05120031 (2) CITY OF CUPERTINOx,a,r.=
BUILDING DIVISION PERMIT °rCUNTRA.CTQIt YNU .MA'T.IpI +
BUILDING ADDRESS: PERMIT NO.0 512 0 0 3 1
78 PEACH BLOSSOM D
R'S NAME: PERMIT ISSUE DATE
ANDY SHIA 12/07/2005
SANITARY NO. CONTROL NO.
7D&w
fIENGINEEN: BUILDING PERMIT INFO
BLDGUM
O ELECT O PLO O
LICENSEDCONTtACIORSDECLARATION JobDescri tion
eby af0m Net I am liwnacd under providam of CMpter 9(rommencing p7d10)afDivision3oftheBuia andProfcunmCade.. myIkenmis
�deffm UPGRADE ELECT. PANEL (200AMP)
C'S DECr
oil ARCHITECT'S DECLARATION
I understand my plata null he used as public records
9o5 Liecomd Pm(essiontl
.7y OWNER-BUILDER DECLARATION
1 hereby affirm that I am uempt(rum Uta:Conlractm's License law for the
O O following memo.(Section 703 I.S.Business and Professions Cale:My City or county
Ile! which requires a permit to construct,altar.innProve,demalah.Or repair any lon ctum $1750
_Zm pdoru its issuanatM ce.alaurequireapplicant formch pennitm 0k signed summem
g < died Wislicensed prommmthoprovisions ofOcConnscmislurnmlaw(Chapra9 Sq.Ft.Floor Area Valuation
that he is ixe with S reform and
th bash f r th the Bmimssand on.Anyms Code)of
..
that W u exempt thert(mm and the buil for dee alleged exempUm.Any MolNon of
SOctlm 7031.5 by any applicant fm a permit subjects dee applicant to a civil penalty of r Occupancy Type
nos more Out five hundred doll..(S50DL
❑I,u ownu of the pmpwy,m my wploym wide vases u theb mic Cmnpcmom.
will do the work.ands:The CurctsnotsLicas,Law do for ask apply to an Buttam Required Insppctions
Nd Pmfe work Code: structure
Can 1,not Intended Lkeme law doe.ret apply e an Bums ss q
property who builds or im proses thereon.and who duebach work himself or through his
awn employees.provided that Such improvements am not Intended moff,red for sale.IL
however,the building or improvement lssed within am year of rompledon,the owner- /
builder will have the burden of proving Nu W did not Wild or improv fu purpose of
builds L
1,as owner of the property.am exclusively contracting wide licensed contractual m
nstroct dee pmkct(Sec.7014,Business and Profecdom Cade:)The Canuaemrl I.I.
came law does not apply to an owner of property who Wilds or Improves themm,and,
who contracts for such projects with a wren or(s)licensed pununt to the Conaolues
License Law,
I am exempt under Sao 'BA
PC for Nis mum
Dente
WORKER-SCOMPENSATIONDECLARXID N
I hemby affirm under penalty of perjury one of dee following dalmatians:
Have and will ommem a Certificate of Concent to mif•Imum far Wosser'sContrast.
sstlm,as provided for by Section 3700 of the labor Code,for the performance of the
mass for which this permit is Issued.
❑1 have and will maintain Worker's Compensation Insuntw.as required by Section
3700 of the Labor Cale,for the performance of the work for which Nis Permit is Issued.
My Workees Compensation Insurance carrier and Policy number tae:
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM W ORKERS'
COMPENSATION INSURANCE
md;radon need but W completed If the permit Is for am hundred mllan(Sim)
ter less)
I certify that in the performance of the work for which this permit ts Issued.I alWl not
employ any pumn in any manner an y,n becamo subiect m Ue Waft"'Compewtion
Laws of C&Iif.mla.Dau
APPliCem
NOTICE TO APPLICANT`.IL after making this Cenificate of Faemption,you should
become subject in the Wmkees Compensation provisions of me LAW Code,you most t
,J O foMwith comply with each pmvisiom or this permit shall W damr4 revoked.
Z CONSTRUCTION LENDING AGENCY
gY•vE Ibechydrmn that duas
concentrated.lending ancy,for ar
sic famence of
7 the work for which this Permit 6 issued(Sec.3097.CO.C.)
a� landa's Name
z LmOn'.Address
U O 1 ttnify that I have read this appilcation W sum that the aWw infomW m is
Ile,F coma.I agree to comply with all city and county unit .and sum laws nhung m
O V Wilding convection.and hereby authorize mprosentasim of this city to Omar upon the
W aWn-an n coned property for impecdon purposes
fY (We)agree an save,indemnify and kap hamku the City of Cupertino against
(A liabilities,judemenu.emu aid cap..which may In any way a..mgslml bid City
U 4 in comegmae of the Coring of this permit.
APPLICANT UNDERSTANDS AND COMPLY WITH ALJ.NON-POINT Issued by: Date Z—?_O-
SOURCE REGULATION
�2Re-roofs f
Signeum ol'Applicun o r Data Of Roof
HAZARDOUS MATERIALS DISCLOSURE .)pe
Will d e applicant or forms,building occupant am or handle hazardous maccrial
Onod by dee Cuptnlan Municipal Cade.Chapter 9.13,and the Health and Safety
o,Senior 25533(87 All roofs shall be inspected prior to any roofing material being installed.
C ❑YssNo
(7d-,__4W11mroraunhorizcd.graH_
Will deo applicmt oil fusurc Wilding aeupam um equipment m devices which If a roof Is installed without first obtaining an inspection,I agree to remove
t hazardous air cmuminmu u defired by the Day Area Air Quality Management all new materials for inspection.
bict7
❑ye. 'Flu.
1 have mad the b.4Nms materials mquimmenu under Charter 6.95 or the Califon
Health urentl yhowa mend,aws�Willy uammtsM le Occup torthe
not &&anyhow. .til Nath,m Ildlhy a nod fy th afthe ofthg
irements Which Must Wmct Pdar tai of a Certificate Pr Occupancy. Signature of Applicant Date
ia/�� All roof coverings to be Class"B" or better
Dam
Community Development
10300 Torre Avenue
s
Cupertino CA 95014
Telephone(408)777-3228
fITYF Fax(408)777-3333
It
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #
vr� -�
OWNER'S NAME: � siY� PHONE #
GENERAL CONTRACTO o'�.�G Go/� sTcvcr� FAX #
I am not using any subcontractors:
Signature Date
Please check a licable subcontractors and complete the followin information
Ug7SUBCONTRACTOR 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
AM Tile
/OX-7 oma
Owner/Contractor Signature Date
CITY OF CUPERTINO
CITY PERMIT APPLICATION FORM o_J a�
CUPERTINO
N # 3 t 6 l l ll— Date:
wilding Address: Mailing Address (if different from building address):
7,;1, 7,Y f Gv T,^,o
Owner's Name: Phone#:
h/Vv S/y/,�7 pvff- a.s - 6ag
Contractor: License#:
/7100R ,- Cni✓'rc v c Ti o,✓ gO SS
Contact: Phone: yob_39 Cupertino Business License#:
Gv,•-4�; Fax: S3J
Building Permit Info:
Bldg flsoo/v // Elect t Plumb ❑ Mech ❑
Job Description: 9E,clricz,l�i9N=L
Residential �N�T//��ti4 o�OA Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Proiect: Occupancy Group:
�S o
Type of Construction: Please check this boa if the project is a
secoad-sto addition: ❑
ro'ect Size: Standard E3Laze El Major El
uant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBQILER3. 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
1 # 3z �
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a � CITY OF CUPERTINO
CUP
Ef�TINO PERMIT APPLICATION FORM
uanti 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
BNUCOM v2 New Comm Plumb PLUMBING
BOVERTUvM Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
MIXTURE 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
BPSPRATK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTR.A.P Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstaR/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUIIOING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reins ection 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 of Furnace MECHANICAL
BRENUI RNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood rH CHANICAL
BREMMISC Misc Apparatus 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 Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPEf�TINO PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BREMSIGNAD Rmd1 Signs Add Branch ELECTRICAL
BREMSIG Is Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems I MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special b3spection BUILDING
BSWIM Swimming Pool ' BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERAI Temporary Bldg Permit I BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electricals foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plnmbin Permit Issue PLUMBING
PPLBG PlumbingFees foot PLUMBING
PLLONGRNGC PlanningLR Commel Multi-Fam PLANNING
PLLONGRNGR Planning L6ng Range Residential PLANNING
ZADDCHG Address Chane BUII-DING
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