04090088 (2) CITY OFCUPERTINO d^ �•
Buaoirvc olvlsloN. 'PERMIT 'IN' 'C1RMA.Tf1N
BU ILDING ADDRESS: PERMIT '.04090088
1 n4 NTT J0WaRQ1iTR IN OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY OL NO.
11CHTTECTIENGINEER: BUILDING PERMIT INFO
ELECTPLUMB MECH
0f.LICthatED CONTRd under S DEoons or hap FINALE®
1 hereby affirm that 1 am lixnxtl under proluiona of Ctuplcr 9(commencingON
Job Descriptio
h Section] ofDivision SofNO Business V Pr�l'essiuns Cade,Wd my license isull fares andnCl ELEC. PANEL UPGRADE (200 AMP)
te C'S DECr CONTRACTOR: BENDER ELECTRIC
l AR HTIECnte DELA SEP v 1004
�i IurtdentanJ my plans shell he uxdu Publicmrenrs
On
3lG t; Licensed Professional - BUILDING S OWNER-BUILDER DECLARATION r/ I L®�N �/
0 1 hereby.(Tran Itut I am exempt from dm Cnnlnetor's License Law for the
0 0 which
re moon. enta n commoner.
Business and ProRaio li Code:Any city or county
$�i whirh xyui s a a permit re cores the alkA improve,for such
demolish, file
e a sig any statement prior to its issuance,also requires do,the applicant for soca permit to files signed scatemem
Fs�Q that menti gwit pursuant 70th)pro visions 3Ne Co Business
License Law(ChartersCod)9 Sq.F[.Floor Area Value[ 1500
as
F (commmmingwiNSereirom and
ndth hands for
fee
theeged exemndon.An into Cole)or
y�$ Net he Is exempt therefrom and dw buil far Ne alleged esemp0on.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more Nan five hundred dollen($500).
❑1,as owner of the property,or my emplayem with wages a their sole compensation, 3 7 5 3 8 0 17 , 0 0
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Pmfestions Codc:no Conuacmri License Law dass not apply to an owner of Required Inspections
property w ho bui Ida cr improves thereon.a nd who does such work himself or through his
own employees,provided that such improvements are not intended or offered for We.If,
however.the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or Improve far purpose of
.is.).
❑I,as Owner of the property,am exclusively contracting with licensed comments to
coawct the project(Sec.70,14,Business and Professions Code:)The Contractors Li.
came Law does not apply to an owner of property who builds or improves thereon,and
who commas for such pmjecb with acomncmr(s)licensed pursuant to the Comndob
License Law.
❑I am exempt under Sea .B At P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decla dioa:
1 have and will maintain aCortificete of Cement to self-insure for Worker'sCompcn-
sation,u provided for by Section 3]00 of the labor Cade,far the perfammna of the
work for which lair permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3100 of the labor Cade,for the performance of the work for which this permit is Issued.
Worker's Compenn anIr-IIn�nsurance artier and Policy number ac:
mer ,• C..CO Q 0 Policy No.:
CERTIFICATE OF EXEMPTION FR KERS'
COMPENSATION INSURA CE
(Thu section need not be cnmplcted if the permil is for enc vu talon dnllam(51(10)
or lax)
1 certify that in the performance of the work for which this Permit Is issued,I shall not
employ any parson in any mannersa as in become subject a the Workers'Compeneadon
Laws of Cashfumia.Date
Applicant
NOTICE TO APPLICANT:If,after making this CeNficate of Exemption.you should
become subject to the Worker's Compensation previsions of the Labor Code.you must
.JO forthwith comply with such provisions or this permit stuff be deemed mvaked.
.Z-i CONSTRUCTION LENDING AGENCY
y
[-� Thereby affirm that the.is a construction lending agency for the performance of
6i> the wells fur which this permit Is issued(Ser.3091,Civ.C.)
Le do'a Name
r7 z Lenders Address
V Q I certify that I have read this application aM soon Nat the above information is
{[a F cores.l agree to comply with all city and county ordinances and scale laws misting to
DU building construction,end hereby name.rep.senotives of this city to enter upon the i
fSd shave-mcmioned pmpcny for Inspection purposes. a
(WcI agree to e,indemnify,end keep harmless the City of Cupenino against
i t f/1 Rabilities,judgmcn , sus tad expenses which may in any way scene againsuaid Cily
U.^7j m conuquccce o gr 'ng of this permis
APPLICANT T NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R U
-� J-C4 Re-roofs
S'gn u Anowelor
HAZA"OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building accureat store or handle haardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
'jjWmdt'SectiYoea n 25532(a)? L�No All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or future building account use equipment or device:which If a roof is installed without first obtaining an inspection,I agree to remove
mil haaarthos air contaminants as defined by the Bay Ara Air Quality Management all new materials for inspection.
District?
❑Yes AN.
I have mad the hu tAims materials requirements under Chapterd.95oftheCalifor-
nlaHcaltilASafetyCod ecdos�1505.25533 and 25534.1 understand thaifthe building
does mol curtcn0y a CCCCCC:te t�iit et itis my spouiaility to mals' lac mcuput nl the
requirements w ' ust f prior m issuanrc of a Cerdficao of rcapanry,�./^11 Signature of Applicant Date
<� t,
Ow r 11
1.c a rot Data All roof coverings to be Class"B"or better
Community Development
„' 'S:y 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
� CITY OF Fax(408)777-3333
UPERTINO
Building D7FAX #artment
JOB DRESS: c�
ICO �J o \/ ' PE T U�D O OU oC>
OWNER'S NAME: J PHO
GENERAL CONTRACTOR:
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followmi information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
y-' Electrical GN L6(-'T(Z G'-io 1385
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
ctor Signature Date
CITY OF CUPERTINO
CUPEkTINO PERMIT APPLICATION FORM
PAPN#� l� 3� U / Date: O�
Building/Address: / 1D C MailingdYrLe� (if�erent from building address):
Owner's Name: (DPhone#:
D
Contractor: �LaC
� License#: Qn 3-5 O
Contact: Phone: �{ - upertino Business License#:
Fax: an,Iq LN I -via
Building Permit Info:
Bldar Elect p . Plumb ❑ Mech ❑
Job Description: F,L Up - o
Residential L�1/ w(�/t Commercial ❑
Sq.Ft. Floor Area: /"'` -_ $/Sq.Ft.:
Cost of Proj t: Occupancy G u
Type of Construe ion: ;(J(1 Please chec t isjx if t roject is a
v` tory
ro'ect Size: Standard Lar e ❑ Ma'or ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER1 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
o C3S^
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CITY OF CUPERTINO
CUPEI�TINO PERMIT APPLICATION FORM
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 Pb1g 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 Stonn/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 cfin 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
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPE(�TINO .
PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BRENIVENFAN 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
BSVvgM Swinuning Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bld Permit BUILDING,
BTEMPSVCS Tem 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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