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05110061 (2) FCITY OF CUPERTINO �y,y* j}fj �v(g,► `" A " `�� g BUILDING DIVISION PERlv'11T °CQ " ,v ,. ,*� 1�T>E�,) t1l.f�ATI y.+° •is`C BUILDING ADDRESS: WATER QUALITY PLUMBING P"" "0'05110061 10299 MILLER AVE # V#4 OWNER'S NAME: PERMIT ISSUE DATE MR. FITCH 1860 ALMADEN RD 05 NE: SANITARY NO. CONTROL NO. (408) 267-9330 ARCHmSCT/ENGINEER: BUILDING PERMIT INFO BLDG EI.ECI' PLUMB MECH 3Op LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby+from But 1 are licensed under pmu visioo'Chapter 9(ormo ncing its Seclion70DR)of Division 3 aides BusincesuJ Profcuom Code,and my license is in inn fora eM GAS LINE (UNIT # 3 #4) ��? License Claes Lo,g a Dem I ARCHITECTSCTS DECLARATION ECLARAT I undersand my pins shall be usN as public records yLLV e LL Licensed Professional O OWNER-BUILDER DECLARATION 0 1 hereby e(Trm Nn 1 em.script fern Ne Norman.an Cos I.kena taw for mft y / COO followingmann. emtO 7ss I.S.s,Jan. andne.aceCode:Anymy ailcounty / 2900 which n:qu4ea a perms re essences,thou Jnr,hnpmw,h pencil sii,or mpdr any eemctum 6 thimms1 iuuerce,Jwa,to foo theapplianiratde:act permit w0matlgacd swemem < this he lad.,wit puraw 7000)of DiJ . 3tse the License law(Chap0)r9 Sq.Ft. Floor Area Valuation E�$ "he is earn with Sued.pt 7000)and the DiaMion r the al BuJr0)vand RMleged assompaIM Myi ltdCade)or _ Of section 703p 1.5 by arty applicant m e permit subjaV 0u epplian to a civilpenaltyof OR not mom man rw huMmddollua(M). r Occupancy Type ❑L"comer oftse property,or my maployces with"gas u 0aemanle eampmuNon, win do the work and thesuornre mint Wendedmortcrud formla(Sce.7044,Business Required Inspections and Pmfessiam code:The Canuecmfs Lixme law dm mot apply man Owner of q p . prapeny who builds or imprones mterean,and who dou such acre himself m through his owoanplaym,pmsdcdmataehimprowmanutaerotinlow molfmadfmsale H. however.the building or Impmwmant is Bold within mm year Mcoopletion,the owmr- buiWer win haw 00)Marden of proring mat he did col bWW or impraw far purpose of ale.). ❑1,u mane r of the property,w aclusiwly cub uu7ing with Ric m al ccomm nos w coavuct me pmjm(See.7044,Busims aM Prufesdmta Cade:)The Communes U. coma Law dm as apply m N caner of pmpeny+ holds er impmws common.Nd. who a rmsee fer such pmjem with aconuumr(s)Roamed person[to the C=UaCtmea Liceme law. ❑lunaeroptunem See .B&PCferthumumm Owns Dau WORKERS COMPENSATION DECLARATION I hereby arhra order penalty of prrpary,one of de following declarations 1 Wer and will maintain aCerMiouaf Cament w self-Iuure farWortrea Compeer atian,u pmvi@d(m by Solan 3700 of the Labor Coda.Ter due performance of U0) were for which this permit is issued. 1 haw and will maintain Worker's Compensation Imuran,u inquired by Section ]700 Mme laborCude,far 0)p peJormano of the work fat which this permit Is lama. My Worker's cCoomppensation Insenrxe carrier and Policy number are: - Canitr. [.X].1 1 '� Policy No. k -4 CEATIF 0h OF EXEMPnON FRO WO ERS' COMPENSATION INSURANCE (This union and rot he computed Base rental,u("mhun& ft (SHIR . or less) I cartify,coat in the performance M The work far which this permit Is Issued.I then Me employ anypermn in any manmrso as m became subject w the Warkerf Compe mahon Laws of CJifamia Data Applicants NOTICE TO APPLICANT:If.after making this Certincam of Emmption,you should baeome subject in the Wmkefs Compensation provuiam of cop Labor Code you mum .,O forthwith comply with such provisions m this permit Mail W deemed mwk.d. z 0CONSTRUCTION LENDING AGENCY [. 1 Iamb,serum Rest them is a camwcdna leading agency,far the performance M Dari the ware fur which this permit M issuc l(Sec.3097,CN.C) a 0 Lommes Name lender's Adders V Q I cer0fy that I haw read this application and sum coat the new Information u fy F carrcn.l agree in comply with all city and cowry,adinueu and sou law relski;in Q V building construction,and hereby authodse rtprtunumes of this city to enter upon the L27 ahwe-mentioned property for Inspection purposes (Wc)agree tin aur,indemnify and hap humleu the City of Cupertino against it to liabili0a,judgmenu,can and apema which may In any my Meuse,against add City fJ7 in consequence of the granting althis permit. •^� APPLICANT UNDERSTANDS AND WILk COMPLY WITH ALL NON-POINT Issued by: Date B URCE REGULATT f Cilia s nuurta pYtThtract `'1 Data Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building mcupanlsime or handle hazardous mamrial a donned by the Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety ode,Suction 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. Oyu mNo Will the applicant or future building OmpanT use equipment m devim which If a roof is installed without first obtaining an inspection,I agree to remove emit bawaNnm Jr canmminanu at danced by the Bay Area Air Quality Management all new materials for inspection. District Py,, El yes, rt7No I hew mad the baarrcirJa"'enciaurequiremcnu underchaptarms afthe Caliper. ni,Halth&Seedy Coek.See0om 2541.5.25533 M425734.1 ummmmW d atlN0)buil0lag dm not currently haw•temn4 Net It u my mlhiity w notify the oaupant or the re ulmm nu which meso lose lues .CurtneateofOccop ail. Signature of Applicant Date I,—� All roof coverings to be Class"B"or better Owner ail int or .doge Dam' ' Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY 0, Fax(408)777-3333 �UPEkTINO Building De artment JOB ADDRESS: PERMIT # oVq ,� (43" � 3 � oS—/I OWNER'S NAME: PHONE # _ 3 GENERAL CONTRACTOR: IFAX # A I am not using any subcontractors: C72- Signature Date Please check applicable subcontractors and complete the following information 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 ontractor Sign a Date 00CITY OF CUPERTINO CUPEkTIN PERMIT APPLICATION FORM APN# •2 u -gO t i � 0 Z Date: J/- / Q4/ . 0�_ Building Address: 1 u Zg ml. � Mailing Address (if different (from building address): w Owner's Name:' Phone#: 5?3— — Co tr tor: Li #: 2�305-0) g 4L 1umbl�r) Contact: J Phone: Cupertino Business License#: Fax: Building Permit Info: . Bldg ❑ Elect ❑ Plumb Mech ❑ Job Description:, /lQ� Residential ❑ lII Commercial ❑ Sq.Ft.Floor Area: $/Sq.Ft.: Cost of Proj ect: 2 90 D 0 0 Occupancy Group: Type of Construction: Please check this box if the project is a, second-story addition: ❑ Project Size: Standard ❑ Laze ❑ 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 Elec 600V>1000A ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY EnER BUILDING BENERGYADD EnerU Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 j� �a CITY OF CUPERTINO CUPEfiiTINO PERMIT APPLICATION FORM Quantity Fee ED Fee Description Fee Group BNOCELL Miscellaneous Fee BUILDING BMTTIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERMIE 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER InstaWAlter 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 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation ofFumace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMNOC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREN20LE 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 2 of 3 ow CITY OF CUPERTINO CUPEfZTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Si s, Maz uee 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 Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING TENTSVCS Tem Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electricals foot ELECTRICAL NPEPERAUTFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL PERMITFEE Mech Permit Issuance MECHANICAL PERMPTFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3 of 3