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03010014 (3)J ��n o CUPEI�TINO CITY OF CUPERTINO f c� PERMIT APPLICATION FORM APN #' 3x9.2 - 32 - d 57 7 Date: t 2 f 03 8uildirig Address: 2,26,:;l . c� zeh �,� 0A k- La *l C ULp2Ji `�'� C', CA- s Owner's Name: i /11 a ryt, �] o�t� �-j�S Phone #: 4o13 _ 2-5 6'- Q 9 sg; Contractor: Cu,pehfin a kj f-Ch Q.h DObi License M 6804 -6 3 Contact: J4hk Be Ap-zyar� Phone #: �►og r 5l-J _ �Sc� � , Applicant/Contractor: Fax #: 6 Z� . 0 4- Buil g Permit Info: Bld Elect (Plumb) (Mech) Jo escription: Residential: V/ �j'f Gh 1a`'S to, t,� V2-Z ?Odo Commercial: Sq.Ft. Floor Area: S /Sq.Ft.: Architect/Engineer: Valuation: Type of Construction: Occupancy Group: r G Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Irid/Off/Comm/ uasi BUILDING IBCONSTAXBQ 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 Enerev BUELDING .. BENERGYADD Energy Add Multi BUILDING ' BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mt. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BNEWMULTI New Multi-family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMIAM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 1 of 3 .f� zo7�cP � ZslZ•z� "„ w >;� Fee ID Fee Description Fee Group zr New Multi-family Res -M CITY OF CUPS TINO CITY OF CUPERTINO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BNUMULTI New Multi-family Res PLUMBING BOVERTWE Ins ection Overtime BUILDING BP13ACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMUE Bldg Permit Fees BUILDING BPFMrM 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 Repipe Of-Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING B Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo 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 Reins ection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfrn MECHANICAL BREMAIIGAN A/C Units <- 10,000 ciin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Buswa s ELECTRICAL BREM[FIXT Lighting Fixtures ELECTRICAL 13RENUUM Relocation of Pumace MECHANICAL BREM1iURNOV Relo Furnace > IOK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL 13REMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BRENG RAPP 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 lleatini MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL' BREMSIGNS , Remodel Signs, Marquee ELECTRICAL BREMTH.EATR ! Theatrical Lighting Fix ELECTRICAL 2 of 3 aw, CITY OF CUPERTINO CU P CITY OF PERMIT APPLICATION FORM ua t' Fee ID Fee Description Fee Group BREMVENFAN Vent Fan Single Duct MECHANICAL 13REUWNSYS Ventllatioa Systems MECHANICAL BSCBLVD Scb Specific -Plan BUILDING BSEISNIICOM .Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSF &2FAM Sin le & 2 Family BUILDING BSFNA Single Family New Add BUILDING BSPECIAL Special Ins ection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power' ELECTRICAL BTEMPPERM : Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMYNEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical s . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Numbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler > IM to 1.75 M Btu MECHANICAL 13BOILER5 Boiler > 1.75 M Btu MECHANICAL 3 of 3 BUILDING DIVISION PERMIT )ING ADDRESS; OWNER'S NAME: FISHER WILLIAM H 2 AND MARY ARCHITECTIENGINEER: ROp LICENSED CONTRACTOR'S DECLARATION K I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section lOW) of Division 3 of the Business and Profession Code. and my license is F a y in lull force and et%cL z ;a License Clan lic. 0 C ^ ` Date Contractor r�ixSy ARCH] TEC I S DECLARATION I undersland my plans shall be used as public rccnrds KOyU W rS Licensed Professional L6 O OWNER - BUILDER DECLARATION an n 4 2 l hereby affirm that I am exempt from the Contractors License Law for the u> IZ O following reason. (Section 7031 .5, Business and Professions Code: Any city or county a LO�r x„ which requires a permit to construct, altor. Improve, demolish, or repair any atrucwm F y prior to its issuance, also requires the applicant for such permit to rile a signed statement mm that he is licensed pursuant to the provisions of the Contractors License Law (Chapwr9 F (commencing with Section 7000) of Division 3 of the Business and Professions Code) or o% that he Is exempt therefrom and the basis for the alleged exemption. Any viotation of Section 7031,5 by any applicant for a permit subjects the appficwl to it civil penalty of not more than rive hundred dollars ($500). [11. as owner of the property, or my employees with Wages as their sole compensation, will do the work and the strtsctwe is not intended or offered for side (Sec. 7044, Business and Professions Code; The Contractors 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. I!, however, the building or improvement is sold within one year of completion, the owner. builder will have the burden or proving that he did not build or Improve for purpose of sale.). N 1, as owner of the property, am exclusively contracting with licensed contractors to conswct the project (Sec. 7044, Business and Professions Code:) The Contractors Li- ccr= LAW does not apply to an owner of propeny who builds or improves thereon. and who contracts for such projects with a conuactor(s) licensed pursuant to the Contractors License law. ❑ I am exempt under Sec. n , B & P C for this reason yr wl d� c� Date D '� WORKER'S COMPENSATION D RAT70N 1 hereby alfirn under penalty of perjury one of the following declarations: [3 ]hive and will maintain aCerrificateof Consent toself- insure for Workres Compen. salon, as provided for by Section 3700 or the Labor Code, for the performance of the work for which this permit Is issued. el I have and will maintain Workers Compensation Insurance, as required by Sccdon 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance canier and Policy number am; Cairier.5 A F VNb Policy No.: ¢ 10 -00 '2— CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This senlon need not be completed If the permit is for ane hundred dollars (S 10D) or less.) 1 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 NOTICETO APPLICANT: If, after making this Certificate of Excrapdon, you should become subject to the workers Compensadon provisions of the Labor Code, you must O 0 forthwith comply with such provisions or this permit shall he domed revoked. z ' CONSTRUCTION LENDING AGENCY Cn (+ +-r 1 hereby affirm that there is a construction lending agency for the performance of r> the work for which this permit is issued (Sec. 3097, Civ. C) WC4 0 Lrnde es Name z Lancim'sAddress V O 1 certify that I have read this application and state diet the above information is LT♦ "-+ correcL 1 agree to comply with all city and county ordinances and state laws relating [a O V building construction, and hereby authorize representatives of this city to enter upon the W shove- mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against ,.., In Babilides, judgments, costs and expenses which may In any way accrue against said City U 7 in consequence of the granting of this pefmiL rte- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURC REGULA7T0 R /) t 'Signature of ApplicantlConlrector ^�G1 etc HAZARDOUS MATERIALS DISCLOSURE Will the applicantor future building aecupanta[ore or handle hayanious material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safcty Code. Section 25532(a)9 []Yes INO Will the applicant or future building ompsm use equipment or devices which emit ha=Vom air contaminants as defined by the Bay Area Air Quality Management DjUrict7 ❑ Yes AANo J I have read the hazardous materials requirements under Chaptcr6.95 of the Califor- nia Health & Safety Code, Sections25505. 25533ard25534 .I understand this ifthe building does not currently have a tenant, that it is my responsibility to nodfy, the occupant of the rcqu= f a Ccnificatc Of occupancy3 CUPERTINO KITCHEN DESIGNS IPERMITNO. 10562 S DE ANrZrA BLV I APPLICATION SUB DATE ( 4 0 8) 257-4 9 0 0 SANIrARY NO, CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 Job Description KITCHEN & MS BATHRM REMODEL Sq. Ft. Floor Area $15 M00tion Occupancy Type 102 - PIERS equfred Inspections 103 - UFER 104 - REBAR 105 - ANCHOR BOLTS 106 - SEWER & WATER 202 - UNDERFLOOR PLUMBING 203 - UNDERFLOOR MECHANICAL 204 - UNDERFLOOR FRAME 205 - UNDERFLOOR INSULATION 301 - ROUGH PLUMBING 302 - TUB & OR SHOWER 303 - ROUGH MECHANICAL 304 - ROUGH ELECTRICAL 305 - FRAME 306 - HOLDOWNS 307 - INSULATION 308 - SHEETROCK 309 - EXTERIOR LATH 310 - INTERIOR LATH 311 - SCRATCH COAT 313 - ROOF NAIL 501 - FINAL ELECTRICAL ENERGY 502 - FINAL PLUMBING ENERGY 503 - FINAL MECHANICAL ENERGY 504 - FINAL BUILDING ENERGY 505 - FINAL ELECTRICAL 506 - GAS TEST 507 - FINAL PLUMBING 5 FINAL MECHANICAL 09 FIN /2-, Issued b y 5 N G 51 WORKS Date Re -roofs Type of Roof 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 all new materials for inspection. Signature of Applicant Date AIT rnnf rnverinac in he f'Tasc "B" nr hetrer