03040022 1- 11
11 .
�� " ` w eCITY OF CUPERTINO a
BUILDING DIVISION PERMIT ' ' - �'
BUILDINGADDRESS: PERMITNO.
21092 WHITE FIR CT 03040022
OWNER'S NAME: PERMITESUEDATE
HOJO 04/03/2003
E; SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH '
BOC LICENSED CONIRACIOR'S DECLARATION O O
tY`af 1 hereby itmem But l am licensed under ProvisProvisions;or Chapter 9(commencing Job Description
wh"aclimi7 )orDivlsiot 3 of the Buxi Profeeelaa�slCode.and myllcemois
rel 1m�14t aS,L���
ig- Licencont REPIPE/ELECT UPGRADE/LIGHT .FIXTURE
ARCall the oiDEC ATION C & . 0 VALLEY CONST.
My I uMarwmLmY Plana shell he wed as public nrnma
V
Licensed Professional
OWNER-BUILDER DECLARATION
a 1 hereby.(See But 1 1. .Bump]from Ne Contractors Code:
License Law for the �w
ao followingmoan.permit
Romera5. . liar.aandow,denuu Code:Any city sicounty /
H$Ir which its i ma a permit W rat.the
elm..Improve,h por x i m mach any ammu n
FiSa pdmWiniuunco.also requiwa thcappn"ntfm aucM1peter'slecom ave ChWmanl
�y < (that immi 1e wing
with
Sectiottathcpmvielom rel Bte Conuacw'x dProelsw fChapter9 Sq.Ft.Floor Area Valuation
g $ (cammcs exemptM1Smilrom andth Dlvision3 die
contortion.
AnyAcCMe)of
�.. But he"is exempt therefrom and the basic for the alleged exemption.Any violation of
• Senot more than five hundred doll...($500). y Type
cdan 7031.5 by any applicant for a permit subjects the applicant m a civil penally of
APN Number
❑t"owner oftbe pmpmy,m my employcu with mgrs u theirwie compenaedon,
will do thewark,and the smtctumisnotinended orofremd forsale(Sec.7094,Budom. Required Inspections
and Prohnslons Cod.The Conuactofs License Law don not apply W me an Owner of Q p
property who bulldsorimprov"thewon.and who doessuch workhimselrmthmughhia 101 - FOUNDATION
we employees,provided Ibstsuch imprevemmmare notlnended oro0ered forsake.If.
however.the building to improvement Is sold within am year ofwmpledon.the owner. 102 — PIERS
ha ildm will hew;the burden of proving that he did not bund m Improve ren purpnre of 103 — UFER
❑1,as owner of the property.am"elusively contracting with licensed contractors;to 104 - REBAR
eonstmet the project(Sec.7014.Business and Profecsians Cade:)The Contramer'e Lt.
a.=Law does at apply to an owner of property who builds or Inqu..Behind,and. 105 — ANCHOR BOLTS
who concocts for such Projects with a connamor(s)Ikeued pursuant to the Contractors 106 - SEWER & WATER.
Lice.law.
❑1 me wempt under sec. I&PC for this an 202 - UNDERFLOOR PLUMBING
Gm O !L Data 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION 204 - UNDERFLOOR FRAME
hereby affirm under pointy Of perjury ane ofthe fallowing declarations: 205 - UNDERFLOOR INSULATION
aveandwillmainWna Certificate of Consent W selfdtuum fmworter's Compen- ,301 — ROUGH PLUMBING
u provlaca for by Station 37W Of the lobo.Cade,ren the performance of de
work for which this permit is]sued. 302 - TUB & OR SHOWER
❑I have and will maintain Worker's Compensation Insurance,as required by Section _ 303 - ROUGH MECHANICAL
3700 fthe faborCode,(Or the performance oftdp1.work Niepemnittsblued, 304 — ROUGH ELECTRICAL
orker'a Compensation lnsurame carrier and Poliry num em:
order. S^'Ka'FP l^f�.7� PoliryNoq°�6D� 305 - FRAME
CERTIPfC �P170N FR ,WORKER5
COMPENSATION
306 - HOLDOWNSNSATION INSURANCE ,
(ITBN
sean read tetlecampleeremit it Is fmouchundrea dollars(5100) 307 - INSULATION
.ries. .) 308 - SHEETROCK
I certify that In the performance of dv work fm which this Permit is Wood.I shall nm 3 09 - EXTERIOR LATH
employ any person in any manner so is to become subject to the Workers'Compensetlon
Laws of California.Data 310 - INTERIOR LATH
Applicant
NOT3.11 - SCRATCH COAT
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should
become subject W the Worker's Compewtion provisions or to labor Cade,you mull 313 - ROOF NAIL
Z fOMwith comply with such provisions or this permit shall be doemea invoked.
zo 501 - FINAL ELECTRICAL ENERGY
CONSTRUCTION is ICONLENDINCAOENCY 502 - FINAL PLUMBING ENERGY
[r o-yi Ihenby efiirm that ST U TION LEN INGA ageneyfar the performance of
deyurk for which this permit is issued(Sm.3097,Civ.C.) 503 - FINAL MECHANICAL ENERGY
W Lender's Name
az Lender'sAadmss 504 - FINAL BUILDING ENERGY
UO I mortify that I ban read this application and mm List the a1mve information is 505 - FINAL ELECTRICAL
OE_, correct.I agree to comply with sll city and county ordinances and sue lam rchting to S 6 — GAS TEST
U building convection,and hereby anthorha repmsentatiws of this city to enter upon the
W above-mentioned property fm inspection Purposes. O FIN PLUMB G
gy (We)agme he save,indemnify and keep harmleu pe
tie City of Curtino against $ F I AL
,n liabllitiu,judgments.costs and"pensee which may in any wry sccme against Wit City
U 2 in consequence of the granting of this Permit.
A APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOUR EREGULADONS. G
Re-roofs 514 INAL PUBLIC WORKS
MgmurW Appl c uCcOuramor HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
WIII the applicant 01"'t"'
b ding o¢upem care orhandle hararlous matedal
u de0ned by the Cupertino Muni el Code.Chapter 9,12,and the Health and Safety,
Cade,Section 25532(e)7
I—]Yes No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future b Ilding Occupant tae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
heuamous air contaminants fined by the Bay Area Air Quality Management all new materials for inspection.
icl7
❑Yes �t o
Ihow&Safct Ce ,Smnusmaerials5533 ments S534.1under ChaPlcrd.95ofthe Cllding, `
Ldnot
"Ith&SdclyCodc,Scedons 25505,23377 end 255M.1 underscores thmlftha building
currently haw a terms that it ts my femouihility W nodfy the occupant of the
remcm,which must be met prior Winueua ofd Ccnir, of mcupan SI a ursof Applicant Date
e rirea.gen D,e All roof coverings to be Class "Bt'or better
Dot—
rba c
04 A 1 2ti If
rl,,K 4C,4 — 51
t4
p
IN ADMROMICE WITH THE CiTy 01
CUPEMONO C(3DES AND ORDINANCES
,)ATE O
31GH y" 03
Ef)__
This set of pans Lnj _p ..cati_ns FAUST
at!times and itis Uri Y::
ab al
no kept of me jo
lawful ton
Iggs or alteratlom
permission from,
on same vi.,;'U"'n 0
the bud Pt. Cli..Y C4 Cupertino,
Iing �',�
The stampr,7 of pian and specifications
SHALL NOC.,'l He he.d to permit or to b.c. an 6
Ipproval �
, I--,.e .ji,-lation of any PrOYMORS
'i 00V coo O'd nance or state Uw' ryfj
APR 0 D _c;.
�aj. W�
�a � COPS ___
V
CA I 6b
tfAS . .0
1241 L/ic IF PTE DnA;&,,7v 202.
ATY OF CUPERTINO v o f4 Z
CUPEI�F PERMIT APPLICATION FORM
Ah
APN# .2 � � O � Date: '• 6
Building Address:1 2 1 O q 2 Cvfi&P . '►Z 0OU
C' v
Owner's Name:
Contractor: v License : Si Z6 'rt'
Contact: b& g eo Cupertino Business License#:
Permit Info:
Bld i Elegt lamb ech
Job D tial on:
I ential E � del"� (�b itlCi
Sq.Ft. Floor Area: $/ q.Ft.:
Cost of Project: Occupancy Grou _
L
Type of Construction:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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 hld/Off/Comm/ uasi 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
BMITIGATC I Comm. Housing Mit. Fee BUILDING
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TY OF CUPERTINO i
CITY0 PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTUR.E 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
C7 BPREPIPE Re i e Of Fixtures PLUMBING
AN 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> 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
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CITY OF CUPERTINO
CUPEf�Vp PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMPOWER Power Device/A aratus ELECTRICAL
BREMRECEPT Rc tl, Switch& Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs,Marquee ELECTRICAL
BREMTHEATR Theatrical Li hting 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 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
EPERNUTFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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