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05020149 (2) f CITY OF CUPERTINO BUILDING DIVISION PERMITCONTRACTORINk'ORMATION ` ".an2 BUILDING ADDRESS: "'B"'65020149 ERMIT NQ5020149 OWNER'S NAME: PERMrf I.SSUEDATE JEFF YA SANITARY NO. CONTRO PFFIONE: L NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 000 LICENSED CONTRACTOR'S DECLARATION Job Description iMI hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Section 70X)of Division 3 of Ne Business and Prufessinm Cade,and my license is with in fall foam and effect /(�) �q= License Class o Lic.n 1.5'O LtI UPGRADE ELECT . (200AMP) /REWIRING �c Dam comv ser CONTRACTOR: P .J. ELECTRIC . CO . qq ARCHITECTS DECLARATION toI undcrsund my plans shall be used u public records eau o G Licensed Profcssam.1 ` OWNER-BUILDER DECLARATION aq 1 hereby affirm that I am exempt from the Contractor's License Law for the Q O fallowing mason.(Section 703 1.5,Business and Pmfc.glom Cade:Any city or county y3� which requires a permit to ennsvuct,altar,improve,demolish,or repair any structure Fi< prior mics issuance.also requires the applicant for such permit to Ole a signed statement £E that heislicensed pursuanuoNcpmvisionxmfNcComrazmr'aUkenulaw(Chapmr9 Sq. Ft. Floor Area Valua�gTB00 k � (commencing with Section 7")of Division 3 of doB usiness and Professions Code)or _ 3 that W is exempt thetefrmo and the bull for this alleged caemption.My violation of Section 1031.5 by airy applicant far Permit subjects the applicant in a civil penalty of APN Number Occupancy Type not more Nan five hundred della.(5500). 1,u owner of Ne property,or my employcos with wages As tMir sole compensation. 36926005 . 00 will do the wart,and the samemse is not intcadcd w oReaed for sat(See.7044,Bus a ss and professions Code:The Conmcmh Liaise taw does set apply to an owner of Required Inspections property who builds orimproves themon,and whodoetsuch work himself or through his own employees,provided that such improvements art not intended at offered for sale.If, p however.the building or improvement is sold within one yaw of Completion.the owner- y ft builder will have the burden of proving that be did an,Wild or improve for purpose of 0 1. 1,as owner of ct pre.704,.Business exclusively convecting with haloed cnnactors i- �� ts.yry constmct Neproject(Sats 1044.viorofandrty who Code:)The ves domors Li- MAR cense law doll not apply i u owner of property who sed p or ant in the Norton.and /a'I who convects for such prolecu with a eomrumt(q IianuO pursuant m the ConvanoTs rZ�PS C3 ..L.W. L IIS ❑lose exempt under Sac. ,B&PCfor Nis mason �� ' Owner Date 1:111a a y',� G WORKER'S COMPENSATION DECLARATION f]g(f�]ypVlly 401 1 hereby affirm under penalty of perjury one of One following declarations: ❑1 have and will maintain a Ccnificam of Covent in self-insure for WorktfsCompen- smion,as provided for by Section 3100 of the Labor Code,for Ne performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as acquired by Section 3100 of Nc labor Code.far the perfmmanas of Ne wart for which this permit is Issued. My Workcts Compensation Insurance carrier and Policy number sm: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This action need not hecomplcmd if Ne Permit Is formic hundred dollars(SIM) M-less.) 1 anify that in the performance of the work far which this permit is is ad.1 shall not employ any person in any manner so az to become subjmt to lM Workers'Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If.after making this CeniOeue of Excmptimn,you should become subject to Ne Workers Compensation previsions of the labor Code,you mug Z, forthwith comply with such provisions or Nis Permit shall tic deemed raked. Z O CONSTRUCTION LENDING AGENCY [-. I hereby affirm that Vert is a imagination lending agency for the performance of D: Use work fur which this pcnnit is issued(Sol.3091,Civ.C.) W Lender's Name 6. Lcnderi Add. U Q I anify that 1 have read this application and sum Nat Ne above information u 1y H em.cL 1 agree to Comply with all city and county ordinances and state laws relating to O V building convection,and hereby authorize representatives of this city in enter upon the }Lt] above-mentioned property for insPccuon purposes. F, tl (Wt)agree to save•indemnify and keep hammoss the City of Cupertino against !� liabilities.judgments,costs and espmues which may in any way seems against said C1 LY J U z, inconsequence afthe granting ofmisPermit. Issued by: Dat, I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT SOURCE R IA ONS. AA 2,'2Z 'O Re-roofs Signawrc ofA P1 Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Wi11 u se applicant or future Wilding occupant store or handle ha44sdous material as car a by the Cupertino Municipal Cook,Chapter 9.13,and tho Health and Safety ode.Sarson 35332(x)? All roofs shall be inspected prior to an roofing material beim ❑Yea Nm P P Y g g installed. Will 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 mit hamtdaus air conuminanu defined by Ne Bay Area Air Quality Management all new materials for inspection. District? ❑Ycs Nu 1 have rcaJ Ne hmaldmus materials nquinmcnu under Chapter6.95 of the Califon nia HmlthASafcty Cmdc,Sceumsi5N)5,35533 and15534.1 understand thmifile Wilding dPas not currently have a mnam that it is my rammo hility to notify tW occupant ofthc rtquimmewhic must 'm"poortoissuanceofaCemficamofOccupancy. Signature of Applicant Date Owner ma Nmmed agent N o All roof coverings to be Class "B" or better .h., Community Development Fx 10300 Torre Avenue .+ .J Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEkTINO Building Department JOB ADDRESS: PERMIT #bs� �,,77 ciuk1l 2, OWNER'S NAME: PHONE # Xl0 0 - 60 6 GENERAL CONTRACTOR: G—�« etc, �C'�`/ FAX # I am not using any subcontractors: 3 o �i Signaturef Date Please check applicable subcontractors and complete the following ' ormation: 69 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 Owner/Contractor Signature Date CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO N # 3& .,2ZDate: 'L -2 Building Address:` Mailing Address (if different from building address): 1. Owner's Name: �L Phone#: Contractor: { 1 License#: tt `1 C, J liw '��G w ;� Contact: � ,�"" Phone: (,rio)gp1-606 Cupertino Business License#: vAtAt(itc.., Fax: Building Permit Info: / BldgEl Elect Q Plumb ❑ Mech ❑ Job Description: Q ,«t yvv/a, ci ao e u ^� t` ° Ie c"yi y 15- Residential C3� �� ) �� Comm2rrcial ❑ Sq.Ft. Floor Area: Z(4-� $/Sq.Ft.: Cost of Project: Q� Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition:- ❑ Project Size: Standazd ❑ Lar e ❑ Ma'or ❑ 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 lru -L- # Z8 68I 1 of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group lip BMISCELL Miscellaneous Fee BUILDING m BMrFIGATC Com . Housing Mit. Fee BUILDING BNUCOMNM 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 Re eat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING 13PSTORM 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 cfin MECHANICAL BREMAMIAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI A liance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lightin Fixtures ELECTRICAL BREEMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMLSC 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 An BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM ' CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BRENIVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISNUCOM Seismic Commercial BUILDING BSEISNHCRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSW1M 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 Z000 MPERMFEE Mechanicals . foot MECHANICAL MPERNUTFEE Mech Permit Issuance MECHANICAL PPERNHTFEE -Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3