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04010104 (2) CITY OF CUPERTINO "' �g" BUILDING DIVISION PERMIT C,ONTRACTORINFORMAe�ION:;.: BUILDING ADDRESS: UNIQ ELECTRIC PERMIT NO.04010104 OWNER'S NAME: PERMIT ISSL/EDATE 04 E: SANITARY N0. CONTROL N0. IF ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 uO0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 heathy af0rm oat 1 am licensed under,.viaiens of Ch.pltr 9(commencing P r� with5 Pori ]0(il)of DivlaionJ of the Ruainsaend Prefcasionx Codc.and myliccnm is _ mum.eanderree UPGRADE ELECT PANEL I�INALED �_ Lkenm Clsss Lica Da@ CUNractur ARCHITECTS DECLARATION �i 1 undamund my plan.shall M used as,uhlic records p O O Z004 Ddu Ft 3 ta� Licensed Professional g OWNER-BUILDER DECLARATION 4 i S I hereby affirm that I am exempt from the Contractor's Liccnw Law for the BUILDING 00 following reasN on.(SCun 703 1.5,Business and P.fevions Cade:Any city or county K 2 which requires a Nmnil In construct,altar,improve,demolish,or repair any xtrucwm Ply prior m it,issuance.also.quires the applicant for such permitto file a signed statement H< that he it licensed punuenttothe previsions ofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation o (commencing with Section 7")of Division 3 a(ne Business and Pwressions Code)or $ that he is exempt tbcmfr m and the basis for the alleged exemption.Any violation of Section 7031,5 by any applicant for a Permit subject,the applicant to a civil penalty of 31ND4Tl00 Occupancy out more than five hundred danan(S5m). P Y Type 0 1,as owner of But prepcny,or my employes with wages u their sole compensation, will do the work.and the Nactom is not intended or offered(or sale(Sec.7094,Business and Pmfesslos Code:The Contractors License Taw dos not apply or an owner of Required Inspections p.peny,who build]or improves thereon.and who doessuch workhimmlf or Ihmugh his own employes,provided that uch improvement,arc not intended oroRemd for sale.If, however,the building or Improvement Is sold within one year of completion,the owner. builder will have rod burden of proving that W did not Wild or improve for propose of sale.). 03 1.es owner of ere propeny,Wi e.elusively contracting with licensed contractors to construct the project(Sec.7004.Business and Professions Code:)The Comracwea Li. cease Law does not apply to an owner of imperry who Wilda or improves theater,and. who concocts for such pmjCCM win a comnemr(s)licensed purauamio But Contractors IIL�kkenm law. Elamaxem un rSa. ,B&PCf.r Vis rtason wit Data j U o WORKER'S COMPENSATIONDE RATION I ham aR)rmunderper tyofmduryomoftmfallowingdalantimu: hew and will mainuins Cwifiesteof CommnuomlGinsumfm Worker's Campem - amion,as provided for by Section 3700 of the Labor Code,for Ne perfarmmse of the work for which this permit is laved. 0 1 haw and will maintain Workers Compensation Insurance,as required by Section 3700 of ere IaWrCode,for she performance cite walk for which Via permit is issued. My Worker's Compensation Insurance carder and Policy number sm: Cartier: Policy Na.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Ohbmterm Need nm hecomple¢d irthe perms is forone hundred dnllsr n](10) err lass.) 1 Conry Vel In the performance of the work for which this permit is issued.I shall not employ any person'.a ]nam w as w Mcoarcud eito Be,Workeri'Compensadim - lawsofCalif, V— Applicant NOTICE�����(O((()111 APPLICANT:Ilk after making this Certificate of Exemption,you should broom the Workm a Compensation provisions or the Labor Code,you must .J ,z foMw ply with such provisions or this permit shall W deemed revoked. 'ZO CONSTRUCTION LENDING AGENCY ,y. ILeath a1Rrm Vat there is a construction lending acne tnr dm F Y g g Y" perfurmarsc of F4 ti the work fur which this permit is ibfucd(Sec.3097,Civ.C.) W A Lender's Name z Lenders Add., V Q 1 cenily that I low rad this application and sone that the show information is H correct I aLme to comply with all city and county ordinances and sort laws matin,to �U building convection,and hereby authorivn representatives or this city to enter upon the W abevomemienedproper1 forInspection PUrPOwhich ma gL (We)agree Ir ave,indemnify and keep harmless the City of Cupertino again. h in Cries;judgments inning expenses which may in any way acme against said City t.)z Aconsequence oft he Permit. 2 o-+ ADERSTANOS AND WILL COMPLY WITH ALL NON-POINT Issued by: DateSA 10 f) Sm Cantraotor ITT part Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or fmwe building occupant store or handle hasaNeus material as deRned by the Cupertino Municipal,Code,Chapter 9.12,and the Health and Safety Code.section 25532(a)7 All roofs shall be inspected prior to an roofing material bei. F1 Y. Q9 Na P P Y g g installed. Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove I hazardous air cerneminano as defined by Be Bay Arca Air Quality Management all new materials for inspection. utricR ❑Yes $Nu I hew mad ere h 7nN w materials mquimmenu under Chspwr6.95 of ere Cslifor- ria Health h Safety Code,Secdos 255)5,25573 and 25530.1 understood that if the Wilding docs not currently ave a tenant net it is my respunsihility to notify the mutant of the mquimmcnta h hma.bcmetPriorwissuanccofaCCMrlatcofOccapmcy.. Signature of Applicant Date I is ` All roof coverings to be Class"B" or better o ere a hon agent sw g - CITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM WF,PN11 Date:/ _ 2 Building Address: s-I .rp r Te rY- e 1^. CL„ r 6�o, C,Q _ �1 Owner's Name: Phone#: 1— 'n to st,uzHn o?. 2tj-- 667(- Contractor: License#: Contact: Cupertino Business License#: B 'ltimg Permit Info: $ Elect Plumb ❑ Mech ❑ Job De iption: esrdential © u � e{?2of c N A''� L119`� Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: I o _ 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> 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 -2,q Z-1R 1 of 3 163. !(3IN CITY OF CUPERTINO , n, fiOF' 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 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 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 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfrn 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 > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREVE-4 PP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL AOL BREMPOWER Power Device/Apparatus ELECTRICAL 2 of 3 IaalAl, CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Sips 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 BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Ternporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp 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 BMISCELL Building Misc Fees BUILDING 4ry 3 of 3