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04110023 (3)Q z F a !s3 a U U 0 Q F u CITY OF CUPERTINO RM �N,-°. BUILDING DIVISION PER BUILDING ADDRESS: PERMR NO. 04110023 OWNER'SNAM : PERMIT! ISSUE DATE NE: SANITARY OL NO. ECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 jLICENSED CONTRACTORS DECLARATION Job Description r1licrebyriffloodualamj ,p��{ 7") of Division 3 of the Bu nes and Professions Code. and my license is ry and cfeasaia.WATER HEATER/ELECT./DRYWALL GARAGE convc CONTRACTOR: NOR -CAL CONTRACTORS ARCHITECTSDEC .ATIONa dersland my plans M., be a5cd u puhllG mrords i _ . Licensed Profession al S OWNER DECLARATION exempt License Law far the 1 hcmhy off rte Nat 1 our exempt from the Contractor follOwing mason (Seedan ]In 1.5, Business and Prof sstium Code: Any city or roomy - which requiras a permit 10 canstrcl, alar. improv. demolish, or repair any structum prior m its issuance. also mquires tW applieant for such permit m file a signed statement I,licenadpunuant1. orMeCommon',LianseLoa (Chapter 9 Sq. Ft. Floor Ar ea Y32000 Met eprovisions G Met he $ (m mmeneing with Section]000) of Division 3 of Ne Bisineuand Profusions Code) -1 Nat he is exempt therefrom and Ne basis for Ne alleged exemption. Any violation of APN Number Occupancy Type Salon 7031.5 by arty applicant far a permit subjects the applkant m a civil penalty of not mare Nan five handled dollars (2500). ❑I,ummroftlepropcny,ormyemploycuwithwaguuthe'usolecommnudon, 36909004.-00 Required Inspections q winds lhcwork.and the suunum isnnamendedaraffared to, sea (Sax. 7014, Business and Professions Cade: The Contractors License Law dote not apply to an owner of chwmdarafrar through his b, p rpm ss��® himprowm eaMWmoR,mdfor Ownemplo providmprovesthaconandwho sum not �p p6'161 or i proveet wtsamnet Owner. however. Ne building or improvement is sold within one year of completion, purr owner- however, Me building JI'//p tipCg�� L■per 1,�' Wilder will have the burden of graving Nat he did not build or improve (m puryose of salt.). ❑ 1, as owner of the property, am exclusively contracting with licensed conuacmrs w hg 1 O a1LoOe Lit O J Cade:) t]e Li- comtmct Be. prejaci (See. 7W. Business ad sad Pro(essiomCalamities ,� cense Law docs not apply m an owner of property who Wilds or improves Neuron, and who contracts far such projects wiNvcontnemr(s)li<emetl punuanuo Ne Canaanois q Lice exempt B h P C for this moon ❑lam exempt antler Sec. . j��,�,Jq�� r If mrser, I � Id{pp5�gry Owner Dam nt7 WORKER'S COMPENSATION DECLARATION 1 hereby aim under penalty of perjury ane of the following d <laestoma ❑ 1 have and will maintain aCenifmaneof Canxnt to self-imule fm Worker's Comp rt- ezuon, u provided far by Section 3700 of Ne labor Code, for the perharmana of the work for which this permit is issued. 1 have and will maintain Wmkcfs Compensation Insurance. as mr ifted by Section 3700 of the Ube, Code. for Ne performance of the work for which Nis permit is issued. ' My Worlar's Compensation Insurance carrier and Policy number ale: '] C •_ Zu �sN t� .Ral�ry Np.". CERTIFICATE OF EXEMP IONJitO WORKERS' COMPENSATION,INSURANCE . (ITis xmiw need not Wcompleted lithe permit is Forane hundred dollars (EIIX) tr los.) I cerlry Nat in to Performance of Me work for which this permit is issued. I shall net employ any person in any manner so as to become subject 0 the Workers Compensation Laws of California Data Applicant NOTICE TO APPLICANT: If, after making this Ccnifieatc of Exemption, you should kcome subject in Ne Wmkei s Cimi'm cation provisions of the Labor Code, you moat z roMwith comply with such pmvisinm or this permit shall M deemed revakcd. Q CONSTRUCTION LENDING AGENCY 1 hereby Office Nat thrrrc he eomtm boo lending agenry for Me p Ki mance of Nc work for which this permit is issued (See. 3097, Ci,, C.) QLender's Name z Lender's Address Q 1 cer ify Na I have read this application and sun that the above information is J f-' coned 1 agree to comply with all city and county ordinances and stet, laws relating to U building construction, and hereby aothorim representative of this city to enter upon the above-mentioned property for impcedon purposes W .r (We) agree to saw, indemnify and keep hnmleu the City of Cupertino against ti liabilities, may in any way accme, against said City / judgments. costs and experu s which z in conscgmanee of de granting of this permit. ^ APPLICANT �U_Ng ERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOUZE R'Ey•� ATIONS. (/ Issued by: Date Re -roofs SiS e,tT of APPlicanOConl.cUU Dam HAZARDOUS MATERIALS DISCLOSURE - Type of Roof Will the applicant or future building occupant store or handle hazardous material M dented by the Cupertino Municipal Code, Chapter 9.12. and Bic Health and Safety Code, Section 25532(4)? All roofs shall be inspected prior to any roofing material being installed. ❑Yu Na If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant use cquipmem or devices which emit hazardous air ronmntumms as defined by Ne Bay Area Air Quality Management all new materials for inspection. Outlet' ❑ Yu I have mad the haza our materials requirementsuntkrChapter 6.95ofNcCall far. niaHealth ASafety Code, ScNom 25505.25533 and MrM. 1 Milkmaid! Met if the Wilding docs not currently haw a tenant, Out it u my mspemi nutty m nod fy the Occupant of Ne rcyvim cuts whichaIna no met,Q\terill iss-uancelof a cenuficaa ofOccupancy. Signature of Applicant Date c Lt All roof coverings to be Class "B" or better Deraatw�<dBFenl Daae 20 MI;�. 1 tFovR fIz< eAT<o DOOV. w/ self Closlag 06A SEI " 73C �Qc . -T1z41 +7 . vat wZ, p- 0 0 C, s 1s 17A PRIMED ON NO. 100NI CIPANPmwe (G ) FA M [ Ly (ZCDO rA 0. S/ r. �Qy wG�� YP� RECEIVED NOY 08 M C17Y OF CUPERTINO £ 1tEDING DEPARTAfIMIT Sc o�F of vJo °r �y� top! CN) 2-00 /4 -MP Se�\7ica_ W A, -v- E L O iF a G►� F. SPARK ARRESTER REQUIRED `i„_ Z l� t: uiJ �o�S� �- Z - C^� 6\S"' �,1� �� 1� WQ 11 TICS, i�V GA -i2 IN C— 7:1-,r 5.,. la},o til 01 t� lr- �`�' N C ��A, LL f � >= 100 A M� }-U �K PNC 2 a' L \ y In t i �J g ' i (,1`4) 200 A, M? NP S ci cck;t S i i 2— e - - Fir Fr I1 IN MMIFLAN'" WiTH TF€ U rI C„Tif9l� -_•Alt- SIGffI:D -- —. This set and specaiczinens fru De kept ci the icb at all timsa and it is 0 lawful to mare any charges or altsrad& On same without wrivan pernnis=fieri frull the building Dept., Clay of Cupertino. The stamping of this plan and speclhcatisM SHALL NOT be held to permit Or t0 be ar oppcoval of the violation of any provisions any Go Otdrnano 01 iMts Law. REVISIONS BY r N 0 1 N 0 N Goa v 77- Q G Q — �0 v Q _ A U L l� Vov Date I j3 —2S --0q Scale Y'4'/_1e Drawn K 5 Job Sheet Of 1 Sheets CITY Or *CUPERTINO *CITY OF CUPERTIN(O PERMIT APPLICATION FORM APN # 3 K f Fee Description Date: I t — 3— Building Address: Mailing Address (if different from building address): 102-33 So cw %(,� cc ko0 Owner's Name: BBOILER2 Phone #: 0e\)'%kIF S+Ir;<<e BBOILER3 -a8- 2s2- nzioz Con(ractor: BBOILER4 License #: j�1 r— CG ( Co.) k- r 4-0 BBOILER5 S C) 3,s-- Co act: Phone: GZ9- S, A -5 i3 Cupertino Business License#: E- r -J Fax: 4 23 - 063 'Ind/Off/Comm/Quasi Building Permit Info: BCONSTAXBQ Con. Tax for BQ Zone Bldg,XL Elect Plumb Mech Job Description: M 17�j wu'rc 2 ` e �z` BCONSTAXR �\ Residential �� `a BELEC1000 Commercial ❑ Sq.Ft. Floor Area: BELEC1001 $/Sq.Ft.: `F3c7 BELEC200 i Cost of Project: BENERGY Occup y Group: BUILDING BENERGYADD EnerRy Add Multi Type of Construction: BINVESTIGA Plea check t ox if the project is a WOo,b t 2Ar^ • a second -story addition: ❑ Project Size: Standard Large ❑ Major ❑ 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 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 > I OOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD EnerRy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING dS� 1 of 3 C WITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity 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 13PLANCKADD 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 Install/Alter 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 of Furnace MECHANICAL BREMFURNOV Relo Fumace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL REMNRAPP Rem Non -Res A liance ELECTRICAL REMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT R air/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO WITY OF CUPERTINOO PERMIT APPLICATION FORM L7 Quantity Fee H) Fee Description ' Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Si az s, 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 BldgPermit BUILDING. BTEMPSVCS Tem Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electricals foot ELECTRICAL MI EPERTFEE Elec Permit Issuance ELECTRICAL 1 MPERFEE M Mechanicals . foot ME CHANICAL MPERMITFEE ech Permit Issuance MECHANICAL PPERMITFEE Igplumhing Permit Issue PLUMBING PPLBG lumbin Fees foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3