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06050094n+' CI fY bF CUPEkTINO �CTY OF CUPERTINO PERMIT APPLICATION FO M �J APN# `7', �� 0/ ,-3 J I Date: G Building Address: Mailing Address (if different from building address): ' ?J G -,:T� % C- (; °CiNS C ) C-7 C 3 L if Owner's Name: 5 /1 s /-/r1 c Phone #: �i c' 2 / S Zi zi-S Contractor: 0UNC�'L %L19C License #: Contact: Phone: 40 2 2 / 1? �i 'Fax: Cupertino Business License #: Building Permit Info: Bldg a Elect Plumb ❑ Mech ❑ Job Description: Residential ❑ Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: l/ -- Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Boiler > 500K to 1M Btu Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > l OOK to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILERS Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAX14 Hotel and Motel BUILDING BCONSTAXR Constax - Resi/Mobile BUILDING BELEC1000 Elec 600V <= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING I of 3 CITY OF CUPERTINO *CITY OF CUPERTINQ 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 BPCESSPOOL Atmospheric Vacuum Cesspool PLUMBING PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE 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 Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/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 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 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 2 of 3 CITY OF CUPERTINO BUILDING DIVISION PERMI - J COl T .."CTC)R.II BUILDING ADDRESS: PERMIT NO. 06050094 21796 STEVENS CREEK BLVD OWNER'S NAME: PERMIT LSSUE DATE SASHA CUKIC 05/11/2006 _ PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a 0 0 a O p LICENSED CONTRACTOR'S DECLARATION Job Description F I hereby affirm that I am licensed under provisions of Chapter 9 (commencing Z u� with Section 7000) of Division 3 of the Business and Professions Code, and my license is ' <N in full force and effect. INSTALLING ICBO SKYLIGHT y ? License Class Lic. N F, w Dam Contractor ARCHITECTS DECLARATION 2 c4 ¢ I understand my plans shall be used as public records yaU Licensed Professional N oy OWNER- BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the p O <m° following reason. (Section 703 1.5, Business and Professions Code: Any city or county which a to construct, alter, improve, demolish, or repair any swciure $1100 Z y requires permit prior to its issuance, also requires the applicant for such permit to file a signed statement he licensed of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation that is pursuant to the previsions Y F o (commencing with Section 7000) of Division 3 of the Businessand Professions Code) or i 3 m that he is exempt therefrom and the basis for the alleged exemption. Any violation of XUR MVer U U Occupancy Type Section 7071.5 by arry applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections will do the work and the structure is not intended or offered forsale (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 oroffered forsale. 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.). A 1, 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 . ntr who contracts for such projects with a contractors) licensed pursuant m the Contractor's License Law. ❑ 1 am exempt under Sec. , B & P C for this reason / Owner WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I haoe 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 for which this permit is issued. ❑ 1 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 number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE r (this section need not be completed if the permit is for one hundred dollars (SI00) ' or less.) 1 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 bccf�e sub' to the W rk ' Compensation � �� Lo v Laws of Californ' Dale, S Applicant /JS -e? Cr" 4f NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should become subject to Lhe Worker's Compensation provisions of the Labor Code, you must Z O forthwidt comply with such provisions or this permit shall be deemed revoked. z CONSTRUCTION LENDING AGENCY (--� 1 hereby affirm that there is a conswetinn lending agency for the performance of C4 the work for which this permit is issued (Sec. 3097. Civ. C.) Name QLender's Lenders Address Z , U Q I certify that I have read this application and state that the above information is CL '--' correct. I agree to comply with all city and county ordinances and state laws relating to 7 U building construction. and hereby authorise representatives of this city to enter upon the above - mentioned property for inspection purposes - a Ht) (We) agree to save, indemnify and keep harmless the City of Cupertino against Iiabilitics,judgmenLs, costs and expenses which may in any way accrue against said City U ,Z in consequence of the granting of this permit. _ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by Date SOURCE REG LATIONS. _ S 'IN ay �` � —C 6' -j " , Re- roofs Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicanr 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. S 25532(a)? All roofs shall be inspected to any roofing material being installed. ❑Yes �jNo El Yes prior 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 e emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? C-) Yes afqu I have read the hazardous materials requirements under Chapter 6.95 of the Cali for - nia Health do Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a tenant that it is my responsibility to notify the occupant of the requirements which mu t-4r met prior tu,issliancc of a CcrtifRatc of Occupancy. 'J— /6"Y L � A- (7-` Signature of Applicant Date All roof coverings to be Class "B" or better Owner or authorized aunt Datc lj C.> C..> LIZ C� OA 137