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04080032 (2) CITY OF CUPERTINO �' nuu.nlnc DrvlsloN PERMITCONTRACTOR INFORMATIONS BUILDING ADDRESS: PERMIT NO 04080032 OWNER'S NAME: PERMRISSUE DATE NE: SANITARY OL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MCCH x1 , LICENSED CONTRACTOR'S DECLARATION .0C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(rommcnem, Job Description <z a, with Section 70rr of Division 3 of the Business and Professions Code.and my license is in full force and meet. 5'e,= License Classtic.. REPLACE ELECT. SERVICE MAST. a Data Cunvactor a ARCHITECTS DECLARATION aces, I understand my plans shall be,used az public records OyU S t- Licensed Pmfcssional ''O� OWNER-BUILDER DECLARATION 'e Y 1 mmby of in that 1 am exempt from the Contractors Liecnac Law fnr the 00 follnwmg moon.(Section 71131.5.Business and Professions Code:Any city m county 1,m a! which aspires a permit to construct.alter,captive,demnlixh,or repair any suunum m"^ prior m its issuance.also rcquiru the applicant for such permit m Glc a signed statement ��a that he is licensed pursuanan the previsions of the Contractor's License Low(Chapter 9 Sq. Ft. Floor Area Valuat on cxs p F o (cat be is(commencing Sanson?and dr,Division r the the Business and Professon.Any Cock)or i 5� that he u exempt therefrom and 0m buts for Ne alleged exemption.Any violation of Section 1031.5 by any applicant fon permit subjects Ne applicant to a civil penally of 3.?VFp4nig§er00 - Occupancy Type not more than firs hundred dollars($500). 1,azawaeroflmpmpeny,ormyemploycuwiNw guns Ncirmlccompcnution. will do the wofs,antl the swan¢a not i Lice= or^w do forsalc(Sect oia,Business dna rmrassiuna code:The Cpnuaapr'a Liamc Law aura not apply m an owner of Required Inspections property who militant improves thereon,and who does such work himself or through his Own employees provided dthictsuchnot intended forsalc. however, due buildinOr iacmentiscold within one year ofcompletion.me owner . our lder will have Ne burden of proving that he did not build or improve for puryose of sale.). 1,as owner of the property,am exclusively contracting with licensed contractors to aonalr CL the pmjen(Sec.10x4.Business and Profusions Cade:)The Contractor's U. cane Law docs not apply to an owner of p open who builds or improves thereon,and who cpnoacts for such prujects with G nGactor(s)licerwil pursuantm 0m Convanoh License Law. ❑lam candOt u m .B&to par is �/ Da WORKER'S COMPENSATIONDECLARATION 1 hereby of poor under penalty of perjury one of the following drelandio . I bas and will maintain a Certificate dComcm to selDinsum for Workers Compere sation,as provided for by Section 3100 of the labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,az required by Section 31(1!1 of are Labor Code,for the performance of the work for which this permit is iiaused. My Worker's Com pensadon Insurance carrier and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu It.need not beeumplao:d if that permit is far one hundred dollata IS In0) Ices.) 1 certify that in the performance or the work for which this permit u issued.I shall not employ any person in any manner so is to become subject o the Worken'Compensation Laws or California.Da¢ Applicant NOTICE TO APPLICANT:If,after making this Ceni Beam of Exemption,you should become subject to the Worker's Cam peosation provisions of the Lothar Code,you must ,JO forthwith comply with such provisions or this permit shall be deemed mvnked. z IZICONSTRUCTION LENDING AGENCY 'r. 1 hereby affirm that there is a construction lending agency lot the Performance of (� ? the work fur which this .it is issued(See.7091,Civ.CJ !g] 0 tender's Name �z Lc d is Adtlr... U 1 certify that 1 have read this application and sum that the above information is canci l agree to comply with all city and county ordinances and same laws mlaling to pU building construction,and hereby authrei¢rcpmacnutives of this city to enter upon that W ahave-mentioned property fat impecdon purposes. (We,)agrtc to save,indemm(y and keep harmless the City of Carpentaria against F , Baburtin,judgments,costs and expenses whim may in'any way accrue,against said City U Z in consequence of the grating of this permit. ^' APPLICANT UNDERSTANDS A WILL COMPLY WITH A•L Ngg9N-POINT Issued by: Date SOURC�RE UL TI`S. �y��/�Or� 5% Re-roofs S gnathr�opLan !ORI., L311eT Type of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle harardous..Wrist az defined by the Cupeni^o Municipal Code.Chapter 9.12,and the Health and Safely Coda.Section 255J2(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Ya k�I Na Win thea applicant or(future building occupant use equipment or devices which I(a roof is installed without first obtaining an inspection,I agree to remove pp g p a Air Quality nI harardnus air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection. isvia? ❑Yes �Nu I have mad the haramboiss materials rtqurmmcnu under Chapter 6.95 of Ne,Cali for. aria Hcahhi52, &Softy Cwle,Sccdum 25 I5,25577 and 25574.1 undersand that 1f the burbling doe not cuncmly have a ren th it is my responsi bit by mrrry}}WWy��ry the upant of the rcyuircmr Which Must el anti:suanaamr,CeNEa Signature of Applicant Date mmrirmag art a t Da All roof coverings to be Class "B"or better .k. Community Development 10300 Torre Avenue x nCupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408) 777-3333 UPEI�TINO Building Department JOB ADDRESS: PERMIT # O � L /o /`10 Ritt AW , OWNER'S NAME: PHONE # o �C a GENERAL CONTRACTOR: j V - 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 p1z C Excavation Fencing Flooring: Carpeting it 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 Owner/Contractor Signature Date wm CITY OF CUPERTINO a CITY OF PERMIT APPLICATION FORM D� aj � CUPEkTINO N # Date: I ( Jin a Building Address: n �� D Mailing Address (if different from building address):EW AW Owner's Name: 'j� V Phone#: Contractor: License#: Contact: ^ /_ Phon Cupertino Business License#: Fax: Building Permit Info: Ck si_�,YV-16Q Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential ❑ Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: �} /1 _ Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard Large ❑ Major ❑ 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 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> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 r 4�- CITY OF CUPERTINO CUP TYOF No PERMIT APPLICATION FORM 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 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 Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING dh BPTRAP Kitchen Trap PLUMBING lop BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER WaterHeater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMARUTAN 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 Fumace> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREN MISC Misc Apparatus ELECTRICAL BRENR RAP 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 A pliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CUP TYOFFINO 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 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 Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING S 3 of 3