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03040043 (2) FOW ITY OF CUPERTINOBUILDING DIVISION PERMITLD1�0511S MADERA DR PEaMIrNo.03040043 NEIjSJdk[.t u'NA ,PASTUSZKA PERMIT ISSUE DATE 04/08/2003 EITISS04/08/2003 NEL SANITARY NO. CONTROL NO. RCHItECTR3N01NEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Boo LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing Job Description with Section 7")of Division Sof the Business and Professions C.&...d my license I. in full tome and effect. 58' fee...Class Lie.0 SERVICE UPGRADE �'If�RALw�® 1- Dam Contractor ARCHITECTS DECLARATION I understand my plans shall be need as public records APR 14 2003 3p Licensed Professional OWNER-BUILDER DECLARATION .�<E 1 hereby affirm that I am exempt from the Contractor's Ucenm Law for the BUILDING p0 fallowing reason.(Section WF31.5,Business and Professions Code:Any city or county M 12 which requires a Permit to construct.alter.improve,demolish.or mpsir any structum I-Zsn poor in its issuance,also rmulns the applicant for such permit to rileulgned statement £ G that he is licensed remain to the provisions of the Commenr'Wawc IAW(Chapter 9 Sq.Ft.Floor Area VI a Ion N (commemingwith Section 7000)of Division 3ofthe BusinessandI'mrosionscock)or $ltb a that he is camera themfmm and the basis ren Ne alleged outsider.Any violation of Section 7031.5 by any applicant for a permit objects the applicant to a civil realty ofp y 714,9 not mom then I.hundred dollars($500). 3�Wi Yn�7 00 OeGD araC VJ C ❑1,u owner of the property,ce my employees with wages u Neinola comravin lon, wllldo thework,and the southern b pot Intended eneffeed formic(Sm.7W.Business and Preeminent Cock:The Commmes License Law it=not apply 1.an caner of 304 — ROUGH I�i d.'III.vg+w4r. ns property,who Wlldsor increases lhermn,end whodocimetwork himulfor ihmugh his 501 - FINAL ELECTRICAL ENERGY ownemployea,provided that such improvements ate not Intended or onered forala If, forwent,the building or Improvement is mid within am you ofcempledon,the owner. 505 — FINAL ELECTRICAL Wilder will have We burden of proving out he did rel Wild in improve for purpose of gale.). ❑1,a owner of the property,am exclusively contracting with licensed contraction to comouct the project(Sec.7044,Business and Professions Cade)The Conlnthors LI- ame Law does not apply to an owner of property who Wilds or Improves thereon,and who Acta for awh prejeeta with a moamor(G liamed Punusnt m the Contractors L Law. I ams mptLntler Sec. .B&PCfor breawn Owne WORKS 'S COMPENSATION DECLA Ott I hereby affirm uncle penalty of perjury ane of the following deetaratiom: have end will maintain a CeNOate or Co..,1. If-aum for Wo lne's Comp n- on,u provided for by Section 3700 of the Labor Code,for the performance of The wok for which this permit Is Issued. ❑I have and will mminaaln Worker's Compensation Iwunmm,a required by Section 3700 north.LAbor Cade,for the peRprmmce of the wok forwhich this permit is issued. My Workers Compensation Insurance carrier mit Policy number am: Caller. Policy ble: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thisamilen paid not hecomplewd If the osrmh is Imone hundred dollen(SIM) in Ices). 1 mnify that in the perfer ane of the work for which this permit is Isaud,I shall not employ any person i murT m me subject to the Worker'Compensation I.us of California. Applic L V 4m: APPLICANT:If,after making this m mac ei EaemPimn,you thoulC =one at a The Worker's Compensation provisions of she IA Wr Code,you mon ,JO fonhwhepmPly with such provisions m this permit&hall he deemed revoked. 'Zti CONSTRUCTION LENDING AGENCY (+ I hereby Mm that them Is a construction lending agency for The performance of - > the wok for which this permit Is found(Sac.3091.Civ.C.) fs1 Q lenders Name Under't Address [)Q I unify that 1 haw mad this appilmdon and slam that the above information is comet.l agree to comply with all city and county ordinances and state laws MIRLIPS to 0 rl'J building construction,and hereby authentic representatives of this city to enter upon the W .hove-mentioned property,for imrection purposes. (We)agree 1.ave,Indemnify and keep harmless the City of Cupertme against ,,o) liabilities,judgments.tom and expenses which May in any way same againat said City V 7 In consegwnce of the gaming of this permit. rte• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N-POINT Issued by: Date 9= C/�� tiA r�2 to Re-roofs gnuu�f pp HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof Will the applicant or forum building=.pro nom or handle h rusews mammal u defined by to Cupenhm Municipal Cede.Chapter 9.12,and the Health and Safety Code.Seems 25532(.)7 ❑ L All roofs shall be inspected prior to any roofing material being installed. Ya L No Will the applicant or owe building occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove It hamdous air corm nonan as dented by Ute Bay Arms Air Quality Management all new materials for inspection. Irict7 ❑Ya o I hew read the hasminfilturrowerhallniquincirsents under C•hapmrh.95 of dte Califor. nla Hcnithh Safety Cody Sccdone25505,25533 md255M.1 undeawd thetif the building dent not currently haw a cream.Nat It h my responsibility to nobly t oc e cuPml of the reyulre entawIt. th rho eI 'onuissuaceofeCeniRcateof c nor. Signature of Applicant Date All roof coverings to be Class"B"or better cr or mil o ved agent Dam 1 W CITY OF CUPERTINO ` I Y OF 3 54 CUPEkT1NO PERMIT APPLICATION FORM PN# --12Date: -�- 0" a-�-� Building Address: 10511 > Owner's Nam Ph U SlU 9 V� Contractor:? License #: R�1`c�N �� azt G Contact: Cupertino Business License#: Building Permit Info: Bld lect ng Plumb ❑ Mech ❑ AID idential ``� ommercial ❑ Sq.Ft. Floor Area: N tGo $/Sq.Ft.:. Cost of Proje 1oov _ Occupancy r up: ' r Type of Co struction: Quantity FeelD 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 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 2, 7 lof3 A�—/ 2— CITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM QuantityFee 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 Multifamily 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 hid 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 Pipe PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units<= 10,000 din MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY 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 2 of 3