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05030119 (2) CITY OF CUPERTINO w% BUILDING DIVISION PERMIT CONTRACTORINFORMA,TION .., BUILDING ADDRESS: PERMIT N%5030119 OW NER'S NAME: PERMIT ISSUE DATE ONE: SANITARY 10. CONTROL NO, 1' emc CHITECT? GINEER: BUILDING PERMIT INFO BLDO ELECT PLUMB MECH LLICENSED CONTRACTOR'S DECLARATION O O O O I hereby affirmNat I am licensed under provisions of Chapter 9(commencing Job Description hSecdonTorat)ofDivision 3 orJte Business arta ProreseionsCode.and my license is full foraands t. LSIL;e ,� Lie,e 0 ADD 5 RECEPTALES/2 SWITCHES Dam Contractor ON DIDICATED CIRCUIT ARCHITECT-S DECLARATION wu I rgawmyplanaawlheusedaspublicmourda CONTRACTOR: ALL THINGS WIRED INC. O Lic sed Professional S OWNER-BUILDER DECLARATION .�0 0 I berthy affirm the 1 1. exempt from an the Contactoo e:Any c law for the .I m O following mason.(Section IID L5.Business and improve. dm oli Code:Any city of county $ which require•permit tD mnsuucL eller.Improve,demolish,or rtpair any structure �� A Fiy prior m its issuance,also requires the applicant for Such permit to Rle a signed sutsmenl sm`e that he islicensed pursuanttothcProvisions(If the Contrecmr'sLianxLAW(Chapmr9 Sq. Ft. Floor Area "d 1 Vi jValuation ant-$ (commencing with Section 7")of Division 3 or the Business and Profession Code)ot / that be u exempt themfrom and the basis for the alleged exemption.Any violation of /.�A: 1:f 2 5 0(] Section 7031.5 by any applicant fora North subjects the applicant to a civil penalty of APN Number 60:: Mt mom dun five hundred dollars(M). r� p� •),gry El 1.AS owner ofthe property,or my employees with wages u their sole compesuadon, will do the wort and dre structure u not intmMed or offered for We(Sm.70",Bologna It And Pmfessioos Code:The Comment's Liana Law does not apply to an owner of � Required InspectlonsN a/ property who builds or improves bereon,and whodoes such work himself or through his V own employes,provided that such improvements tie trot intended oroRmed forWn IL t however.the building or improvement is sold within one year of compledun,the owncr- buildcr ,will beve the W sten of proving thg be did not build or improve for purpose of saeJ. C]1.1.as owner of the property,am exclusively contracting with bombed contravene;to convect Ile project(Sec.7061,Business and Professions Code:)The,Comrazmr's Li. souse law does not apply to an owner or property who Wilds or impmves humor,and. who contracts for such projects with a cnnvactm(s)licensed pursuant to the Convectors License raw. 0 1 am exempt under Sec. .B h P C for this mason Owes Dam WORKER'S COMPENSATION DECLARATION - - 1 hembY afBrn under penalty of perjury one of the following declaration 1 have and will maintain a Certifinm of Convent m self-intim for Workers Compen- (!, cation, AS provided for by Section 37W of the labor Codc,for the pcsfosmana of the work for which this permit is issued. ❑I have and will maintain Workers Compensation lesu ague.AS scquired by Section 37W of the Labor Codc,for the Performance of Ne work for which this permit is issued. Ca Mympeation lanae Policy No.:2 y 'v 2�_ u� C RTI•ICA OF EXEMPTION MOM WORKERS' COMPENSATION INSURANCE (Thi;Section need not W compiemd if the permit is rorone hundred dollasa(SIM) nr less) I cesfify that in the performance of the work for which this Permit u issued.T shall nue moPloy any person in any manner x AS In become Subject to the Workai Compereation Laws or California.Date Applicant NOTICE TO APPLICANT:IL atter making this Certificate of Exemption,you Should became subject to the Worker's CDmpcnsation previsions of the tabor Code.you mug .J z III comply with Such provisions or this permit shall be deemed revoked. 'ZO CONSTRUCTION LENDING AGENCY [-+ Ihereby"M dist them it.coruvuctinn torningagemy,for the perimmance or C > the work for which but permit is issued(Sec.3097,Civ.C.) fed Lenders Name z 1<nderi AM. U C I certify that I have read this application and gone that the above information is Ik. F moose 1 agree m comply with all city and county oo irbo ce,and sure laws relating m OU Wilding convection,and hereby amhurin nprosenatiws of this city to enter upon the UJ above-mcnuoncdpropertyst for;expenses which ms (We)agree ro vie,indemnify and kap humkss the City of Cupenino again dFi h liabilities,judgments.casco antl expenses which may in any way accme against said City U z in come of the gmmiogofN permiL '--' APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR LATI S �'- 0S Re-roofs SlCnamrco ApplaanVConMcmr Dam HAZARDOUS MATERIALS DISCLOSUREType of Roof Will the applicant ser future Wilding occupant gore or handle hansdous..Wool as defined I.Y.the Cupertino Municipal Code.Chapmr 9.12,sod the Health and Safety CoJc ❑Tcs 25532(x)? >�^'D All roofs shall be inspected prior to any roofing material being installed. sun the Applicant or rumm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit ha ardous air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection. Dinner? ❑Yesu I have mad the le ardeus materials requircmcros undo Chapter 6.95 of the Califon ria Health ctyCodc.Section 25505,25533 and 25531.1 understand Nat if lM Wilding della no u ndy baro apn enL Nat dly rapershilily ro nobly the cesupant of the reymi ch onto r its nI.cemaeamyf cep _ Signature of Applicant Date Owner or authorom agent Duero All roof coverings to be Class 'B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 ato Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEkTINO Building Department JOB DDRESS: PERMIT # I OWNER'S NAME: PHONE # GENERAL CONTRACTOR: AX # SAO _a1g2 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSIN SS 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/Contractor Signature Date � - CITY OF CUPERTINO QTY OF PERMIT APPLICATION FORM CUPEkTINO APN # Date: 3m(a - o Building Address: Mailing Address (if different from building address): Owner's Name: Phone#: %,k. LlV%— Contractor: License#: Cntact: Phone: Cupertino Business License#: �P(o2(q - Building Permit Info: Bldg ❑ Elect L9 Plumb ❑ Mech ❑ Job Description: �yy��,l t vCU 4- Residential (� 2 J SINi (nes iokd� "Co ercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Ct of Project: Occupancy Group: 2Soo . �o Type of Construction: Please check this box if the project is a second-story addition: ❑ Pro'ect Size: Standard ® Lare ❑ Ma'or ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK 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 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 BELECI000 Elec 600V <= IOOOA ELECTRICAL BELEC1001 Elec 600V> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING 13ENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 � �S i /76- CITY OF CUPERTINO cuPErtF PERMIT APPLICATION FORM -QuantityAlf 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 Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING EdEBPWSVCS Main Water Service PLUMBING :BREINSPECT Reins ection Fee BUILDING MACOVER A/C Unit> 10,000 cfm MECHANICAL MAIRHAN A/C Units <= 10,000 cf n MECHANICAL EMAPPLI A liance Install MECHANICAL BMBUSWAY Remodel Busways ELECTRICAL BREW IXI 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 Mise Ap2aratus 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 I Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs 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 Insection BUILDING BSWIM 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 PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3