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04040035 CITY OF CUPERTINO (�/�}�} p OT 7 (� N BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. _ RVS OFN MERRITT 04040035 ,OWNER'S NAME: PERMIT L�UEDATE NE:RV SANITARY 1 OL NO. ARCHTIECOENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 yop LICENSED CONTRACTOR'S DECLARATION Job Descriptionv� 1 Wreby affirm that 1 am licensed under provision,of Chapter 9(commencing with Seciion 7"f)r'f Division 3 of the Businosand Professions Code.and my licenmis Imfell mmaandercem' TEMP ELECT. OUTLET tn? Licence Class Lie.# :i Dem Contractor ARCHITECTS DECLARATION 1 urW,mmnd my plana shall W used an public records to 3CI Licensed Pmby iffir mml OWNER-9UILDER DECLARATION a I herchy.(firm that 1 1. exempt from the Connector's License Lew for the i e o following noon.(Sadao 7fq 1.5,Business and Profcasions Cade:Any city or county a�B which ree,tho a permit m construct,elm¢W prow,demolish,m repair my structure Go Fzy priorm its issom.,al...,ubm lheapplicant fwmeh permilto fle.alimelitanmenl FF that he is licensed pursuant to the provisions of the Comment's License Law(Chapter 9 Sq.Ft.Floor Area Valuatio 5$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)ser d'l that he is exempt Nenfrom and the basis for than alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 M_NN**gr0 O Occupancy Type not mom thin Eve hundred dean.($500). ❑1,an owner of the Property,or my employs,with wages a their sole compensation. will do the work,end lheahucture Isnot intended orercend f.rsan(SttA044,B.itr•• Required Inspections and Profession,Code:The Castra.mrs License Lew don net not apply m an owner of q P pr.peny who buildsorimprovestbemomandwho doessuchwmkhimselforthrough his ) awn employers.provided if, however.the building or improvement i,told within one year of completion.the owner. Wilder will have the burden of proving that he did not Wild or improve for purpose of sale.). ❑1.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Conumnr's U. mome Law dose not apply to in owner of property who Wilds or improvas themon.and, who contracts for such pmjeem with a contractor(s)licensed pursuant to the Cnnmmus'S License Law. ❑lam exege ,B&PCfor this mason L Own Dan VORKEft. OM ECLARATION ,1 emby affirm under pcna0y of pe Zr-ry e of the fallowin' clm we - IhawandwlllmainuinaCeriificomufConsentloselfins, it or re Compen. sation,as provided for by Seetwo 3700 of the Labor Code,for the performance of the work for which this permit is banned. ❑I haw and will maintain Workers Compensation Insurance,m mquWd by Section - 370D of the Labor Code,for the performance of the work for which this permit is Issued. My Workers Compensation Insurance carrier and Policy number art: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (lois section nsed nl.I W comphowd If the permit is forms,hundred dollen(SIM) or lens.) 1 certify Net in the performance of the work for which this permit is issued.I shall not employ any person in any manner m as n become subject to the Workeri Compe.ation Laws of California.Dam Applicant NOTICE TO APPLICANT.If,eAm,making this Cmufcatc of Exemption,you should become subject en the Workers Compensation provisions of the labor Code,you must wJ'Z foMwith comply with such previsions or this permit mail W deemed evoked. ZiO CONSTRUCTIONLENDING NCY F. thereby from that there is....mutton lending sleety fm Nce e performanof p:7 dm work fur notch this permit u issued(Sec.3097,7.CiCi,v.CJ 0.Q Landers Name �z Lenders Address V O 1 certify that 1 have rued this application and awe that the soon information is lL HWo m.I agree to comply with all city and county ordinances and stem laws minting to O V building construction,and hereby authorise representatives of this city to enter upon the W aurvcmend.ned property for inspecdon purposes. gL (We)agree to saw,indemnify and keep harmless,the,City of Cupertino against y liabilities,judgments,corn and expenses which may to any way acerem affluent said City U Z in consequence of the 6rantin6 of spermim. APPLICANT UNDE STAN D WILL COMPLY WITH LL NON-POINT Issued by: Date rhautdous L ONS. Re-roofs ApPlicann t D NAZAR S M (ALS DISCLOSURE Type of Roof the applicant or future building occupant store or handle hanrdons material y the Cupertino Municipal Cade,Chapter 9.12.and the Health sad Safety n 25532(.)? All roofs shall be inspected prior to any roofing material being installed. . �W the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove ous air contaminants as dcBned by the Bay Ana Air Quality Management all new materials for inspection. ❑Yes �Xo 1 haw read the hamolous numials ngtflour is under Ch.pmr 6.95 ofthc Califm. his Health&SafetyCodc,Sections 25505.25533 md25534.I understand thaidthe building docs not.mo nny h. .tun Natit u my mspo.ibility n notify the.ceup.l.f the 11 men hi ust prior to issuance of aC'mricamofOempEwy Signature of Applicant Date owne amtn.rir. sent All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 I It Telephone(408) 777-3228 CITY OF Fax(408)777-3333 $MkTINO S. Building Department JOB ADDREO., PERMIT# OWNER'S N fM - NE # 3 - GENERAL CONTR / FAX # I am not using any subcontractors y - Signature �4 D e 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 Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile t Q Owner/ cq Si a to C - CITY OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM C5 ° APN# Building Address a S /!/ Cr.C/E Mailing Address (if d'fferent from building address): Owner's Name: Phone#: Contract r: License#: �Gfit/v� Contact: Phone:P/ 3�-3 ?i Cupertino Business License#: Fax: 9J1 Building Permit Info: Bldg ❑ El Plumb ❑ ch ❑ Job Description: Residential ❑ V' ommercia Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: ? Occupancy roup: Type of Construction: Please check this box if the project is a / Y second-story addition: ❑ Quanta Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILER1 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 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 > I OOOA ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Ener Add Multi BUILDING Investigation fee BUILDING BINVES:Tj5:A BMITIGATC Comm. Housing Mit. Fee BUILDING 2SIb7 1 of CITY OF CUPERTINO E F PERMIT APPLICATION FORM CUPEf�TINO Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTBAE 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 0Ind 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 Tr a PLUMBING BPVENT Alt of Drain& Vent PLUMBING BPWATER Install/Alter Water Pi a PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 clin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Buswa s 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.A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/A aratus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL - - - BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heatin MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL jjjjjj� BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 CITY OF CUPERTINO W CUPEf�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL N REMVENSYS Ventilation S stems MECHANICAL BSCBLVD Scb S ecific Plan BUILDING SEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM SwimmingPool 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 • 3 of 3