02040003 PITY OF CUPERTINO s_ ""' - �
BUILDING DIVISION PERMIT V'CONTRAGTORANFO
BUILDING ADDRESS: PERMIT NO.
.OWNS PERMIT 156
,N (KT.191 SANITARY NN LNO.
ARCHITECTAINGINEER: BUILDING PERMITINFO t
BLDG ELECT PLUMS MECH
�00 LICENSED CONTRACTOR'S DECLARATION
I hemby.foral l Retainer under Provisions of Chapter (commmcing Job Description
m NRetainer ,
with Seedon 70M)of DMalan Sof Ne Bolnrn and Pmfudmu Cade.and my Rem m Is
In fun forte and effect. FINAfLUM
Llcanso CleoLic.N
f. Dem Contractor ELECT METER & 1 LIGHT
ARCHITECTS DECLARATION #
Imdermnd my prior.alrsll be urA as public rtcwd. SEP 2 9. 2003
3,
Licensed Professional
OWNER-BUILDER DECLARATION
gf I hereby affirm that I am exempt from the Communes License Law for the BUILDING
S,o O following moon.(Section NO 1.5,Business and professions Code:Any city or county
$ which requires a pnmit to ennnron,abler,barren,demolish,an repair my structure 1
prlom its lssusnco.arw repribilbe.pplinnt(Drench permit¢fare sdgned daement
< thathcislicensed pursuant mtheproviahasnfNCConlncter'.Uccom Ltw(ChaNer9 Sq.Ft. Floor Area Valuation
Fpsreexamining with Section 7000)of Division 3 of the Business and Professions Code)w $1500
3..
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Sectio,7031.5 by any applicant for a Permit mbjech the applicmt to a civil penalty of /{p r Occupancy Type
not¢ort Nm fin hundred d.11.(5500). 31,62( (J"$ / 00
❑L as owwor ofine prostrol o mY emplaym with wgea u metr(Sec.
044.B Business
.4 do theaion,anddemucmmeanots Lacestended Law
dd mare(Sm.in a/,Bwitm
roti Profcaarous Code:The Canvaetort License Law dace not apply m an owner of 304 - ROUGH EdIIR6PE4tiPf's '
property who build,.,herwom.them.,and who dauuch wokhimmlfmthrough his 501 - FINAL ELECTRICAL ENERGY
m -i,
ownemployces,provided that such Improvement,a ,ror Intended uraQered for robe.if, n
however,the building mrimprovement is sold within arc year efeomple0on.the owner. 50S — FINAL ELECTRICAL
builder will ban the media of proving that he did not build o Impure for purpose of
as I.
as owner of Ne property.am exclusively convening with licensed comicmn to
no met the pmject(Sec.7041,Business and Profeulon.Code:)The Conusomrs LI•
ease Law duce 0a app m an owner of Pro"my who Wilda or Improm Nereus.and
who contracts pro with...ntractor")Ilcaasetl patient to the Contranora
I3canm 4w. .I
Inn exempt under Sm .B&PC for this remora
Owner am
WORKER'S COMPENSA EC TION 11
71 y ;rte Q'�-•---�_
Ihemby elRrm under Pe of of pnjury oro of oaNwrrg. n
I haw and will maintain a Certificate of Ca sem to self-Iu me feeW rt Compen- )
13C7]'Co
an,as provided for by Section 37M of the Libor Cade,for the perfomtance of the
e,for which Nt,permit Is lasuetl,
I Lan end will mein Wn Workers Compensation Inmrsnee,as required by Section
of the Labor Code.for Ne pofumente of the work for which this permit is Wued.Wartime,Compensation hmrame carie,and Policy numberrtier. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE 1'�I
(This section need not becanpleted If the pomit is foram hundrodollars(SIM)
ver sits.)
I eenify that In the Performance of the work for which this Permit is issued,)shell not
employ any person In my manner sen AS to became subjcctla the Workeri Compri ntlon (
Laws of canromba.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Cer iftnm of Exemption,you should
become subject to the Wohers Compensation provision,of Ne Labor Code.you must
.JZ forthwith comply with such provisions or thin Permit start be deemed ranked.
OCONSTRUCTION LENDING AOENCY it
F 1hembyerionaNatthcrt incomtrucdnn lending agency far the Performance of
SS ice„ the some for which this permit I.issued(Sec.3097.Civ.C.) .`
Ig1 Lender.his
z Landers Add., .i
V Q 1 campy that I have read this application war mer,not the eWve information 1.
ly with all arty and county oNinancus and sou hue.resider,
0 building eommucaon.and hereby suborderrepruenmives of this city m enter upon to
D, corm"'1"=,a comp
shove-mentioned property fm iaspcnion Pmlema.
L. (We)agree to raw,indemnify and keep Monkey dm City of Cupertino gaitut
Ujr InconsegenceofnWcosts
ummiand expenses which mryinany wyecrneadaimtaid City V`"�3.t[N .I
V 7 APPLICANT
oftWRSTAN of this permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs l
1-9Signature of ApplicmyCCCCCCant,,,,,,iaaccccmr DamJ �'i
f A�DOUS 1d RIALS DIS RE Type of Roof
Will de appli vetRpt/.fin bulldi ante m endlc hanrdous mamdd
as dcfinetl by de Cu n Mun ipel C par Z. rad the Hearth and Safety
Cade,section zss33 )] All roofs shall be inspected prior to any roofing material being installed.❑yes o
Will the air cinnt or future dined occupant use equipment or device which
If a roof is installed without first obtaining an inspection,I agree to remove t
It satiety us air conuminent, defined by the Bry Area Air Quality Management all new materials TOT inspection. t
strin7
❑Yes Nu
I hew mW the hmaNrwmamrids requirements under Clt,Pter6.95of the Celifm- 'I
niab aith&Sdety Code,Sccdoas25WS.25533and73734.1odcmmdthoifNc Wilding
dors not emrenlly how a meant,Nat It h my responsibility m mmdl'y the occupant M the
tequimmcus which must Wm at Peterft Cam mof Occupancy. Signature of Applicant Date
OwncronuNorim ¢ Banc o
dal m All roof coverings to be Class nBn or better
I
n
:�CATYO
CITY OF CUPERTINO
PERMIT APPLICATION FORM 03 6 �Z v 0! 3
CUPEkTINO
APN # Date:
Building Address:
v 23 N. I, e Rr k e 7
Owner's Name; Phone#:
C u kv\ kiGtr c-i V4 1 d — �— "
Contractor: License#:
Contact: Cupertino Business License#:
Building Permit Info: 19
Q h/
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: / Occupancy Group:
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 1 M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75MBtu 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
BMITIGATC Comm. Hous4ng Mit. Fee BUILDING
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.1 f I - CITY OF CUPERTINO
CUPEI0 PERMIT APPLICATION FORM
QuantityFee 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
BPFIXTURE 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
• BPREPIPE Repipe 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 din 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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grei Sa CITY OF CUPERTINO l
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
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
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 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 Issuance PLUMBING
PPLBG PlumbingFees foot PLUMBING
ZADDCHG Address Chane BUILDING
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