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04040116I 0z z V x� L4 C C UJC OU. F FV U2 CITY OF CUPF,IL'I'INOr�'x . 'v+ °sew=°>t rte.&, v BUILDING Dlvfslory PERMIT (,ONTRACTOR INFORMATION ' BW LDING ADDRESS: PERMIT NOn 4 04 0116 OW NEWS NAME: PERMIT ISSUE DATE ANJALI & VIREND 04/19/2004 ONE: SANITARY NO. CONTROL NO, ARCHEEEC PENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MICH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hhereby afOmrm at I am licensed ander provisions of Chapter 9 tcommet,as with Section? M)of Division Sof are Businessand Ptofessions Code,and my license is tofall fineaeffect. CHANGE COOKTOP TO GAS License Classs Lie. M ��® Dam Contractor. ARCIIITECT'S DECLARATION 1 understand my plans shall he used as p.hlic records MAY 140 2004 Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 rte exempt from the Cnmramur's License Law fur the sl��®�� following reason. (Section ?031.5, Business and Professium Code: Any city Or county �e tl@IHI which requires a permit to eonsoum, alter, improve, dcmulixh, or repair any motivate 00 poor to its issuance, also requires the applicant for such Permit to file a signed statement Sq. Ft. Floor Area Valuation that he is I ime mcd pursuant to the provisions of the Contractur's License Law (Chapter 9 - (commencing with Section )tip) of Division 3 of the Business and Professions CWe) or that he is exempt therefrom and the bilis for the alleged exemption. Any violation of 3 2` W8ND baber0 0 Occupancy Type Section 7031.5 by any applicant for a permit subjects rhe applicant to a civil penalty of not more than rive hundred dollars (350(1). El I, u owner of the initially. .1 my employees with wages as their sold cma,m itiaa Required Inspections will do the work. and the swnum is not intended or offend for sale (Sec. 70x4, Business road Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who does such work himself or through his awn employees, provided that such improvements we nut intended or offered ler sale. If, however, the building or improvement is sold within one year of completion, the owner. builderwillhave the burden of proving that he did not bund or improve for purpose of G51r, as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec. 7014, Business and Professions CWe:) The Contractor's Li. more law does not apply to an owner of property who Wilds or improves themon, and . who contracts ler such projects with a contractor(:) reerud pursuant to the contractors License Law. l am exempt and r See._ . R k�PCfar this . �..on �' � Owner v Date 7L..� 04 1RFCOh}P'NSAI'ION DECLARATION WOR rebyaffirm under penalty of Perjury one of the following declarations: I have and will maintain a Ccnifieme of Consent to self-insum for Workers Compete ration, as provided for by Section 3700 Of the Labor Code. far me performance of the ..,it for which this Permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 31W of the Labor Code, for the performance of the work for which has permit is issued. My Worker's Compensation Ineumncat carrier and Policy number am: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE maho section need nm W completed if the Permit is for one hundred dollars (3110) or les,) 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 az to Wcome subject to the Workens Compemalion Laws of California, Getc Applicant NOTICE TO APPLICANT: If. after making this Ceni ficem of Exemption, you should Wemm subject to the Worker's Compensation provisions of the labor Can , you man forthwith comply with such provisions or this pcom it shall W deemed mvnked. CONSTRUCTION LENDING AGENCY 1 hemhy affirm arm there is a conzauctinn lending agency Ior the Performance or are work for which this factor It is issued (Sec 3097, Co. C.) Lender's Name _ Larder's Address 1 unify that 1 have mad this application and sate that the above information is mucel. I agree to comply with all city and county ordinances and state laws relating to building construction. and hereby authorise «presenutiws or this city to enter upon the abovementioned property for impedtion purposes. (we) agree to save, indemni ry and keep harmless the City of eviction against liabilities, judgmer s, costs and expenses which may in any way seethe against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOUg�ccE.�RE ULATIONS Re -roofs __d "n 4�1.1/0 � S,g Ire 'Ap Date a60U5 MATERIALS DISCLOSURE Type of Roof Will the applicant or future huilding occupant store or handle hararduus material az defned by the Cupertino Municipal CWe. Chapter 9.12. and the Health and Safety sae, section zss3z(an�.. All roofs shall be inspected to any roofing material being installed. ❑ Ycs prior If a roof is installed without first obtaining an inspection, I agree to remove wu1 me applicant m stare Wining meapant use equipment or devices which ,it us air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection. Istrila?et, ❑Ycs typo I have mad the hammous materials mr,mo mens under Chapter 6.95 of the Califor nia Health 2 SammyCWe. Siemens 25505,25531 and 25534.1 understand and Rate Wilding docs not l'urtcnlly have a mnam, that it is my responsibility on nastily the numpanl Of the aqui mens hien uv mot onrtoissuammoracerdfeamoaeueoey. Signature of Applicant - Date 9a All roof coverings to be Class "B" or better owe soma- n1— Date Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 CITY OF Fax (408) 777-3333 �UPEkTINO Building Department 4 JOB ADDRESL�,-2/0435, DFtY)pS'rrr- HV . CVPFrtTrNO , C4 o 1 PERMIT -t v OWNER'S N N -M e t KI RLos tip PHO los 3 GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followine information - ' V \ LI I ', . • Ir SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing rg n Roofing Septic Tank Sheet Metal Sheet Rock Til ice . D Date e ' V \ LI I ', . • Ir SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing rg n Roofing Septic Tank Sheet Metal Sheet Rock Til ice . D Date *1 f \` CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTRAE inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool 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 Pi e PLUMBING 14 IF BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection 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 > 1 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 Ij 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Mar uee ELECTRICAL 2 of 3 CITY of CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL' BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection 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 EPERMITFEE Elee Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3 of 3