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04030005CITY OF CUPERTINO da - mss' `A44�X � BUILDING DIVISION PERMIT a CONTRACTORaINFOR..... • ,. BUILDING ADDRESS: PERMIT NO04030005 4030005 OWNER'S NAME: PERMIT 155UB DATE ONE: - SANITARY O. 0 OL NO. ARCHITECr2NGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 j� LICENSED CONTRACTOR'S DECLARATION Job Description `§ at I am licensed under provens of Chapter 9 (commencing 1 hereby affirm Niil wish Sation 7") of Divivon 3 or the Business and Pmfeuimu Coot. and my license is , Ila /� ��® �a"!Ycl _? p C(g� 3 ■ CHANGE 13 MOTORS r �k{' ARCHI CI'SDEC TIGN MAR 0 2 2004 1< uMc ynJm 1^sshel u Coolie records { BUILDING "teems mid esuA noxi OWNER -BUILDER DECLARATION q 1 .(firm shat 1 a.1. escmpr from the Genlnclard License for the j D city o following recon. (Seruon 703 1.5. Business and Professions Cadc: Any city nr county mcco JE! which requires a Permit to construct, alter, improve, demolish, or repair any structure QQQ ;y prior to its issuance. also requires she applicant for such Permit to rile a signed statement lJcenseLaw 9 Sq. Ft. Floor Area Valuation r< ja tat he isliccusedpursinanttoWepmvisionsoflOcContractor's (Chapter (commencing wish Sukon 70W)of Division 3 of the Business and Profeuians CMO) or c dun k u exempt sheservm and the bssu fee she alleged csempdon. Any viOlatioe of 31Wbi fp"erO 0 Occupancy Type Sneed. 7031.5 by airy applicant for a permit subjects she applicant b • civil pc..try of not in= Nan five hundred dollars (5303). 0 1, ss owner of the property, w my employees with wages ss shelf solo compensation, Required Inspections P will do dm work and the dwctum u rest imended or offered forests (Sec. 7W. Business and Proressiov Cede: The Conttacmrs License f.w does err apply b an owner of 9 prupenY who brei lds or ire pmvv thereon, end who does swh work himtel f or through his Own employes, provided Nm such improvements tie not inbMed worried for sale. If, however. she building or improvement is sold within one Sear of completion, the owner - builder will have thc burden of proving Nat he did not build or improve for purpose of ss10.). ❑ 1, u Owner of the pmprny. am reclusively contracting with licensed eomnebn mo covtnct IM project (Sec. ]044, Business and Professions Code:) The Contractors Li - cove Law don not apply b an owner of property who builds or improves themen, and , who concocts fee such projects with a conuacbr(s) licensed Pursuant b the Contractors License Law. ❑ 1 an estop, under Sec. . B & P C for Nis ronon Owner Date COMPENSATION DECLARATION 1 hereby affirm under penalty of pedur, one of the fallowing declarations: 1 have and will maintain is Cenifmam of Consent to sel6insure for Workers Compere oon, as provided for by Section 37M of Ne Later Code. for Ne Pedmmance Of the rk for which this permit is issued. 15ag;WORKERS I have and will maintain Workers Compensation Insurance, m required by Section 00 of Ne Labor Cede, for Nr peRorma cm Of dere work for which Nis permit u issued. rarme carfim end(P.olicy numbs, Me. g�v kknA,3o7OF sY iiyNo,: gCOMP E3 ON FROM WORKERS' PEN ATIONINSURANCE (Those mwednotbecanplebdifdopermit IsfmarchuM dnilan(SIMI less.) 1 cenify that in Ne Performance of Ne work for which 013 permit is issued, 1 shall not employ any penon in any manner m u in become subject o use Workcri Compensation Laws of California. Dau Applicant NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should become subject b the Workers Compensation provisions of the Labor Code. You most Z forNwub comply wish such prpviuona or this perm I shill Is, deemed mWalud. C CONSTRUCTION LENDING AGENCY 1 hereby affirm shm Nen its construction lending agency I'nr the performance of 7 the work for which this permit u issued (Sec. 3097, Civ. C.) Lenders Name Z Lenders Addmv Q 1 certify Nm I have tad Nis application and dune Net Ne shove ws rmmiun is Correct. I agree 10 Comply wish all city and county Ordinances and arm laws miming no 1 e bueve-omonswnionmdherebyvNorixreomtsenutives of this city to enter noun she for , a fq ahnvLl(we)mlM property, anloopPurposes. indemnhopociiify s agamnst in M UK City ruCa against Nd hick may (we) age b COSU and liabilitles.judgmcnu.costs and cape"•^, which may in any Way Accrue gYvm mid City pf U 6 �/ I Z ^ APPLI ANT or the UNDWTANDS A mh. APPLICANT UND TANGS A WILL COMPLY WITH ALL NON -POINT Issued by: Date SOU CE U NS. Re -roofs Sign sere of App ica Dab HAZARDOUS MATERIAL. DISCLOSURE Type of Roof Will she building store w handle hazardous material a C.pam ior mfurore e. Chapter ss defined by the Cupertino Municipal Code. Chapmr 9.12, and the Health and Safety otic. section 25532(11)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes AN. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment of devices which in hazardous air contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection. District? ❑Yes Q'Nu 1 have reel One harallous materials requirements under Chapter 6.95 of the Califon nia Heillh&Safety Cade. Secures 255(15,25533 amt x5534.1 dthn if the building Joca Ib, c.oily hart a am., Nam ire a my mapmuihilil b nose ant or do mq ire hiehm,rtl�j�"etpri9r ::usnmoracuti e. Signature of Applicant Dale ,t" ipl //— • f/3/0 All roof coverings to be Class "B" or better Owner or atimorind agent Dab r i CITY 0f UPEI�TINO' Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRES,s/ 1a8?)D i{ u^es�et.d (�A�e✓) �o PERMIT # Q 3,-�)fo�2 OWNER'S N jj() M PHONE # 5 (U- 520 36 GENERAL CONTRACTOR: , - FAX # 5lv 7-7711 I am not using any subcontractors: Signature Date rno>ao rino le annlirnhla a„hrnntrartnrS and complete the following information: ZA i Owner/Contractor Signature _ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing j` Heating /vUnYe L 1, M2 c1,c n i 7 521638 Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Til Date e ZA i Owner/Contractor Signature _ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing j` Heating /vUnYe L 1, M2 c1,c n i 7 521638 Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Til Date CITY OF CUPEkTINO r-1 CITY OF CUPERTINO PERMIT APPLICATION FORM o�z o��s r N # G1 t' �T� +per o 9 O 37 Date: Building Address: 199a6 Homs Mailing Address (if different from building address) Owner's Name: 16 /H Phone #: Contractor: MaL1c� MPC�ah, License#: Contact: 1 Phone: ,b e 80.0 Fax: 510- 9-55,0a 5kv-735-7711 Cupertino Business License#: Building Permit Info: Bldg ❑, Elect ❑ Plumb ❑ Mech Job Description: y„9 13 Yh(t.+s Residential ❑ on E^�sY,ti�) J, Pe✓S. Commercial Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: f $ Coo . Up �eJ Occupancy Group: Type of Construction: Eai54i0. AA.Xe,Y5 Please check this box if the project is a second -story addition: ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL i BBOILER3 Boiler> 500K to 1M Btu MECHANICAL i BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ 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 Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING W #2`66 V 1 of y -P �f 5 / , -D l CITY OF CUPERTINO CITY OF CUPERTINO ' PERMIT APPLICATION FORM Quantity Fee ID BNUCOMME Fee Description New Comm Electric Fee Group ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME 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 Dis osal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Stonn/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 Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfrn MECHANICAL BREMAIl2HAN A/C Units <= 10,000 cfm. MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BRFMITJRN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BRENflqRAPP Rem Non -Res A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/A aratus ELECTRICAL BREMRECEPT Re tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Re air/Alter Heatin MECHANICAL BREMRESAPP Remodel Res ADDliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 SII CITY Of CUPEI,TINO CITY OF CUPERTINO PERMIT APPLICATION FORM Ouantitv Fee ID Fee Description Fee Group ATR Theatrical Li ting Fix ELECTRICAL FAN Vent Fan Sin le Duct MECHANICAL SYS Ventilation S stems MECHANICAL D M Scb S ecific Plan BUILDING OM Seismic Commercial BUILDING RE Seismic Fee Res BUILDING BSPECIAL Special Inspection 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 Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERNUTFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3