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03070128 (2) CITY OF CUPERTIN0 �`�� '4n= Tse: BUILDING DIVISION PERMIT CONTRACTOR INFORMA1dION is rSz6�'�ti "uYY5:3X�w nom„¢ s" �e3€.c?;c�£ BUILDING ADDRESS: SMARM' WINDOWS & DOORS PERM(TN'03070128 Dwf: ' NA E: Wy 6305 DOUGHERTY RD PERMIT ISSUE DATE ONE: (925) 556-6010 SANITARY NO. CONTROL NO. ARCHITE TrENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH SOC LICENSED CONTRACTOR'S DECLARATION Job Description 1 herchy art,.that I em licensed under provisions of Coupler 9 monorr ndng with Semin IXltB nrDivielon of NC Businoxs end Pry(/mnm CnJe,andm license is 'gym in full fn red )l t NsL �P a t�g1 N�p ,�4a ^1z Liaise A ue.N 1-1 _� 4 REPLACE FURNACE & ADD A/C il'"'tlB�YALE0 09D Cumnc �! ARCHITECTS DECATION c D m bZ (� ''yy Dru l understand my plans shall he used u pis fie records AUC '+ ZDO,J Licensed Professional OWNER-BUILDER DECLARATION <� 1 hcrchy affirm that 1 am exempt room the Contncmr's Licen¢Law for the BUILDING 1'1 DO pg�1 O O following meant.(Section 7131.5,Business and pros essions Code:Any city or county UJ L NG $ which requires a permit to construct,alter,improve,demolish,or repair any swcture FZ< Her ill its iuuana.alw requires the sPPlicem fnrsuch permit to IIIc a.iShad statement ££ss That he is licensed Pursuant to the previsions of the Connector's Limnae Law(Chapter 9 Sq. Ft. Floor Area Valuat]on CFO (commencing with Section 70(f))of Division 3 of she Business and Professions Cout or `t$ Nat he is exempt therefrom and the basis for the alleged exemption.Any vinic ton of Section 7031.5 by Any applicant for it permit subjects the appfiant In.civil penally of APN Number Occupancy Type Bat mon Nan Eve hundred dollAs(M). ❑Lssnwnttaftloth seny,mmyemplended wino wguualeifor gale(Sec. 044,8 sins, T will dolhewark,andtheAc Contra noti Licenser offeredgnotapply tan Bonino 106 — SEWER I� NAg ect]Ons prof.red Professions Code:The Contractor's License Law docs or apply lf an owner of q own enywhos,promed that enheoeomantl who dasanchwne himselfofthrough his 202 — UNDERFLOOR PL BING howemltloyeeailding or imrovemsuch entI.Admenssarcne year of dmor atteree for ole.Lr, 301 - ROUGH PLUMBING however,doe building or improvement is Add within one year of completion,Ne owner builder will hoe the burden of proving that he did not build or imprnw for purpose of 302 — TUB & OR SHOWER olcJ, ❑Lu owner of the property,am exclusively cenuacting with licensed contractors to 502 - FINAL PLUMBING ENERGY construct the projc r(Sec.7Da9,Business and Proresaiao Code:)The Contractor's Lt. 506 — GAS TEST arise law does not apply to an owner of property who builds or impnvu thereon,and 507 — FINAL PLUMBING who contracts for such projects with a cmnramortq liarixd pursuant to the Committee. Lleense Law. ❑ 1 am exempt under Sec. B h P C far this mason Owner Due WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declinations: 1 have and will maintain.Cenif¢ne of Consent to self-imun for Worker's Compen- otion,u provided for by Smion 3]110 of the labor Code,for lite perfannartm of the work for which This permit is issued. ❑I have and will maintain Worker's Compensation Insunna,as required by Section 3]00 ofthe Labor Code,for the Performance of the work for which this permit is issued. ' My Workler'f Cngpenutinn Insurance artier And Policy number art: 'cr. �t -F.r�( pc1��No.: CERTIFICATE OF EXENIFFICIN FROM WORKERS' COMPENSATION INSURANCE (This seeunn coed not becomplesed if the permit is far mm hundred dollus(610(r) ,it less) I cenify that in the pertmmarec of the work for which this Permit is issued.I shall not employ any person in any manner sex As to become subject o the Workeri Compemation Laws of California.Date Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject to the Worker.Com pen dation provisions of the Iahnr Code,you must .JO forthwith comply with such provisions or this Permit shall Inc,deemed revoked. ,z_t 55 CONSTRUCTION LENDING AGENCY '(•+� work for by which thi Nn Vert iso construction 7,Col.agenry for the Performance of .7:)z lxnz'sAddres which this permit is issued(Sec.3097,Civ.C.) LqM Undcri Name z LenJeri Atltlmas L)Q 1 cenify that I have read this application and sum that the above information is lf. F nmect,I agree to comply with all city and county onlinames and&into laws relating to , pU building construction,and hereby authorise uprescrinves of this city to enter spin the til above mentioned property for inspection purposes. y Wc)agree m u inticmnify and keep harmless the City of Cup wino agsinsl y liabilities.jud on Is.C s ndexpensea which may in any way accrue agaiml Aid C)Z APPin cat UNDEf the�Lln, of.ANthis D WILL COMPLY WITH ALL NON POI Issued by: Date 1// sou CUL Re-roofs emreo pOHA, ntncmr Dam ARDOUS MATERIALS DISCLOSURE Type of Roof Will theor future building occupant store ser handle hilam us material o defined by thn Municipal Code,Chapter 9.12,and te health and Safely awe.sem es s / All roofs shall be inspected prior to any roofing material being installed. ❑Yea t9r Wilt the applicant orfuture building occupant use equipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove Ihadous air contaminants u defined by the Bay Ana Air Quality Manag0'1�'lrirt? ement all new materials for inspection. ❑Yes all. I have mad Ne hanNnus materials requirements under Chapmr 6.95 of the Califor- niaHcalthKsafny c,Section255115.25533 it 25534.londerstmtd thwlithe building Jres note en a eram,Nat it is my responsibility m notify the occupant of due rcyuiem a mtheme,prior toiaavaneenr.0 'Edam roc .my. Signature of Applicant Date w 0 All roof coverings to be Class "B" or better cr nt audhoi4 agent - se R CITY OF CUPERTINO � QTY OF PERMIT APPLICATION FORM 6 7 c)/-z,?c)/-z,?c)/-z,? CUPEkTINO APN# („ Z_ Date: Building Address: ' `% Mailing Address (if different from building address): 7 S �/3 82 g r 0/1- Owner's ame: Phone#: P Contrac or: !l License#: S<r Contact: SB»-a-.T-2 c Phone: (eo/D Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect C- um Mec Job Description: 1-2- 1 Residential Ale, Commercial ❑ Sq.Ft. Floor (,ra��C C4 $/Sq.Ft.: Cost of roject: yl X13 , a - Occupancy Group: Type o nstruct . Please check this box if the project is a Ah second-story addition: ❑ Quantity Fee ID 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 1 of3 � � / �• �� r ,051 CITY OF CUPERTINO CUP-v-aof O 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 BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmos'beric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINfERCEP 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 .S'toml/Raln 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 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 BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL 2of3 4 i CITY OF CUPERTINO CM OF PERMIT APPLICATION FORM CUPEI,TINO want' Fee ID Fee Description Fee Group 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 Sips, 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 Inspection 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 MPERMEEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERNUTFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3