04070051 (3) CITY OF CUPERTINO
BUILDING DIVISION PERl� CON TRAG PCIR TNEORM O'A;4
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BUILDING ADDRESS: PERMITND
NOLASCO CONSTRUCTION 040700.51
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ER'S NAME: PERMIT ISSUB DATE
BABU NOTT 2E;2 T4RnqR Rn
PRONE: SANITARY Oo C N ROL NO.
(650) 289-0411
ARCHITf:Cf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MT:CH
_op LICENSED CONTRACTOR'S DECLARATION
F I hereby affirm that I am licensed and lovlsions al'Chap er 9(commencing Job Description
ZW with 5cnia�t]f�lU)nfDivixion3of the BusindPmfcssinm Code,anJ my licenreis
4�„ mmnrore d t. Cq2 63 3� 2 NEW FACETS/1 SHOWER VALVE (BATHRM)
pn? License Class ee Lic.0
?H❑ Data Contractor O
'app'tj' ARCHITECTS DECLARATION
Y C i I undwso od my plans shall he used as public recmda
Jm
3 w H Licensed Nomosional
i O a OWNER-BUILDER DECLARATION
<8 I hereby affirm that I am exempt from the Comment's License Law far the
pO fulnwingmasnn.(Suedun 703L5.Business and Professions Code:Any City Cir county
Z
m� which requires a permit in construct,alter,improve,demolish,or spair any structure
s"^ prior to its issuance,also requires ilia applicant forsueh permit m rile a signed statement -
��< Sq. Ft. Floor Area Valuati
that he is licensed pursuant m the revision,of the Cnmmsem's License law(Come,9 on
�zF$ (commencing with Sectio 7000)of Division 3 orthe Business and Professions Code)or
i _ dam be is exempt therefrom and the basis for the alleged exemption.Any vialatian of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 SUI&MuinliterO0 Occupancy Type
nut are than five hundred dollars($50B.
0 1,as owner of that pmpcny,or my employees with wages as their sole compensation,
will do the work,and the swcnre is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contactor's License Law does not apply to an owner of Required Inspections
Property who builds oris proves thereon,and who does such work himself or through his �/ qa
own em ployces,provided that such improvements are not intended or offered for sale.If, //1
however,the building or improvement is sold within one year of completion.the owner. 7/
builder will have the burden of proving that he did not build or improve for purpose of O�
sale.).
0 1,as owner of the property,am exclusively convecting with licensed convectors to
Conswm the projcn(Sec.7W.Business and Professions Caer:)The Contractor's LL
use Law does not apply to an owner of property who builds or improves Hereon,and.
who contracts for such projects with a contracter(s)howeetl pursuant to Ne Convector's
s Lew.
mo exempt under Sec. ,B&P C for this reason
1 n
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations: -
0 1 have and will maintain a Certificate of Consent to self-insure for WorkersCompen-
sation,as provided for by Section 37W of the Labor Code,far the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of the work far which this permit is issued.
My Worker's Coal awasti Cil s be end Policyoumherare:
Cartier. -
obey No,: _
ICERTIFICATEMPr10N FRHKERs'
COMPENSATION INSURANCE
(This section need not be completed Wine permit is for one hundred dollars P$100)
or less.)
I certify Nat in the performance of the work far which this permit is issued,l shall net
employ any person in a y c so mbecomeSubjennthe Workers'Compcnsation
Laws of Cabfarnla.D+oeb.--//
Appli �CANT:Y making
NOT E O APPLICANT: a tsaking Wis Ceti of Exemption,you should
f beton comply
the Worh roCompcor ibis provisions of the Labor Cade you must
Q forth n comply with such provisions or Nis permit shall be deemed revoked.
z tiCONSTRUCTION LENDING AGENCY
'rat I hereby affirm that there is a construction lending agency for the performance of
(�7 the walk for which this permit is issued(Sec 3(197,Co.C.)
W�A Lender's Name
]z Le clef's Address
V Q 1 certify that I love read this application and state that the above information is
F correct 1 agree to Comply with all city and county ordinances and sure laws relating to
Q V building construction,and hereby amhorim representatives of this city to enter upon the
r W above owntim-ed property for inspection purposes. G
(We)agree to save,indemnify and keep harmless the City of Cupertino against '\
FFs 0 liabilities.judgments,costs and expenses which may in any way aceruc agonstsaid City
U Z incunseyucnecnfthegrantiagurthis permit. /
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APPLICANT UNDERSTM'Ds AND 1 COMP Y WITH ALL-40N-POINT Issued by: Date
SOUR UL
5 `�� Re-roofs
i5¢o�iuic of ApplicartsComeacuor H
HAZARDOUS MATERIALS DISCLOSURE Data Type Of ROOF
Will the applicant tar future building occupant store or handle hasmdous material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
ode,Section0Yet; / 'u
155R(a)? All roofs shall be inspected prior to any roofing material being installed.
I ❑Ycs �3.
Will the applicant or Adult building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit Doondous air calumetCita az dedned by the Bay Area Air Quality Management all new materials for inspection.
Dislria?
0 Ycs u
1 have read the havandous materials requirements under Chapter 6.95 orNt Califnr.
nis Hexlth&Safely Code,Saudims15505,25533 and 25534.1 understand has if the building
Jots not c'unen0 have a tenant at it is my pons' ility to notify the necimem of he
ew�catmdu, rt m' dant eenrriea orOcaant. Sienature ofApplicant Dale
Data y
Owner dr amnariaod agent o oma All roof coverings to be Class "B" or better
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OCITY OF CUPERTINO®
*CUPEVO PERMIT APPLICATION FORM
APN # -3K2- o / � Date:
Building Address: (, Mailing Address i dif rent fr m buil ng address):
Owner's Name: Phone#:
v me
Contractor: / License#:
olasGn �s�r'�co Grote (;2623-'
Contact Phone: 2 69-Gy2/ Cupertino Business License#:
TC'V�-z Fax:
Building Permit Info:
Bldg ❑ Elect ❑ P1umb '9 Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
2 e-w ce7`S
Type of Construction: Please check this box i roject is a
second-stor addition: ❑
Project Size: Standard Lar e ❑ 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 Elee 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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ITY OF CUPERTIN0
CUP TYOF O PERMIT APPLICATION FORM
Quanti 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 rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Tra 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
BREMAIRHAN 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
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 R air/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Ap Hance ELECTRICAL
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ITY OF CUPERTIN(*
CUPEt�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Sips 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 In2ection BUILDING
BSVYTW 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
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