04050043 (2) CITY OF CUPERTINO
y BUILDING DIV I910N PERMIT ' gN�RA('7T0A�
BUILDING ADDRESS: AAN KY CONSTRUCTION CO PERMIT"4)4050043
?no qTr)NTyT)AjFL ]DR
OWNER'S NAME: PERMIT ISSUE DATE
4
NE: SANITARY NO. CONTROL NO.
(408) 234-2673
ARCHITECnENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
30p LICENSED CONTRACTOR'S DECLARATION Job Descriptionyd U 1 hereby airman Nli
at I am mned under provisions of Chapter 9(commencing -
with Sechia 0(lo of Division 3 of do B no and Professions Coad and my]icon=is
Off n � iofItI effee �1 p//32- ELECT PANEL UPGRADE .
LIZ Dicers=CI s _ RCHI'IELTSh ARATIO
eq �Ic `
Y 8 1and my plans shall M used as public records
D U V
G
Licensed Pmfcssinnal
3 OWNER-BUILDER DECLARATION
ON
1 hereby.oRirm Nal 1 am exempt from iee Contractor's License Lew for the \)
t O O following=aeon.(Section 7031.5,Business and Professions Code:Any city or county
81000
k$V which requires a Permit to construct,alter,improve,demolish,or repair any somehow
y�r prior it,its issuance,also mquirea the applicant for such permit to file a signed umtemem
EAG that he is licensed punuantmmeprovisionsoftheCOmrutur'sLicenseLaw(ChaPOO9 Sq.Ft.Floor Area Valuation
$ (commencing with Section?")of Division 3 of the Business and Professions Code)or
]hat he u rec mm diumfrom and ftbasis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 20e10 0 Occupancy Type
not more N=five hundred dolian(5500).
❑1,n owner of tiro propeny,m my employees with wages w dmirmle compensation,
willdothework,anddwstrvciumisnotintendedoroRemdfonale(Sec.7044,Business Required Inspections
and Pmfesslons Code:The Contractor's Liceme Law does not apply toe an owner of 9 P
propeny who builds or i mprovas therso n,and who does such work bimsel f ter through his
Own employees,provided thatauch improvements art nothmanded maRered forssle.If,
however.the building or improvement is sold within one year of completion,the owner
builder will hive the burden of proving that he did not build or improve for purpose of
sa.j.
❑1,as owner of the propeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Lt.
m®e law does not apply to an owme of property wbo builds or improves thereon.and,
who contracts for such projects with a contractor(s)licensed pursuant in the Contmctars
License Law.
❑1 am exempt ander Sec. .B k P C far hia ma=n
wner Date
WORKERS COMPENSATION DECLARATION
1 hereby alarm under penalty of perjury one of the following declarations:
1 ban and will maintain aCenificae of Consent to=IGimum for WorknesCompen-
makut,as provided fm by Scene.3700 of the Labor Code.for me perfmmeoce of the
work for which this Permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code.for the performance of the work for which this permit is Issued.
My Worker'2 ase. In unnu artier and Policy numbcnrc:
r. —Po CY a�S"9
ERTI ATEO KEMP170N WORK:RS'
COMPENSATION INSURANCE
Mosseetion need not M1ccompieted if the permit is for one hundreddol Wa($IOI))
or less.)
1 certify that in the performance of the work for which this permit is issued,1 shAl not
employ any person in any manner=as to bmomc=bjut to tM Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making id;Conifrcete of Exemption,you should
become subject in the Worker's Compensation provisions of the labor Code,you must
O forthwith comply with such provisinas at this permit shall Is,deemed invoked.
Z y CONSTRUCTION LENDING AGENCY
[—r ]homey M.mat then is a construction lending agency for the perfurmmce of
Z'> the work for which this permit is issued(Sec.3097,Co,C.)
aQ Lender's Name .�
Z Lender's Address
Q I certify that 1 have rued this application and ante that the above information is
0 U correct 1 agree to c comply with all city and county ordinances and sok laws relating ro
pU .midi-numthuuctiaoentl hcmbyauthori=tinge. hives of this city reenter upon me
4t7 shove-(W tion re.to save,
for indemnify
an shoo ha. of
(We)egrtetosave,inticxpegandkeep hay in anmOCitymCupenst id City
N incosiequence oto greind of ten=emit. may in anyway accrue against said City
tJ'� in consequence of Ne granting of this permit. _
s"s APPLICANT UNDERSTAN AND LL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUL
S— �
I" `Lr�;Dd`f Re-roofs
stun ofA canVCon r
HAZARbOUS MATERIALS DISCLOSURE Type of Roof
:/ Will the applicant orfutum building occupant more or handle hazardous material
u defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
ode,sortie,8s32(a)?
Yes All roofs shall be inspected prior to any roofing material being installed.
❑ �o
Will ie applicant or future building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7Dia
t hazardous air contaminants as defined by to Bay Area Air Quality Management all new materials for inspection.
rict?
❑Yes PNU
I have mad thehmardous materials requirements under Chapterd.95 of the Califon
Health@ Safcycode,SecGoru 8505, 533 antl8534.Lundemand thatifthe building
s not currently haw a ten t dot i s my maiwasih'dy ro notify the mcupmt of the
uirtmcros which mu ep' wismanccofa Ccrdfca¢oroccup ry. Signature of Applicant Date
neraraa dwaege ' Dam All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aClOF Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
o sfo cqe cD p_
OWNER'S NAME' Aae PHONE#
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR 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
Tile
r/Co actor Signature —7ZT>te
'; i - CITY OF CUPERTINO o
CITY OF PERMIT APPLICATION FORM
CUPERTINO
N#
32-9 37 c) Date: f-T-0/[
Building Address: Mailing Address (if different from building address):
9 7201 1/IH kMAS Sam G
Owner's Name: Phone#:
g -Z 3q
Contractor: License#:
A/V K .n C F 7 03 -a-
Contact:f�v�� T Phone: _ Cupertino Business License#: Z
L( Fax:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
Residential ® Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: /wW Occupancy roup- l
Type of Construction:u � Please c ck this ox if project is a
Adilksecond-st ❑
lauta/
ro'ect Size: Standard ❑ Laze ❑ Major ❑
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
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CITY 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
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 InstaWAlter 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 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
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
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SamCITY OF CUPERTINO
CUP CITY OF
O PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
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
BSPECL4L Special Insection 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING •
ZADDCHG Address Chane BUILDING
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