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02100171Ci � CITY OF CITE' OF CIJPE12TIlaT0 b Z 1 00/ 7 PERMIT AFPLICATI019T FORM APN # ' �. � ,� /� �. Date: l� BAPPLOTHER V MECHANICAL 0z- Biiildirig Addr ss: Construction Tax BUILDING 10'2,-) 5 1,1 M ei gtvj). Two CA Owner's Name: AY CwkN BCONSTAXBQ Phone #: 60 -761^ 5� Contractor: �-Yu,� l�t-r BCONSTAXH License #: 7Z6 Contact: . vr,u BCONSTAXR Phone #: Applicant/Contractor: BELEC1000 Fax#: ELECTRICAL 13ELEC1001 Elec 600V > 1000A ,'Buildik Permit Info: BELEC200 Bldg Elect ,✓ Plumb Mech escription - BENERGY Energy Residential: APP/ 1? Commercial: Sq.Fi. Floor Area: BUILDING $ /Sq.Ft.: Z 7 S BUILDING BMITIGATC Architect/Engineer: BUILDING Valuation: Res. Housing Mit Fee BUILDING BMNEWMULTI Type of Construction: MECHANICAL Occupancy Gr p: New Multi - family Res ELECTRICAL ELECTRICAL T Quany:y Fee ID Fee Descri tion Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONTSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Connn/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL 13ELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Ener U Add Multi BUILDING BINVESTIGA Investi tion fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi - Family Res MECHANICAL BNE'WNIULTI New Multi - family Res ELECTRICAL ELECTRICAL BNUCOMME New Comm Electric BNUCOMIVIM New Comm Mechanical MECHANICAL PLUMBING BNUCOMMP New Comm Plumb l of 3 9��_20 by 1, CITY OF CUPERTINO CITY of PERMIT APPLICATION FORM CLIPEkTINO Quantity Fee ID Fee Description Fee Group BNUMULTI New Multi-family Res PLUMBING BOVERTIME Inspection Overtime- BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUMDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BP]NTERCEP Ind Waste Interceptor PLUMBING $PLANCHK Plan Check Fee BUILDING BpLANCK.ADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers . PLUMBING BP SPRINK Lawn S rinkler/B ackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Ira PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reins ection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Buswa s ELECTRICAL BREWW" Lighting Fixtures ELECTRICAL BREN FURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > IOK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Nsc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance .' ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tI, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BRENMPALT Repair/Alter Heatini MECHANICAL BREMRESAPP Remodel Res A lance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL 2 of 3 Woo_ ayuy�i ~nCa ~]� Oz`y* 0 F ,4 t:ar 9�1� 3au tr. t u 0 aX_� w ^v, O L$ a O0 W� C1~ ❑ �Dz U u. O W Uz CITY OF CUPERTINO DIVISION BUILDING PEE r BUI R BLVD AYUB KHAN PERMITNOL2100171 OWAYU&IEKHAN APPLICAiJ30SP'2%T� 2 0 0 2 PHONE: SANITARY NO. CONTROL NO. ARCHrrECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION I hereby, affirm that I am licensed under provisions of Chapter 9 (commencing ADD 7ob Description 725 SQ FT with Section 7000) of Division 3of [he Busi� d Professions Code, and my license is ' . , in full fo d effect License Lic. p Date Con c ARCHMCTS D CI.ARATION 1 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 $105000 following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to rile a signed statement that he is licensed pursuant to the provisions of the Contmcturs License Law (Chapter 9 3s7, ,r yy� SA 51 .Lt Ai! jj$lUBtIQR (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Plq N Occupancy Type p y yp Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of net more than rive hundred dollars (s50D). 10 2 — PIERS ❑ 1, as owner of the property, or my employees with wages as thew sole Compensation, Required Inspections ' will do the work, and the structure is not intended or offered forsafe(Sec.7044, Business Professions Code: The Contractors License Law does to and not apply an owner or 104 — RE13AR property who builds or improves thereon, and who does such work himself or through his own employ=. provided that such improvements are not intended or offered forsale. It. 105 — ANCHOR BOLTS however, the building or improvement is sold within one year of compledon, the owner- builder will have the burden of proving that he did not build or improve for purp of sale.). 202 — UNDERFLOOR PLUMBING ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to 203 — UNDERFLOOR MECHANICAL construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- censeLawdoeanotapplytoan ownerorproperlywhobuddsorimproves thereon .and, 204 — UNDERFLOOR FRAME who contracts forsuch projects with acommetor(s) licensed pursuant to the Contractor's 205 — UNDERFLOOR INSULATION License Law. ❑ I am exempt under Sec. , B & P C for this reason 301 — ROUGH PLUMBING Owner Date 302 303 — TUB & OR SHOWER — ROUGH MECHANICAL WORKER'S COMPENSATION DECLARATION I hereby afrtrm under penalty of pedury one of the following declarations: 304 — ROUGH ELECTRICAL ❑ I have and will maintain aCert(ficaw of Consent to self- insure for Workers Compen- 3 0 5 — FRAME sation, as provided for by Section 3700 of the labor Code, for the performance or the work for which this permit is issued. 3 06 — HOLDOWNS ❑ T have and will maintain Workers Compensation Insurance, as required by Section 3 07 — INSULATION 3700 of the Lftr Code, for the performance of the wet for which this permit is issued. My worker oreyen Gonl urancecarrierandPo y number am: 308 — SHEETROCK Ca er. G� POE Nn.: 309 — EXTERIOR LATH cE ACCOMPENSATION PTTCEORKER3' INS AN 310 — INTERIOR LATH (This section need no[ becompletedif the ptrmitisforone hundred dollars (5100) 311 — SCRATCH COAT or less•) 313 -- ROOF NA I L I certify that in the performance of the work for which this permit is issued, I shall not 5 01 — FINAL ELECTRICAL ENERGY employ any person in any manner so as to become subject to the Workeri Compensation Laws of California- Dale 502 503 — FINAL PLUMBING ENERGY — FINAL MECHANICAL ENERGY 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 504 -- FINAL BUILDING ENERGY forthwith comply with such provisions or this permit shall be deemed revoked. 505 — FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY I hereby alrirm that there is a construction lending agency for the performance or 506 — GAS TEST the work for which this permit is issued (Sec. 3097, Civ. C.) 507 — FINAL PLUMBING Lenders Name 508 — FINAL MECHANICAL Lenders Address I certify that I have read this application and state that the above information is 509 — FINAL GRADE correct- I agree to comply with all city and counly ordinances and state laws relating to 5 FINAL PLANNING building construction, and hereby authorize representatives or this city LO enter upon the above - mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against 14 FIN PUBLIC WORKS liabilides, judgments, costs and expenses which may in any way accrue against said City in consequence orahe granting of this peril. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE R GULA O Re -roofs Type of Roof rgnaturcof plicandContractor Date HAZARDOUS MATERIALS DISCLOSUR Will the 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, Section 25532(4)7 ❑ Yes �jNo All roofs shall be inspected prior to any roofing material being installed. If a roof is installed 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 dcfrned by the Bay At= Air quality Management all new materials for inspection. District? Yes 9No ❑ I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safely Code, Sections25505, 25533 and 25534.1 understand that if the building does not currently have a tenant, that it is my responsibility ro notify the occupant or the mquircmen which must etpnortoissuanceofaCertifies urOctupan . Signature ofApplicant Date All roof coverings to be Class 'B" or better Owner o orizcd agent Da