03090151 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMIT L CONTRACTOR INFOMATIO
BUILDING ADDRESS: PERMIT N'03 0 9 0 15 1
' nQQn ER—A�NCG CT
OWNER'S NAME: PERMIT LSBUE DATE
SANITARY NO. CONTROL.NO.
ARCH=CDENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
j00 LICENSED CONTRACTOR'S DECLARATION Job Description
UI berehy arum met I am licensed under pmviaons of Chapter 9(commencing P
til w,NScetion7")of Division3ofine Businass N.fessinm Code.andmyliccnseis
c„ mrmlrareeanaerrz`h REWIRING (E) LIGHTS/INSTALL FIRE BELLS
a? License Class Lk.g
DateContmnor
'v ARCHITECTS DECLARATION
Ea 1 understand my plans shall he used as public records
yU
Licensed Pmfcssianal
OWNER BUILDER DECLARATION
ay 1 masa .Sect on 1 em exempt from Be Contractor's License Law for the
o following mason.Permit
t IIns5,Business and Professions Code:Any city or county
'o which rcyvies a permit m construct,.ince impmm.demolish,or repair any xwaure
xi
poor o its issuance.also requies Be applicant for such Permit o file a signed stamment
EDBpursuant B
at her is licensedpursuanotprovisimvofticConmcmr'sLicenselaw(Chapter9 Sq. Fl.Floor Area Valuation
(commencing with Section]8W)of Division B of the Business and Professions Code)or
$ that he is exempt mcrtfront and Be basis for the alleged exemption.Any violation of 32610055 . 0=
.Smion 7031.5 by any applicant far.Permit subjects Be applicant 1.a civil penny of APN Number ... Occupancy Type _.
not more than five,hundred dollars(SSW).
❑1,as Owner of the pmpcny,or my employees with wages as Bair sole compewtlpn, p pT TT'�
will do Or works,and Be structure is not intended or offered for sale(Sec.90VI.Bumarss — L td7 '1i15 t10ns
and Professions Code:The Claremore,License Law dose not apply to an owner Of 501 — FINAL ELECTR I AL ENERGY
property who builds or improver thereon.and who does such work himselfor through his
employees.own Provided that such impr°mmenu are notintended o offered for sale.If. 505 — FINAL ELECTRICAL
how ver,me building or improvement is sold within one year of completion.Be owner-
builder will ham the burden Of proving that M did not mild or improve for puryosc of
e.).
1.as owner of Be pmpcny exclusively convecting with li cd comaemn to
eo met Be project(Sec. .Bumne no Pmfesu ns Cod Contractor's Li.
terve Law docs of appl ra own P nY who,huil reproves daemon,and,
whocommcts r pctsw o cona')Irsuanuo Our Contractors sJJJg Bg1I WW�"'nllb
License La
am d S. PC far am d D JAPI 2 9 2004
/ i9
WOR 'S MPENSATION DECIAW/s��ON
em yNm,under penalty of perjury,ane Of the °-f Vowing d ciarations: BUIL
I} TNG
wand will maintain a Cenifam of Consent to self-insum for Workers Compere t�r
e�'
as provided for by Section 37 W Of the labor Code,for Be Performance of sm
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
77W of Be Labor Code.for the performance of she work forwhieh this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carver: Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not W completed If rte Permit is for arta hundred dmlars(SI W)
tt Less.)
1 certify dam in the perfmmanec Of the work for which this Permit is issued.1 shall not
employ any person in any manner m as to become subject to the Worluca Compensation
Laws Of Crkhfomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cer iftctic Of Exemption,you should
be:ame subject to ac worker's Compemsatlon provisions Of Be labor Code,you must
z fonhwiIn comply with such prnwnions or this Permit shall be deemed evoked.
O
�^ CONSTRUCTION LENDING AGENCY
> Ibernny affirm that there is a eonswction lending agrney lir the Performance of
Bf work fur watch Nis permit is issued(Sec.W rl.Civ.C.)
QUndcrs Name
Z Lender's Address
t Q 1 certify Bat I haw rod this application y a state next the nbom information is
(•-' Correct,1 agem s comply with all city and county Nlnan es and cute laws elating to
e
t U ah(vengconsned pro end hereby item.rz po.a.nutiws of this city reenter upon dm
[� anove-memioncd property ori cdon pampsea /��/Wv
(We)rime to saw,i minty and keep Ica th Iy mica
f Cuperlino agaiw
Q.
liab"Oes,judgmc a,cos dcapery hi ma in as a y.a cmc a guns)send City
1 z in corssequcrmc due
ingx
AePLI:A N TANG 1 CO LY WITH ALL NON-P INT Issued by:9 Dale
SOURC G 5.
Re-roofs
.to udiavc.loneuxuar .m
HAZARDOUS MATERIALS DISCLOSU Type of Roof
if me applicant or future nuilding Occupant store or handle haaardom material
eGncd by the Cupertino Municipal Code.Chapter 9.11.and Be Health and Safety
ode.Section 25511(a)? All roofs shall be inspected prior to any roofing material being installed.
r]Yet No
Will the applicant or[.,am building Occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
havasdous air contaminants u defined by the Bay Arca Air Coati',Management all new materials for inspection.
nl /
❑Yes
l bavc maJ Be ,usmateriatx rcym rats rC1papmr6.9Saf Bc CaliRr
rain HcaldaAS y .Sec ro 385.255 erW .l umlersmnd Bat Kim building
Jots nut eta ntiy n hi y res ihility m notify Be occupant of the
egaim yw m°a ` ' ° rhw"`°'-°"apadry' Signature of Applicant Date
e Gampncd.gc 7 Date All roof coverings to be Class "B" or better
FROM CUPEPTIHO SAFE STORAGE PHONE NO. 40225:2 66:36 ALL9. 22 2003 12:5GPM P3
rJARA 0. FLVm nEp I ARTMENT INSPECTION NOTICE
FULE SANTA CJAHA COUNTY
' 16 0 Annuail - Cycle
'Ni os Gatrjy. CA )SW2-18 1--...
378- ��pq (408) '.1�78.9342(fa�) 0 Reinspectior)ii'kz 010
0 Construction PC
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a--1 ' C*Y OF CUPERTINO 9 3 0 0 (S
CITY OF PERMIT APPLICATION FORM l
CUPERTINO
N# �Z/ v �� Date:
Building Addrreess:V\ '
Owner's Name: S Phone#:
Contractor: • License #:
Contact: Cupertino Business License#:
Builth ermit Info:
Bld Elec' t Ig`1� Plumb ❑ Mech ❑
CJob escriptibn: qyg !a �
Residential ❑ �""1 F ��w� &,f..�,'/ Commercial
Sq.Ft. Floor Area: $/Sq.Ft.: ,
Cost of Project: Occupancy Group:
Type of Construction: CJ_ - �/U
Adik
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
Iof3 Lq / 79 7 /
CIDY OF CUPERTINO •
CITY OF PERMIT APPLICATION FORM
CUPE TINO
Quantity Fee 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 Multifamil 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• 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 HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMA ULAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM 3USWAY 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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C CITY OF CUPERTIl'�
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 ELECTNCAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb S eci& PlanBUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRIOAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
i BUSLIC Business License BUILDING
/ ELECTRIC Electrical sq foot ELECTRICAL
i EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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