONS. Dale ^ (� � (l ! Re-roofs litractine or Applica�ommuclor Data HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will die applicant or for.. Wilding otcupam pore us handle haardous roamrisi u defined by the Cupertino Municipal Code, Chapter 9.13, and the Health ad Safety Code, Section 35532(a)7 All roofs shall be inspected to any roofing material being installed. [D yes ❑No prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment of devices which it hanrdaus air contaminants u defined by the Bay Arta Air Quality Management all new materials for inspection. .Iric17 0Yea CNo I have sued die h.nsrri mamamdak roqulrements underChapter6,95 ofdm Califor- nts Health Ar Safety Cad, Sectiau25505,25533 and25534.I umicr.taM that Iftim Wilding renot cartenlly haw a lemnt, dial It is my responsibility to notify the occupant of dm hrotor lJprior wig ancerdneamaroasary. Signature of Applicant Date 1G ^ C All roof coverings to be Class "B" or better Owm, or..IhmiaeJ. ml Dala CITY OF CUPERTINO PERMIT APPLICATION FORM APN # ` 3 ( O f� Date: 05 Building Address: Mailing Address (if different from building address): . 10306 Tort e ALL Owner's Name:Phone CITY d{' #: 779 2772 Cv e�1 14 - Contractor: V1/ t - / K' W / License #: � / 2 � I Contact: Phone: Deavlj t ISO Cupertino Business License#: -/t I\ Fax: BBOILER2 Building Permit Info: —/ Bldg[3 Elect (� Plumb f3 Mech.Er� Job Description: Residential Commercial Sq.Ft. Flp6r Area: $/Sq.Ft.: Cost o Project: 0 0C)iJ Occupancy Group: Type of nstruction: (fie lagt CBo11n C, 7—ovro,-second-story Please check this box if the project is a additions ❑ Project Size: Standard Large ❑ Major ❑ Boiler > 1.75M Btu w tob Fps rf ' .Tob 1 of 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 IM Btu MECHANICAL BBOILER4 Boiler> IM 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 w tob Fps rf ' .Tob 1 of CITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM 2of3 Quantity 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 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 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 cfm 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 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 2of3 r- CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl 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 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 PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3 of 3 1 J