09060077 CITX OF CUPERTINO CSI' T1�ACTCt �N o TION:
BUILDING DIVISION PERMIT
. .:
PERMIT NO.
BUILDING ADDRESS:
22221 BITTER OAK .ST MILLION
PERMIT ISSUE DATE
OWNER'S NAME:
9 CONTROL NO.
rt10N
T.TT\T
BUILDING PERMIT INFO
ARCHITECTIENGiNEER: BLDG ELECT PLUMB MECH
INSTALL AC UNIT 0 0
°C ZLICENSED CONTRACTOR'S DECLARATION Job DCSCiIptlOn
m C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z cu with Section 7000)of Division 3 of the Business and Professions Code.and my license is
y in full tome and cffec o 7 a L�x
? License Class_ -!�
t- Dam Contractor
ARCHITECT'S DECLA AT10N
1 understand my plans shall be used as public records
LU
yU
OH Lit enact Professional
0OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
0 O following reason.(Section 7031.5,Business and Professions Code:Any city or county
m P, which requires a permit to construct,alter,improve,demolish,or repair any structure
ZIn prior o its issuance.also requires the applicant for such permit to file a signed statement Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $q.Ft. Floor Area
Fm (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 Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Apr 1 Number
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
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 arc not intended or offered for sale.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 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 Code:)The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work f hich this permit is issued.
have 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's Compensation Insurance carrier and Policy numb/err am:
Carrier A1a1GATORS Poliry No.:W,61
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($1110)
or less.)
I certify that in the performance of the work for which this permit is issued.I 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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
pe+ the work for which this permit is issued(Sec.3097,Civ.C.)
ALender's Name
Lender's Address
U 0 1 certify that I have read this application and state that the above information is
V.'-' correct.1 agree to comply with all city and county ordinances and state laws relating to
0Vbuilding concoction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
►F-t CA liabilities,judgments.costs and expenses which may in any way scenic against said City
U Z in consequence of the granting of this permit. Date
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR ULATIONS.
11-� d Re-roofs
Signat Applicants for Dam T Of Roof
OUS MATERIALS DISCLOSURE Type ill die ap cant future building occupant store or handle hazardous material
as defined by the upwino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes (f}s`to
If a roof is instz.11ed without first obtaining an inspection,I agree to remove
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 all new materia is for inspection.
District?
❑Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building 7 (�
docs not currently have a tenant,that it is my responsibility o notify the occupant of the
;mquiRnts which must be t prior o issuance of a Certificate of 09 Ig'ature of AF 1 is t Datorize g tDamC All roof coverings to be Class'AJ 'or better
Community Development
10300 Torre Avenue
a= Cupertino CA 95014
Telephone(408)777-3228
`CITY OF Fax(408)777-3333
�UPEkTINO
Buildin ; De artment
JOB ADDRESS: �,� f-7-�� O/qk -C7_
PERMI�#o O 7
OWNER'S NAME: ' /L PHONE # q5V - `'
GENERAL CONTRACTOR FAX#
I am not using any subcontractors:
Signafi xre 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
HeatingP-„S rn
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
ro 2 Cs
Owner ontractor Signature Date
CITY OF CUPERTINO
lam 0
FURNA(:E/AC
CUPEI�TINO PERMIT APPLICATION FORM
APN # 5-1 02Z . CU Date:
Building Address:
Owner's Name: � Phone
L�� �.2 �/ '� ,
Contractor: Phone#:&003,72 _CX:7g/
Ir�� t/ Fax#: &5
Contractor License#: Cupertino Business License#:
Contact: Phone#: pG os) 3C/-2-0&v 2-0&v
Tom a 4f&J W Fax#:
Building Permit Info:
Elect Plumb Mech
Residential ❑ Commercial
Job Description:
For Residential Installations:
Attic F-11St 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 Constiuction (Usage Class):
�50
Strapped LJ On Platform ❑ Bonded Ll New Location Replacement
Project Size: Express ❑ Standard ❑ Large ❑ Major❑
Valuation: DU
Green Building: Please complete relevant portion of 1 he Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09
CITY OF CUP_ERTINO
I. ` FURNACE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1 MCRAA Commercial-Repair/Al:eration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorpi ion or
evaporative cooling sy::tem,incl
installation of controls regulated by this
code.
1 MCREPALT Commercial for the ref air of alt/add to M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea he;athing, cooling
absorption,or evaporative cooling sys,
incl install of controls i egulated by
this code.
1 MCSUSHTR Commercial Install/Re'i ocate ea M
suspended heater,reces Sed wall htr, or
floor mounted unit hearer.
1PGASCOM Commerical for ea gas piping System P
1-4 outlets
1BPGAS For each gas piping sy:;tem of 5 or P
more per outlet.
1MCAPPVNT Commercial for the install/relocate/ or M
replacement of ea appl:ance vent
installed ¬ incl in an appliance
permit.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
1 MRRAA Residential Repair/Alt(.-ration/Add to M
I ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorp:ion or
evaporative cooling sy:>tem,incl
installation of controls regulated by
this code.
1 MRSUSHTR Residential Install/Relocate ea M
suspended heater,reces Sed wall htr, or
floor mounted unit hearer.
CITY OF CUPERTINO
FURNACE/AC
CITYCUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1MRAPPVNT Residential for the i istall/relocate/or M
replacement of ea appliance vent
install ¬ incl in an ap 1 permit.
FURNACE FURN/AC
1PGASRES Residential for ea gas piping system of P
1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
J TYPES
1BSEISMICR Residential Seismic B
1 MECPLNCK Mechanical Plan Check M
1MFR=<100 Furnace Syst<=100k BTU install or M
relocate ea forced-air/gravity type
furnace/burner, incl ducts/vents
attached to such ap;)liance up to and
include 100,000 Bt-A
1MFRN>100 Furnace Syst> 100k BTU install or M
relocate ea forced-E.ir/gravity type
furnace/burner, inc. ducts/vents
attached to such appliance over
100,000 Btu/h
1 EPERMITFEE Electric Permit Fee E
I 1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documentation B
1BUSLIC Business License B