04010030 (2) CITY OF CUPERTINO -� J f '`' �*�` "" "''
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION fit
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BUILDING ADDRESS: NOBLE CONST PERMITNG04010030
OWNER'S NAME: PERMIT ISSUE DATE
DRDS 04
ONE: SANITARY NO. CONTROL NO.
(408) 205- ;692
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 E 0 0
"Op LICENSED limand un&rSDECLARATION Job DescriotiOn
F I hcrtby of LIC iNS I am lived under SDECprovision A ION Y(commencing - !C—
n� wiih$Ccli )a Divieia of cBusintcuand prat n d Ibemc 'HALED
mto a rfed� y CHIMNEY REPAIR
LJ Z License Clan Lk.F.a
Data ( TSDE r JAN 1 04
A H"the A. TIO 3 ZO
I v cramnJ my plan shall W amd as public rtcnrds
Oyu
;o Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
<E I hereby affirm
Nat I am exempt from Ne Cormscmts License Law far the
i
00 (allowing reason.(Section 103 IS,Beni.,end Prefaacom Code:Any city ar county
$ which acquires a pcmtit to csmatuet,altar.improv,demolish.at repair any structure
_c prior to its imumm.also reclaims the applicant for such pef011 to Ne a signed statement
< that he is licensed pursuant to the Provisions orthe ComracturiLimnuLaw(Chapter 9 Sq.Ft. Floor Area Valuation
^$ (cnmmchem,w'ith Section 701K)of Division]of Lou Butinum and Profession Code)ur
Net be is exempt Neac(rom and Ne basis for the allcgcd emmption.Any Acladan of win r .p
Section 1031.5 by any applicant for a permit subjects N.applicant to a civil penalty Of 3�PUtdtht�J yyer00 Occupancy Type
not mart Nan fin hundred dollars(SSXE. P Y YP
❑1.u ownu of Ne pmpeny,or my employcu with wagu u theirmee eomNnndon,
will do Ne work,and the swctum is oat imendcd or o(fertd tonal.(Sec.1044,Business
and Par euians Codc:The Conuactori Lim.Law docs at apply to as ow.r of Required Inspections
property who builds or important;Merton,and who does such workhimself order ugh his
awn employees,provided that ach improwarmu are not intended oroRered formic.If,
however,the building or improvement is sold within one year of completion.the owner.
builder will haw Ne burden of proving Nn he did not Wild or improv for purpose of
AMC
Q I,As owner of Ne property,am caciusively contracting with licensed contactors to
comtmct mica(Sm,704,1.Business and Profession,Code:)M Camostat&U.
cense docs nm apply 1.an owner or property who Wilds or improves theRon,and
who motets ounch projecu with a contractors)licensed pursuanuo Ne Commerce,
L Law,
I
am exempt under See. ,B&P C for this mason
Own Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the(allowing declarations: _
I hew and will maintain a Certificate of Consent self-imam for Worsci s Compen.
737,W
ion,u provided for by Section 3100 of the Labor Code,for Ne performance of the
rk for which this pewhic issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section _
of Ne LaWr Code,for the performantt of the work fm which Nis pctmit is issued Worker's Compensation Insurance artier and Policy number art:
rrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not lecompleted I(tbe permit Is(or one hundmd dollen($101)
less.)
1 certify Nat in the rf trachea of the work for which this permit s' d.I shall oat
employ any pc non any
to
Amid become subject to W r ion
Law.of Calif i
Applicant 4142
NO AE T PLICA Ni IL r eking this fsate of Esemp _
hecome subject m the Wan eh ompetamdon I i nano of Ne V Wr Code,you most
., O forthwith comply with sac provisions or this abull W deemed reeked.
E .1 CONSTRUCTION LENDING AGENCY
'Tw Ifahereby whichAffirm lhemit I issued( ecommutation.3W7,lending agency for NC Performanceof
(Yi me curs for which Nis permit is issued(Sat.3091,Civ.CJ
Q
Len cars Name
Z) z Undoes Addm..
V Q 1 ttnify Nn I haw read this application and cuts Nat th.men information it
ty !' correct.1 agree m comply with all city and county ordinances and&rate laws renting to
[S.^7 building conswction,and hereby euthorim mmusenutiws of his city to enter upon the /
milmn
purpo
a abilide.i oll;dprogeny forinspA "which ea. • /
(Wc)egrc sew,lode and keep humleu the City of Cupertino against
IF—t rA Iiabilitlu.jWg u.coeme cape cwhich may in any way theme against said City
V z ,a mora UNDERA Anea pown
pown
ND WILL COMPLY WITH ALL NO -POlrry Issued tiy: Date
BO ULATIO r7l
O Re-roofs
sic arc of/A�pptd n Dam ARDOUSMATLS DISCLOSURE Type of Roof
Will e tarfuture buildi g cu r�rcnr handle henNous material
defined Itenino Municipal o eplor 9.12,end Ne Health and Safety
code.seOdaq1 All roofs shall be inspected'prior to any roofing material being installed.
❑YWillam or future builJin6 ace sex eyuipment or devices whichIf a roof is installed without first obtaining an inspection,I agree to remove
irtrha.dn mmi...0 As dcfi the Bay Area Air Quality Management all new materials for inspection.
❑Yes o
1
he he them sn�makrials myuiacmcnu under Chapkr 6.95 o(mc Califor-
niaHcat s tyC S e uu25505,25533and2553,1.I.dm mnddaeifft Wilding
does no curtcndir b 'e mmol that it As my nmeradhiloy to no'ly tW upon rune
moi mmwhi4 ast a-prmrcomaancenf.Ccrefiate fan . Signature of Applicant Date -
`net or out 0'. d.geat O to All roof coverings to be Class "B" or better
CITY OF CUPERTINO v '�
cuP TYOF o PERMIT APPLICATION FORM
APN# 0 2 d� Date:
Building Address:
D 2 /2 VIS e4
Owner's N e• Phone#: 5� z
Contractor License #:
fro
Contact: / Cupertino Business License4:
/Z
Bui g i I o:
Bl t ❑ Plumb ❑ Mech ❑
J `De on:
gal ❑ ercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
el
Cost of Project: Occupancy Group: ^_
Type of Construction:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 1 OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75MBtu 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> IOOOA ELECTRICAL
BELE 200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. HousingMit. Fee BUILDING
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Sv47amCITY OF CUPERTINO
CUP TYOF O PERMIT APPLICATION,FORM
Quantity Fee 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 Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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 Stomn/Rain 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 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 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
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CITY OF CUPERTINO
CUP CITY OF
O PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMRECEPT Rc d, 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 Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
X. 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 Ternp Dist Svcs ELECTRICAL j
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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
BMISCELL Building Mise Fees BUILDING
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