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00060071000 4,JO7 j -CITY OF CUPERTINO BUILDING PERMIT APPLICATION FORM Building Address: u p ` /02 �o 15q,5,8 ROAD Owner's Name:� / Coepo i2ATio N Phone No: °8 • ? 7 - I �l Contractor:License �elYlE. Co �S lztt G , v w1 �RP- No: 'l l07' 9�j' Contact: M1GDA /1lIG4�ZAR1,0 Phone No: A;K' g� Architect/Engineer License No: C- Ii -4.9s' VoLJ-t-EPe-G2LiMA)3 Energy Add Multi Applicant/Contractor: BOVERTIME Building Permit Info: (circle one) BUILDING Bld lect Plumb Mech 76 - -Description: Residential: ommercial: Sq. Ft. Floor Area: lo, G q.TV.. APN # (Must provide): 20_.0jo Valuation 11, p&C Type of Construction: Occupancy Group: Qty, if Fee ID Applicable Fee Description Fee Group BTEMPPERM Temporary Bldg Permit BUILDING BCONSTAX Construction Tax BUILDING BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BOVERTIME Inspection Overtime BUILDING - BPERMFEE Bldg Permit Fees BUILDING BMITIGAT Housing Mitigation Fee BUILDING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BREINSPECT Reinspection Fee BUILDING BSCBLVD Scb Specific -Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING ZADDCHG jAddress Change IBUILDING EPERMITFEE Elec Permit Issuance ELECTRICAL. BELEC1000 Elec 600V <=1000A ELECTRICAL l BELEC1001 Elec 600V >1000A ELECTRICAL BELEC200 Elect Svcs 600V <=200A ELECTRICAL BNEWMULTTI Multifamily Res ELECTRICAL BREMBUSWAY Remodel Busways ELECTRICAL 1 3� BREMFIXT Lighting Fixtures ELECTRICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BRENIRECEPT Rcptl, Switch &Outlets ELECTRICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lghtng Fix ELECTRICAL BSF&2FAM Single & 2 Family ELECTRICAL BTEMP Temporary Power ELECTRICAL BTEMPSVCS Temp Dist Svcs ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL 2p BAPPLOTHER Other Appliances MECHANICAL BBOILER1 Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler >100Kto500K Btu MECHANICAL BBOILER3 Boiler >500K To 1 M Btu MECHANICAL BBOILER4 Boiler>1M To 1.75M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BREMAPPLI Appliance 'Install MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BREMACOVER Ac Unit >10000Cfm MECHANICAL BREMAIRHAN A/C Units <= 10,OOOCfm MECHANICAL BRE'MFURN Relocation Of Furnace MECHANICAL BREMFURNOV Relo Furnace > 10K Btu MECHANICAL rfj BREMINHOOD Installation Of Hood MECHANICAL BRENIRELOCA Relocation Of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL PPERMITFEE Plumbng Permit Issue PLUMBING BNUMULTI New Mulifamily Res PLUMBING BNUSFD New Singlefamily Res PLUMBING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPREPIPE Repipe Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK LawnSprinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt Of Drain & Vent PLUMBING BPWATER Install/Alter Waterpip PLUMBING BPWHEATER lWater HeaterNent PLUMBING BPWSVCS IMain Water Service IPLUMBING oZ C UC O (r U CITY OF CUPERTINO - BUILDING DIVISION CONTRACTOR INFCIItM }7LR r , PERMIT NO. ' BUILDING ADDRESS: OWNER'S NAME: APPLICATION SUB DATE 1.0240 BURR RD ' DOME .CONSTRUCT101'J , CORP =' 00060071. PHONE: - , SANITARY NO. CONTROL NO. DUP.ECT CORPQRATI,01V80 CAIROL I 1%1A-,S,TREET- • , Q�,/12/20Q1O 'ARCHITECT/ENGINEER:, BUILDING PERMIT INFO .. _ -(415)864-6440 BLDG ELECT, PLUMB_ MECH • ` LICENSED CONTRACTOR'S DECLARATION Job Description . I hereby affirm that I•am ]ieensed under provisions of Chapter 9 (eornmeneing - with Seetion 7000) of Division 3 of the Business and Professions Code, and my license . isin full force and effect. - -, _ License Class Lie. #. - _ Date Contractor ARCHITECT'S DECLARATION 'I understand my plans shall be used as public records h - TENANT IMPROVEMENT.- - Licensed Professional . OWNER -BUILDER DECLARATION . ., I hereby affirm that I am exempt from the Contractor's License Law for the following mason, (Section 7031.5, Business and Professions Code: Any city or county- - which requires a permit to construct, alter, improve, demolish, or repair any structure.- priorto its issuance, also requires the applicant for such permit to file a signed statement Sq. Ft. Floor Area . Valuaii6n ' 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 703 1.5 by anyapplicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). APN Number - Occupancy Type ❑ 1, as owner of the property, or my employees with wages as their sole compensation, J, $2000000. 00 - „ ' � Required Inspections. will do the work, and the structure -is not intended or offered for sale (Sec. 7044, Business and Professions.Code:The Contractor's LicenseLaw does not apply to ari owner of property Who builds or improves thereon, and who does such work himself j'�`� i �o Q�4]( , or through his own employees'' provided that such improvements are not intended or _ offered for sale. If, however, te 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.). - 1.01 — FOUNDATION, Ohl• ❑ I, as owner of the property, am exclusively contracting with licensed contractors to ,, QIP -- I ERS - construct the project (Sec. 7044,+Business and Professions Code:) The contractor's License Law does not apply to an owner of property who builds or improves thereon, �, J — UFE R and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. 104 — REBAR CJI am exempt under Sec. `" , B & P C for this reason ' - - 105 ANCHORJ330LTS ate Owner' WORKER'S COMPENSATION DECLARATION r -.SEWER 1.06 . SEWER .& WATER I hereby affirm under penalty of perjury one of the following declarations 202— UNDERFLOOR, �F'LUMP► I IaIG - ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's ' 203—,,,UNDERFLOOR MECHANICAL Compensation, as provided for by Section 3700 of the Labor Code, for the performance ofthe work for which this permit is issued. ` , `. h o GQl'Y- -- ,LIItiIDERFL00R -FRAME. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 20.5 — UNDERFLOOR' �111SULAT I ON 3700 of the Labor Code, for the performance of the work for which this, permit is - s - 301 — ROUGH. PLUMB I11 NG,'-- issued. My Worker's Compensation Insurance carrier and Policy number arc: ' " - • , _ , Carrier. Policy No.: _ �.,�L 2 '— , TUB AOR SH�J�P•)EP. CERTIFICATION OF EXEMPTION FROM WORKERS' -' r 303. — 'ROUGH - MECHANICAL,,, 303'. COMPENSATION INSURANCE . (Tttis section need not be completed if the permit'is, for one hundred dollars ,r.' !�'��i ROUGH' ELECTRICAL ($100) or'less.),. ., - " 305. = FRAME' I certify that in the performance of the work for which this permit is issued; I 'in ;�ll]j G— HCILDC]V,)1'rIS shall not employ any personany manner so as to'become subject to the -Workers' , - Compensation Laws ofCalifornia. Date ,�77� h ^ vyr7 — I nISL1L(� -t I I ON Applicant .308 — SHEET ROCK - ' NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must _ - forthwith comply with such provisions or this permit shall be deemed revoked. y T ��� — • EX' 1 •E R I O R Lr1TH + , ' CONSTRUCTION LENDING AGENCY - 310 — INTERIOR LATH _ I hereby affirm that there is a construction lending agency for the performance _ of the work for which this permit -is issued (Sec. 3097, Civ. C.) i - 31. 1 -- SCRATCH -COAT . e Lender's NamAddress ,Lender's Address � - � � ].._t — ROOF NC4I L _ ., • . ti'r I certify that I have read this application and state that the above information is r 501, — -FII AL ELECTRICAL . ENERGY .. - 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 502 —. F I NAL ' P L UM B T NG ENERGY, the above-mentioned property for inspection purposes., (We) agree to save, indemnify and keep harmless the City of Cupertino against' 503 — FINAL MECHANICAL -EIV ERG ' liabilities, judgments, costs and expenses which may in any way accrue against said����. City in consequence of the granting of this :• ' , — -FINAL AL1.L L..D I nIG EI�aE RG permit. APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT - Issued by:. ' .'�112I`=t — F TSI EL ECT R ZrCALate SOURCE REGULATIONS. _ Signature of Applicant/Contractor 1 Date Re -roofs . r — ' AS '.i EST - .' "HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material' - ,t,�1(J�- — •F I IVAL• PLUMBING.; ,. Type Of . ROOf- as defined by the�Cupertino Municipal Code, Chapter 9.12, and the Health and Safety - Sy. j�[� — FINAL IpIEL+I'IAIt+! I CAL . - Code, Section 25532(a)? ❑Yes ❑ No .All roofs shall b6309�eeted plW4L aeR0JWg material being installed'. Will the applicant or future building occupant use equipment or devices which If a ro41S;1nStaM#@vit•IIogr# ta�tlLn jjA�ltllp�.�ctlOn, I. agree to remove emit hazardous air contaminants as defined by the Bay Area Air, Quality Management District? C1 Yes C1 No,. all new materialbfP jnspegi TN&p�&uygers *Fa d willcomply with ` all-non=point source regula Ions.. I have read the hazardous materials requirements under Chapter 6.95,of the California Health &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 they - - - - occupant of the requirements which must be met prior to issuance of a Certificate of ' o°°°paney: 'Signature of Applicant Date Aft roof coverings to: be.'Class, `B" or better. . Owner or authorized agent - ' Date _ - , urrwt