09050071CITY OF "UYlt;lciu..U
BUILDING DIVISION PERMIT'
PERMIT NO.
BUILDING ADDRESS: •
10525 METEOR PL E & I CENTRAL PERMIT ISSUE DATE
OWNER'S NAME:
Ll q CONTROL NO.
PHONE:
( 510) 4 [ � 1 — % 0 0 2 BUILDING PERMIT INFO
:HiTECr/ENGINEER: BLDG ELECT PLEB MECH
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
vith Section 7000) of Division 3 of he Business and Professions Code, and my license is
n full force and effect.
.icense Class Lic,
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Dale 1,$_� Contractor
ZT-1
ARCHrrECI'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1, as owner of the property. or my employers with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If.
i
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions
who builds tractor's and.
cense Law does not apply to an owner of property Pro
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law. B & P C for this reason
❑ I am exempt under Sec.
Owner Date
WORKER'S COMPENSATION DECLARATION
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Job Description
CHG OUT FURNC SAME LOC. & CHNG OUT A/C DIFF LOC
Sq. Ft. Floor Area
APN Number
32644010.00
I hereby affirm under penalty of perjury one of the following declarations:
❑ I hsae and will maintain a Certificate of Consent to self -insure for Worker's Compen-
-tion, as provided for by Section 3700 of the Labor Code, for the performance of the
tr for which his permit is issued.
,J I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers ompertsation Insurance carrier and Policy number are:
Carrier. U C*nlicy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars ($ 100)
or Ices)
I certify that in the performance of the work for which this permit is issued. 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alum duet there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection Purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APP 1 NT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO JRCREGUI .Jrio!� 01
Signature of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will doe applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section25532(a)?
[-]Yes 1No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? 1
❑ yes o
1 have read the harardaus materials requirements under Chaptcr 6.95 of doe Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if tbe building
docs not currently have a tenant, hat it is my responsibility to notify the occupant of the
requirem nt rich must met i r to i� of a Certificate of Occupancy.
Owner o i7zd agent Date
Required Inspections
Issued by:
Re -roof:,
Type of Roof
Valuation
Type
Date
All roof 3 shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
All roof coverings to be Class '%`' or better
Date
CITY OF
CUPEkTINO
CITY OF CUPERTINO
FUIR21ACE/AC
PERMIT APPJLICATION FORM
APN #Date:
3 b y C) / 0,
S=r v�
Building Address: 10 rZ S7n
Owner's Name:
Contractor:
�f C't-�c
Phone #: e-1 C -j c c- i_
el CL �� Y� ,! l� E',L.� k q
Fax #:.5—/C
Contractor License #:
Cupertino Business License #:
-�-7?s q/
Contact:
Phone #: -f yj L/
I �5 v S
Fax #:
Building Permit Info:
Elect ❑ Plumb ❑ Mech 1;�,
Residential L2r— Commercial
Job Description: C �+- e e L r
e: a
7-i.� GL.7<- c i,�,
For Residential Installations:
Attic 1:1I`floor 2°d floor ❑
Adhere to minimum setback requirement
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
Strapped On Platform—El Bonded New Location El Replacement '
Project Size: Express E ---Standard ❑ Large ❑ Major ❑
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index. Z-3-
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CITY Of
CUPERTINO
CITY OF I�UPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
FURNACE
FURN/AC
1MCRAA
Commercial-Repair/Alteration/Add to
M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating, cooling, absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT
Commercial for the repair of alt/add to
M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR
Commercial In: tall/Relocate ea
M
suspended heatex,recessed wall htr, or
floor mounted unit heater.
1 PGASCOM
Commerical foi ea gas piping System
P
1-4 outlets
1BPGAS
For each gas piping system of 5 or
P
more per outlet.
1MCAPPVNT
Commercial foi- the install/relocate/ or
M
replacement of ea appliance vent
installed & not incl in an appliance
permit.
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICO
Commercial Seismic
B
1 MRRAA
Residential Repair/Alteration/Add to
M
ea heating appl:.ance,refrigeration unit,
cooling unit,absorption unit,or ea
heating, cooling, absorption or
evaporative coaling system,incl
installation of controls regulated by
this code.
1 MRSUSHTR
Residential Install/Relocate ea
M
suspended heat er,recessed wall htr, or
floor mounted emit heater.
CITY OF
CUPERTINO
CITY OF CUPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
AIR
CONDITIONING
Electric Permit
E
FURN/AC
1 BCAIRHAN
Commercial A/C Units <= 10k CFM
B
1 MCRAA
Commercial Mech Repair/alt/add
M
1
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
B
1 BSEISMICO
Seismic Commerr:ial
B
Travel Documentation
1PGASCOM
Commerical for ea gas piping System
1-4 outlets
P
1PGASRES
Residential for e2 gas piping system
of 1-4 Outlets
P
1 BPGAS
For each gas piping system of 5 or
more per outlet. Comm/Resid
P
1 BREMAIRHAN
Residential A/C units <= l 0k CFM
B
1MRRAA
Residential Meclk Repair/alt/add
M
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
j TYPES
1BSEISMICR Seismic Residential B
I
TI
:EP:ERMITFEE
Electric Permit
E
1MPERMITFEE
Mechanical Permit
M
1PPERMITFEE
Plumbing Permit
P
1
B
1 TRAVDOC
Travel Documentation
1 BUSLIC
Business Licew e B
CITY OF
CUPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Build:ine Department
JOB ADDRESS:PERMIT #
OWNER'S NAME: Z k G ne-,, PHONE # Ve P- 5—O 7— s
GENERAL CONTRACTOR:1 eH f rL l e FAX #
I am not using any subcontractors:
signature Date
Please check anDlicable subcontractors and complete the following information:
Owner/ Contractor Signature Date
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
Owner/ Contractor Signature Date