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FY OF CUPERTINO
BUILDING DIVISION PERMIT
OMESTEAD RD BLDG 61 (WEST BUILDERS, INC.
PROMETHEUS
ARCHrrFCT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hmeby affirm that I am licensed under provisions of Chapter 9 (commixing
with Section 70D0) of Division 3 of the Business and Professions Code, and my license is
in full force and effect. 7 et C
License Class Lic. tit 7 J
Dart 7 t Contractor
< iNlCH77ECl S
DECLARATION'
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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 consrttoL alter, improve, demolish, or repair any structure
prior to its issuance. also requires the applicant for such permit to file a signed statement
dust he. is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) or 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 7031.5 by any applicant for a permit subjects the applicant to a civB penalty of
not more tbam five hundred dollars 000).
❑ L as owner of the property. or my employees with wages as their sole compensation.
will do the work and the structure is not imeoded or offered for sale (Sec 7044, Business
and Professions Code: The Comracttoes License Law does not apply to an owner Of
property who builds or improves thereon, and who does such work himself or through his
we employees, provided that such improvements are Dot 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.).
❑ L as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sea 7044. Business and Professions Code:) The Comrsicutes Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who eomracu for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ 1 an exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 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 for which this permit is Issued
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Libor Code, for the performance of the work for which this permit Is issued
My Workers Compensation Insumuco carrier and Policy number ac
Carrier. 5 //I _lr&A)Q Policy No.: ?�a 16ga &J
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSA71ON INSURANCE
(This sectionneed not be cornpicted if the permit is for one hundred dollars (S I00)
or Iess.)
I certify that in the performance of the work for which this permit is issued. 1 shall no
employ any person in any manner so as to become subject to the Worked CompicMdon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this CeniIIham of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby 1IIhm that there is a construction lending agency for the performance of
the work for which this pemdt is issued (Ser. 3097, Civ. C)
Lender's Nam
Lender's Address
I certify that I have read this application and sure that the above information is
correct. I agree to comply with all city and county or6nances and state laws relating to
building comaruction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. Judgment&, costs and expenses which may in any way accrue against said City
in consequeshee of the granting p IL
APPLICANT UNDERSTA S A I ITH ALL NON -POINT
SOURCE REGULAT70NS.
Signalize of Applicani/Coniri6or Date
HAZARDOUS MATERIALS DISCLOSURE
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(a)?
❑Yes >Ii! NO
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
District?
❑ YesNo
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
does not curtendy have a L the it is my 'bility to notify the occupant of the
requirement& which must o Certificate f aney.
Owner or authorized a enL Dam
1608 4TH ST STE 120
(510) 525-9378
PERM11 NO.
08050187
PERMIT ISSUE DATE
07/09/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
INSTALLATION OF EXTERIOR TEMPORARY PROPANE TANK
AND TEMPORARY UNDERGROUND PIPING.
Sq. Ft. Floor Area 1 $4000 Valuation
326090056m
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, Iagree to remove
all new materials for inspection.
Signature of Applicant Date
. All roof coverings to be Class'n" or better
I
4 CITY OF CUPERTINO
FURNACE/AC
CITCUPEkTINO PERMIT APPLICATION FORM
APN # C) q () U
Date: G. �Z • 08
J
Building Address:
00 Tv59-b
Owner's Name:
Phone #:
050.9'3/.3(057
Contractor:
Phone #: V66 7 L % 90 3 y
-?:k(L-bE56S JAC
Fax #: 41a - 74- 150 37
Contractor License #:
Cupertino Business License #:
e025 73115
;?w(0 /
Contact:
Phone #:/ O . 9(Z , Z,6 rJ. 3
%UOL (7wYV
Fax #: S`l0• 5S0 • Z� l
Building Permit Info:
Elect ❑ Plumb 0/ Mech ❑
Residential Commercial
Job Description: 14c" o-oo ! eM)iNLA-c
QVka
_77AWL
For Residential Installations:
Attic ❑ 1" floor D� 2°a floor ❑
Adhere to minimum setback requirementEl
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Re uired ❑
Cost of Project: Type of Construction (Usage Class):
004 -o-O 2 I
Strapped On Platform 7 Bonded New Location Replacement
Valuation:
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
CITY OF
CUPERJINO
CITY OF CUPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Permit Type
Group
FURNACE
FURN/AC
1 MCRAA
Commercial-Repair/Alteration/Add to
M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by this
code.
1 MCREPALT
Commercial for the repair of alt/add to
M
ea heating appliance,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1 MCSUSHTR
Commercial Install/Relocate ea
M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1 PGASCOM
Commerical for ea gas piping System
P
1-4 outlets
1 BPGAS
For each gas piping system of 5 or
P
more per outlet.
1MCAPPVNT
Commercial for the install/relocate/ or
M
replacement of ea appliance vent
installed & not incl in an appliance
permit.
1 BSEISMICO
Commercial Seismic
B
1 MRRAA
Residential Repair/Alteration/Add to
M
ea heating appliance,refrigeration unit,
(
cooling unit,absorption unit,or ea
heating,cooling,absorption or
evaporative cooling system,incl
installation of controls regulated by
this code.
1 MRSUSHTR
Residential Install/Relocate ea
M
suspended heater,recessed.wall htr, or
floor mounted unit heater.
1 MRAPP VNT
Residential for the install/relocate/ or
M
replacement of ea appliance vent
install & not incl in an appl permit.
0
I
city Oh
CUPEkTINO
CITY OF CUPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
FURNACE
FURN/AC
1PGASRES
Residential for ea gas piping system of
1-4 Outlets
P
1 BPGAS
For each gas piping system of 5 or
more per outlet.
P
1BSEISMICR
Residential Seismic
B
1 MECPLNCK
Mechanical Plan Check
M
1MFR=<100
Furnace Syst <=100k BTU install or
relocate ea forced-air/gravity type
fumace/bumer, incl ducts/vents
attached to such appliance up to and
include 100,000 Btu/h
M
1MFRN>100
Furnace Syst > 100k BTU install or
relocate ea forced-air/gravity type
fumace/bumer, incl ducts/vents
attached to such appliance over
100,000 Btu/h
M
1EPERMITFEE
Electric Permit Fee
E
1 MPERMITFEE
Mechanical Permit Fee
M
1
1PPERMITFEE
Plumbing Permit
P
/
(
1 TRAVDOC
Travel Documentation
B
1BUSLIC
Business License
B
C1 F
CUPEV1INO
CITY OF CUPERTINO
FURNACE/AC
FEE SCHEDULE
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
AIR
CONDITIONING
FURN/AC
1 BCAIRHAN
Commercial A/C Units <= l Ok CFM
B
1 MCRAA
Commercial Mech Repair/alt/add
M
1BSEISMICO
Seismic Commercial
B
1PGASCOM
Commerical for ea gas piping System
1-4 outlets
P
1PGASRES
Residential for ea gas piping system
of 1-4 Outlets
P
1 BPGAS
For each gas piping system of 5 or
more per outlet. Comm/Resid
P
1 BREMAIRHAN
Residential A/C units <= l Ok CFM
B
1 MRRAA
Residential Mech Repair/alt/add
M
1 BSEISMICR
Seismic Residential
B
1 EPERMITFEE
Electric Permit
E
1 MPERMITFEE
Mechanical Permit
M
1 PPERMITFEE
Plumbing Permit
P
1 TRAVDOC
Travel Documentation
B
1BUSLIC
Business License
B