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04040098 (2)r CITY OF CUPERTINO G $ .. ,� Q Qlarder's Z Q ^F U [kl gy N z r"•" 777777777 CONTRACTOR INFORMATION BUILDING DIVISION PERMIT . h..•. i!)� . k`... .b:..iR�edK4 .BUILDING ADDRESS: HO'S CONSTRUCTION PERMIT NO. 04040098 OWNER'S NAME: PERMIT W`cl1E DATE ONE: SANITARY OLNO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR DECLARATION Job Description p 1 Wreby affirm that I am Booed under provisions of Chapter 9 (commencing with SatipnJp%B of DivisionJof de Businem and Pro(cuiumC dmylicemc is L full fosse sad ect. �� Q— ELECT SERVICE UPGRADE (150 AMP) License C Y Lk. g to _ Dam Contractor AR HITECTS OECLA0. ON / e-/ I understand my Plana WII W used u Puhlic records Q Y !' Licensed Professional DECLARATION OWNER -BUILDER 1 hereby .(Siem that 11. exempt from dm fesntr¢oh License Law for the following reazon. (Section 71131.5, Business and Code: Any city os county w, demolish. sig any structure, which requires a alar, improve, demolish, fie pals re vires dct, a pdonnits kuuancc, also requires Um applicant for such pcnniuo file .sign-( statement Sq. Ft. Floor Area Valuau n WmmenccewithS dn7")ofwiviomnfoftheStsinessnlcense(aw(Chaptm9 (eat xempthuce,frn7000) of Division J of the Business and on. AnyonsCMe)or that he is exempt therefrom and the bob for Be alleged exemption. Any violation of he 3 0 Occupancy Type Schon 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of not mon, Nan Ow hundred dollar (5500). AAfk'4`bl9t§er0 ❑ 1, u owner of the property, army employcm with wage u devwle compensation, Required Inspections will do the work, and de manure is not intended or offered forsale (Sec. 7064, Business and Pmfessiom Cade: The Contmcmr's Lin" ` law does not apply m an owner of property who builds or harrows Ihen,on, and who dexaUuch work himself or through his own employers, provided thmsuch improvemwnu art not intended oroRered Burnie. If. however, the building or improvement is sold within one year of completion, the owner, builder will have the burden of proving Nat he did not Wild or improve for purpose of tile.). ❑ 1. as owner of de property, am exclusively contracting with licensed condmetom m construct Ne project (SLC. 7044. Business and Profersiuns Code:) The Commences Li came law doe not apply to an owner or property who Wilds or improves Iheteon, and who canvass for such projects with a contraciur(s) licensed pursuant m de Cormacmrs LirensL law. ' l an exempt under See. , B & P C for this mason Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury, one of the following declarations: I have and will maintain a Ceni icae of Consent self -insure for Workar'sCompcn- mn, as provided fm by Sweden 37M of the IaWr Code. for tW performance of the rk for which this permit is issued. 11c", 1 have and will maintain Workers CampemNon Insurance, m required by Section Wof the Labe, Code, for tM p rformanecof the work far which this permit is issued. yWorkrs C don Inwra,tceca ranrder: -e Policy No.: j X23.3" yam. CER IFICA E%EM N FROM WORKERS' N I COMPENSATION INSURANCE (Thisaection need not becompleted Bthe permit is forone hundred dollar (SIM) or kers) I cenify, Nat in Ne perf.re.a. of the work for which this penmit u isued, 1 shall not employ any person in any manner so as m Wcome subject m tW Workeri Compensation Laws of California. Dam Applicant NOTICE TO APPLICANT: If, ager making this Canlrnte of Exemption, you should hememe, subject to the Wmkcr's Compensation provisions of the fa Wr Code, you mum foMwlth comply with such provisions or this permit.hall W deemed revoked. CONSTRURIONLENDING AGENCY that issed(Sect3 knding agcmy or the ferfurmancc of Ihor which permit the work for which this pcmtit is issued (Sec. 7097, Civ. C.) Name 1<nderi Address 1 ecnify Nat 1 have red Nis application and sum thn the aWve information is coned. 1 agree to comply with all city and county on inane, and stare laws relating m building canawction. and hereby auNodre repnesenutives of this city to enter upon the above-mentioned properiy for inspection purposes (We-) agree to save, indemnify and keep humless the City of Cupertino against liabi lid., judgmcnu, costs cad tarmacs which may in any way accma against said City in consequence of the granting of this permit. ` APPLI NT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOVRREGULATIONS. Re -roofs Type of Roof V Si at a ppIFandC. r Date H US MATERIALS DISCLOSURE Will the applicwt or foto. Wilding occupant sate or handle hazardous mateml as defined by the Cupenino Municipal Code. Chapter 9.12, and the Health and Safety MkCddc. S]553z(a)7 All roofs shall be inspected prior to any roofing material being installed. Max❑T If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant (wore Willing occupant sex equipment or devices which emit haaaNeuS air contaminants as defined by the, Bay Area Air Quality Management all new materials for inspection. District? C3 Yes No Ihavereadthe Wzarduusma dab requirements underChapter6.95ofthe Califor- .mHcalth& a(ety Cade,Sm. m25505.25533and255M.Iwuksm aiflM Wildiag does notc ndy have a mnm� this it u my mxpomihility m nouty de eccupw of mqui cn which must sac met pd orionsuanecofaceniec of OCL cy. Signature of Applicant Date '.rasa. All roof coverings to be Class "B" or better own ,e agent Dam RTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS -PERMIT 7 2 `-Ae # o�vc��9� OWNER'S N PHONE ## Z q7 17 GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: -4^tS-- —Date 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 -4^tS-- —Date 6ffl) . CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Mw 1 of /� � 7 APN # 3 ' Q 3 Date: Building Address:Mailing _7 n 2 � Addre if differe r a- Pit" f i vl c t�from. building address): Owner's Name: e' Tsa-i 7sa; Phone #: Contractor: s Lice se #: % Contact: Phone:51'a 0 wl 78% r7 Ai �j Fax: C ertino Business \ Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech I\ \ ❑ Job Description: Residential z E*rama �0 15-04mlo�\ t Commercial El Sq.Ft. Floor Area: I $/Sq.Ft.: Cost of Project' . O Occupancy Group: Type of Const ction: E 1 Please check this box if the project is a second -story addition: ❑ 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 IM Btu MECHANICAL BBOILER4 Boiler > 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX ConstructionTax 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. Housing Mit. Fee BUILDING Mw 1 of /� � 7 (- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO iw 2 of 3 Quantity Fee ID Fee Description Fee Group 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 rinkler/Backflo 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 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace > IOK 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 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, Mar uee ELECTRICAL iw 2 of 3 C CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group 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 Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS, Trmp 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 Change BUILDING • 3 of 3