03050013 (2) ' CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACTOR INFORMATION. ;.
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BUILDINGADDRESS: AYUB KHAN PERMITNO{O��3DO5OO13
TT\Tr PT IM
OWNER'S NAME: PERMIT bT'A 75/2 0 0 3
YUB KHAN
ONE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INPO
eBLDG ELECT PLUMB MECH
+IOP LICENSED CONDUCTOR'S DECLARATIONO O O O
li I Mmby affinn Nam et I ImcAm4 under pmvidom Of Chepur 9(commeneing Job Description Ips
n� wiqrSoction 7")of Divialon 3ofthe Businwand Procssions Codc.and mylicenmis a�"//�Ap�m®
"
mfull eto=Chumandertmt. GAS RELOCATE
Z
License Chum Con N
�— Dam DEC MAY 0 6 2003
ARCHRECTS DECLARATION
1 undcntanJ my plans ehtll be used as public records
DyU p�
G LkurieOPmfesuonH BUILDING
O OWNER-BUILDER DECLARATION
I hmear .(Sere that 1. exempt from du Contractoo e:An c 4w for site
no following mama.(Section 1031.5. t.Business and He.demolish,
Cole:Any city st roomy
$9 which requires•permit LLt ennumeL alar,improve.demolixh,nr repair any aWclum r
prior Or its issuance,also requires the applicant for such permit to rile reigned statement
that he is licensed Puritans to the prevision of the Contractor's License Law(Charter 9 Sq.Ft. Floor Area $Y �S�tion
SFD (commencing with Section 7000)of Division 3 of Ne Business and Profwiam Corm)or -
'� But he is eampt therefrom and the basis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects Ne applieml to a civil Penshy of 3-ATN310i"erO 0 - Occupancy Type
not mom than rim hundred dollars(5500).
❑1,u owner of ft property,or my employees with wages As their ole Compensation, r777:77
will do the work,and the swoum is rias intended oroRered forsam(Sec.7044,Business - L6 glf Sj eCtlOBE
end Professions Cada:The Contractors License Law does not apply to an owner of 202 - UNDERFLUOR PLUMBING
property who builds or Im provea thereon,and who does such work hi mself or through his
own employe,provided thatmch improvement are not intended arartered for We.If. 301 - ROUGH PLUMBING
however.the building or improvement is mid within am year of completion,Ne owner-
builder will love tit burden of proving that he did ret build car Improve for purpose of 302 — TUB & OR SHOWER
ale.1. 502 - FINAL PLUMBING ENERGY
0 1,As Owner of the property,am ex<Iesively contracting with licensed mntrectara in 506 - GAS TEST
convect the project(Sec.7044,Basin=and Profession Code:)The Contractor's Li-
cave Law dace not pply to an owner of property who toile,or improves thereon.and, 507 - FINAL PLUMBING
who contracts for such projects with a comrutor(s)Iimrued pursuant to the Contractor.
Rl'l am esemp nd�; ee. .B&PC thi raven
r Dau
WORKER'S COMPENSATION DE
Ihembya mtunderpemltyofpduryomofN lowmgdeclua0om:
I haw and will malnuin a Certificate a(Coaent m self-insure for Warkefs Compen-
alian,ss provided for by Saction 3710 of the Labor Cade,far the performance of the
work for which this permit is issued.
❑1 have and will maintain Waftes Compensation Wurmm.as required by Section
3700 of the labor Code.for the performance of the work for which this permit is issued.
MyW fres Compewtion Inaurmm carrier and Policy number am:
Cartier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aeolon mad nothecomplemd if tis(coni,Is Jerome hundred dollars($100)
nr toss)
1 certify Nat to N cr cmc of the wo c for Wphi<h Nis permit is issued,I shell ms
emPlayanypc ray manerm b n6iu jecuo the Wmkerf ComPcnatim
Laws of Califomr au
APPIIc t
NOTI APPLI ANT:If,after making this Campeau of Exemption,you should
become arae No Worker's Compensation provision of tne Labor Cade,you mut
Ofo ov comply with such provisions or Nis Permit shall be deemW mwked. .
zN CONSTRUCTION LENDING AGENCY
(-� 1 herebyeRrm Our tham iso mmtructinn lending agenry for ft cordrmamc of
y' > the work for which this Permit Is issued(Sm.3097.Civ.C.)
W Q Lender's Nauru
Lender.Address
U O 1 certify that 1 haw road this application and sum that the above information is
U, COMM I agree to comply with all city ad county ordinances and sum laws totaling M
0rV' building construction.and hereby summon representatives of this city to enter upon be
W ahove-mentioned property for inspection purpoua
a fWe)agree to sew,indemnify and keep harmless,the City of Cupertino against v(
res liabilities,judgment,costs and expenses which may in any only aceme against aid City `\J
U A7in rmit
APPLICANTeof the UNDERSTANDSthis
AND WILL COMPLY WITH ALNON-POINT Issued by: Date
S REGU TONf
((�� Re-roofs
gnuuoa Applican onumtor Dau
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building accupal seem or handle btudou atrial
as de0med by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
Code,Section as3z(a)7 All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes ION. P P Y g g
Will the applicant or future building Occupant um equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit W,udnus air contaminants ss dcfmd by the Bay Area Air Qxality Management all new materials for inspection.
Diwict7 ppppop...�,.,,,,,,
❑Yes �?No
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sccdom 355115,25533 ud25534.1 unJ mwtd thulf the building
Does not currently haw a tenant,that it 4 my ms croonlity to nndl'y e,yumant of Ne
mquimwhich nor erylpriarmiauanceafaCwf¢a f cy Sign fApplicant Date
r themed agentl//a¢^ All roof coverings to be Class"B"or better
.1
An
CITY OF CUPERTINO C )
CITYOF PERMIT APPLICATION FORM
CUPERTINO
APN #
Building Addr ss:
/In �''� 6
Owner's Name: � � Phone#:
4a8 446 an
Contractor: License#:
A (1,e
Contact: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mcch ❑
Job Description:
Residential 2r orrt?ner e
Sq.Ft. Floor Area: f $/Sq.Ft.:
Cost of Project: Occupancy Gro p:
S6`0
Type of Constru tion:
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
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aRL, CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO ,
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 Multifami] Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
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 Pipe PLUMBING
BPWHEATER Water HeaterNent 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 Furnace> 10K 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
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a '. CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
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
BREMSIGNAD Rmdl Signs Add Brarich 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 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
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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