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04020086 (2)
CITY OF CUPERTINO BUILDING DIVISION pg CONTRACTOR�INFORMA • ON « € •r'-n° F: & r<'fk'.kh Y:'NIDk,Yesec>3 rz `� BUILDING ADDRESS: PERMR NQ,4 02 0086 OWNER'S NAME: PERMIT 15511E DATE HU ND AT,T,Tq0N E: N SARARY QkhOL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 op LICENSED CONTRACTOR'S DECLARATION JobDescrition m I hereby affirm Net 1 am licensed under provisions of coupler 9(commencing P Zto wiNSecuon7"nof Diviaion1ofda Buri ndRofesslons Code.andmylicenseis „ m full roree and erten. . �= ueenteens Lisch , 3 .� DRAIN SYSTEM 120 ' W/A PUMP �o Date i. Tae'nn 57.<�e CONTRACTOR: T S CONSTRUCTION pp ARCHRECT.,I'S DECLARA ION — K< 1 understand my plans shall he uesed he public remade to U G� Licensed pndossional OWNER-BUILDER DECLARATION i 1 hereby arr m Net 1 am exempt from Ne,Contractor's License law for do 00 following reason.(SationTin IS.Boonces and professions Cade:Any city or county / m Pi' which require a permit in construct,alter.'mnprow,demolish.m rel til any nombon Zspriormiu issuance.also require lM appliexmfor such Mrtniuo 0lc aligned susmem That he is licensed pursuant to Ne provisions of Ne,Conlramrs Umns Low(Chapter 9 Sq.Ft. Floor Area Va 0 N$ (eommeaing with Section T000).(Division l of the Businessand Profusions Code)or .. Nat he u campt theoefmm and the,basis for the alleged exemption.Any violation of Semon 7011.5 by any applicant mr a permit subjects the applicant to a ciAl penalty of APN Number Occupancy Typey mot mors Nan five hundred dpllve($50)? 0Lazownerofthepropcny.armyuoploymwiNmguastnekmkcompem6m. 35922053 . 00 will do de wort and arta Prersdans Code,Than mComnuisc.el Ucenc eorLaw does non.p(Spaly mho t.Business awnu or Required Inspections pmpcnyloy=.psmimpML=hiMn,anawbomesslin d ni Offtf Nrovghnis sun cmployrrs,provided Ineuuch imprewmenssam nes can f c mpeered for sale lf. builder.,Ne building h r improvement is sold within one year of completion.the owan builder will Mve the burden of proving Nat he did not build or improve for purpose of axle.). ❑1,as owner of the propony,am exclusively commuting with licensed contractors to construct dill'pmjen(Sec.7(114.Rusinett and Professlmn Ccde:)The Cennacteri U cess law dull or apply to an owner of property who builds ar imprevu thereon,and who contracts for such prejecks with a contractor(s)licensed pursuant in the Conwcats License taw. O 1 ant exempt under Su. .B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby aRrrn under penally of perjury one of then following contentions: ave and will maimun a Ccnifinam of Convent to elf-insure for WorkeraCompen- cauon,se provided for by Section 1700 of the Wnr Code.for Inc Wife...of the work for which on.permit is issued. Fj 1 have and will mention Worker's Compensation Insurance, required m ed by Section 1700 of the labor Code.for the performance,of den work for which Nis permit is issued. My Workers Confirmation lomnnce carrier and Policy number are, Cmae,., � : Policy No.: CERTIFICATE OF EXEMMON FROM WORKERS' COMPENSATION INSURANCE (Thu sedan need not he completed if the permit is for one hundred dollars(SIM) mf les.) 1 unify that in the pmtifnrtnance of the work for which this pmrmil if issued.I smell not employ any pension in any manner s as in become subject o the Worksri Compensation Laws of California Das Applicant NOTICE TO APPLICANT:If,after making this Cenifieete of Exemption,you should become subject to Ne,Workers Compensation pmvisions of the tabor Code,you moue O foMwith comply with such previsions or this permit shall he dimmed invoked. p= CONSTRUCTION LENDING AGENCY 1 hereby alfnm that ft.is a eonstnrctinn lending agency for the pc,fomantt of L> Ne work for which this permit is issued(sec.309'f,Civ,C.) U a Under's Name 4 l;ndcr's Addmu D )Q 1 unify that I bars read this appliaatian and shim met Ne,about information is Pcortex 1 agree m comply with all city and county ordinances and sure laws relating to U building construction.and hereby aatharis repruenurire of this city to enter upon the f17 above-mentioned property for inspection purposes. y gy (We,)agree in sale,indemnify and tap harmless the City of Cupertino against fq liabilities,pcigmcnss,costs dcspcnsewhich may many wayecemcagainnsaid City L/ 2 in eouequena of the Smoking of this permit. APPLICANT NDERST DS AND W ILL COMPLY WITH ALL NON-POINT Issued by: Date SOL RC LATION Re-roofs Signarurc of ApplianVConuaceor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof . Will Ne,applicant or future building occultist store or handle harallous maarial as refined by Ne,Cupertino Municipal Code,Chapter 9.12.end NC HcalN and Safety Code.section 2 512(a)7 M<. All roofs shall be inspected prior to any roofing material being installed. ❑Yu Will thc applicant or future building Occupant use equipment or dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove LL haaardnns air contaminants as defined by me Bay Arca Air Quality Management all new materials for inspection. ouict7 ❑Yes 1 have read the haraNmnmaterials mquiremcnu underehipmr MS of the Califor- niaHealm&Safny Coec,Secvans 25505.25513 and 25534,1 undersand the ifthe Wilding doe not ce ntly haw a tenant,Nat it ii my responsihilily m nodry Ne mcupant of Ne, mgai omen at lcmee riortu aanceoracertineateorOcnlpancY' Signature of Applicant Dale c owner or aumonm 4M Date All roof coverings to be Class"B"or better m j r - � m 3 o c m u�i 3 `: o m O \}} nI . r`� o N y O -PIC Y • ' � f 5 Qo x i /�J 4kITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO APN # .S 5, 2 26 .S� 3 Date: Building Address: 1_ �jl' Mailing Addres (iftdiffererit from building address): J Q 7 �b i4 Owner's Name: hone #: As Contractor: License #: ,y Cvlt/�' UC l'lf©/Y d f 3 Contact: n Phone: t/ upertino Business License#: Fax: . D 03 - I 45, Building Permit Info: Bld EleC� Plumb ❑ Web ❑ Job escri Fes' t( PITY OF CUPERTINO UP TYOF O 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 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 Interce for 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 " Storni/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 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 BREMPOWER Power Device/A paratus 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 Si s, Marquee ELECTRICAL 2 of 3 (CLQ ?11TY OF CUPERTINO CITY Or PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREMTHEATR Theatrical Li ghtine,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 Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE PlumbingPermit Issue PLUMBING PPLBG Plumbin Fees foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 CTY OF CUPERTINO I . BUILDING DIVISION PERMIT COlVTRACT,ORIIVFO MATIONS'''; BUI,DIN{i ADOR3 5' PERMIT N64020086 4020086 Ms NAME: PERMIT ISSUE DATE / PHONHE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 uoo LICENSED CONTRACTOR'S DECLARATION Job Description y C I hcmby affirm it T am liecrued under provisions of Chapter 9(Commencing p n<Ls with Sadon]IXp)af Division]af NC BusirmasaM Pmfusinru Codc.azul myliccnsc is a infull force and efrol- '�3: Limaaelaa Lie. 9/33p� DRAIN SYSTEM 120 ' W/A PUMP cm,,.Er <�on<5 ref 'cab CONTRACTOR: T S CONSTRUCTION ARCHnELTSDECLARA ION z< I understand my plans shall W used u public records �yU ywt; Licensed Professional S OWNER-BUILDER DECLARATION iP 1 herchy affirm Nal 1 ad scraps from the contractor's License Law for the a0 following moon.(Secuon 703 IS.Business and Profession Cade:Any city or county which require a pandit to construct.alcor,improve,demolish,or repair any structure FZi print in its issuance.also requires Um applicant for such Permit to rile a signed statement that he is licensed pursuant to the pervisimss of the Comrazdri U..Law(Chaptem 9 Sq. Ft. Floor Area VahkltlOn.00 niFG (commencing with Section 7")of Division 3 of the,Business and Professions Cade)or �11U an $ that Is,u exempt th,refrom and the basis for the alleged exemption.Any violation of Section 7031.3 by any applicant for.permit subjects the applicant to a civil penalty of APN Number Occupancy Type not mom than five hundred dollars($500). ❑1,se;owner ofthe property,or my employees with wages as their sole compcnu0on, 35922053 . 00 will do the work.and the swans is not intended or offend forsake(Sm.]066,Business Required Inspections and Profession Cade:The Contractor's Liaise law does not apply s e an owner of q p property who buildsarimproves thereon,and whoduessuchwadhimself or through his ownver.onbuipsvidr improvement m<M1 improvements tie not ear ofdora0,red forare ow.Ir. 1 Wild,,r,Ne buildingb r .ofpis said within ane year of completion,N,Owner. builder will have Nc burden of proving Net the did not Wild or improve for purpoa of E alcJ. ❑Las owner Of dm property..Business ad c fusaires with liaised mntranoss i- / cure La the project(See.o in werorand property who ui Code:)The Contractor's n j cense taw doe not apply je an owner o(pspeny who Milds or improver Nemon,and. who contracts for such OmKcu with a contnnor(s)licensed pursuant in Us Convacloh License law. I em exempt under Sec. .B B:P C far Nia mason r Data WORKER'S COMPENSATION DECLARATION 1 hereby arms under penalty of perjury one of an following declarations: 64 bass and will maintain a Certificate of cmuem to self-incus(wwmicer'sCOmpen- sound.as Provided(a,by Section)700 of the labor Code,fm the pmemunu Of in, work for which Nis permit is issued. ❑1 bare and will maintain Worker's Compensation Insurance.as required by Section 37W or are labor Code.for the penro mance of the work for which this permit is issued. My Wornes Compensation Insurance carrier and Policy number an Carrier. Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE mussection need not to completed if the permit is for one hundred dollars(SIIX) or less.) I unify Nat in the performance.1 0.work for which this permit is issued.l shall not employ any pe son in any manner sec as to become abject to the Wodma COmpcnsatlon Laws of California.Da¢ Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subj=t to the Workers Compensation provision of the Labor Code,you muse .JZ forthwith comply with such provisions or this Permit shall Its deemed revoked. zCONSTRUCTION LENDING AGENCY [•+� I hereby affirm Nat Ncm is a construction lending agency far Ne perenounce " a Ne work for which this permit is issued(Sec.3097,Civ.C.) W Q Under's Name 0. Lender's Address M V Q I certify Nat 1 bane mad this application and mute that the ashen,information is LL F-' torten.I agree to comply with all city and county ordinances and sate lava slating to W movengcenmuclioeand hereby auNadmrcoesca. utivcs Or Nis City mcnmr upon Nc }I37 above-(We)aod gree un avcrty(odemnify ain dd keep es. f, 1 (W,)agree m ase,indemnify and which hay in m the City of again,against y inconsequi ce of th.erauud capcncsmit. may in any way accme agains aid City �. f,z in consequcncc of NC granting of this Permit. ^ APPLICANT DERST DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURC CATION D y 2 Re-roofs Slgnemrc of Applicant/Contsacsr Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future building occupant scoreor handle hazardous material rimed by th,Cupertino Municipal Code.Chapmm 9.12,and the Health and Safety m.S:,to.25532(x)? All roofs shall be inspected prior to any roofing material being installed. Lj es Win Will Nc applicant of rums building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by Me Bay Area Ait Quality Management all new materials for inspection. District? ❑Yes �ta 1havereadthehm MN mesrialssquimmenmunder ,Chapmr6.95ofNeCalifor- nia HcalN h Sdcty Code Sccuons25505,25533 and 25536.1 undersand the if tM Wilding doe rad v'u tly ham a mnan4 Nat it is my msponibility m nauly the aeeuPam Df the dyuir wnmh at lc met norm :uanceof,Cva mOfOrcgpanx Signature of Applicant Date c (� owner er aamorm.e agent Dan All roof coverings to be Class"B"or better