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04060053 (2). CITY OF CUPERTINO BUILDING DIVISION PERMIT I PNTRACTOR TNFORMAT.IONt BUILDING ADDRESS: 21 AR QR(74ART) rT SC PLUMBING PERMIT NO.O406OOS3 OWNER'S NAME: PERMIT ISSUE DATE JIM NAGSU )NE: SANITARY CONTROL NO. C 6509641310 AR CHITECDENGINEER: BUILDING PERMIT INFO - PLUMB MECH 0 0 LICENSED CONTRACTOR'S DECLARATION Job S 1 tl 1 heroby affirm that 1 am licensed under provii of Chapter 9 (commencing with Sectio 0(10 of Division Sof the Buslrxss and Profcaslom Code.and my III,.. Lf -11f Cl Lm.x�>- r'j-�S7 fnfo.CI ect �'7—T GAS LINE FOR COOKTOP NOV os 2004 Dau Comrxur ARCHDECYS DEC ION 'nndc�yPtsmelulibenxda BUILDING Licensed Professional OatNE. BUILDER DECLARATION I Mushy. that 11. exempt from the Convenors Lew for the 703 1.5, Business and Rv2uiov Cade: Any city or county (Sec e: Any following fusion. (S. which reyuima s pcmil m crams alter, improve, ticm car repair my xlmnuus I,, illy prior m its le licensed p atsu usquiuss the applicant far such permit m 01e a algae(netemem the that purwanunNcofDislomofNcConvenorsLleemelaw(Chapter9 Sq. F[. Floor Area Valuation (commencingseam t Section of ac Busimuand andtheleadsfar on.AnynnaC°dgar that he u exempt therefrom and the bub (m Ne alleged eumpdoo. Any violation of 3 AFN MnlSer 0 0 Oe Occupancy Y�YP Section 7031.5 by any, applicant for a permit subjects tha applicat, to a civil penalty Of not mom Nen live hundred dollan(S500), ❑ 1, as owner of the property, or my employees with wages as their vele compensation, - willdodtewark.mdtheaunure is not intended caramel forWe(Sec.70aa,Business Required Inspections and Pmfeviom Code: The Conerecmr's License Law dote rot apply toe an mvner of 9 P property who Wilds or i mprovu thereon, and who docs such wank hi msel f or through his own employees. provided thatsuch improvements tie notintended oroaered for sale. If, however, the building or improvement is sold within one year of completion, Ne owner. builder will have the burden of proving Out he did am build or improve for Formic of sale.). 1, as owner of the property, em exclusively convening with licensed mnrocua to convect the pmjecl (Sec. 70", Business and Professions Code:) The Contractors LL _ rove law dote not apply to an owner of property who builds or improves themon, and who comms for such projects with a conwcur(s) liaved pursuant se Ute Contractors Liana Law. 0 lammmaninunder Set ,B&PCfmthbreaan Owner Dau WORKERS COMPENSATION DECLARATION 1 barony alunder Penalty of perjury ram of the following declarations: raffirm, I have and will maintain a Certificate ficate of Consento sols'-insum for re Workers Camper. anion. u provid for by Section 37W of the Labor Code. fm the Performance of the Work for which this permit is issued. ❑ 1 ban and will maintain Workers Compensation Insuraa, u required by Section "I of the labor Code. for the perfarmaa of the work for which this permit it issued. - MyWorkeryCompenmdonlmu cartiu and Polity number art: Curie T .Policy No.: CERTIFI ATE OF ESP MPTIONO KERS' 67 COMPENSATION INSU (This sock. need not be completed dine lemic is for ram hundred dollars (SIM) or Mss.) I anify that in the Performance of the work for which this permit is issued, I shall not employ any Person in any mamearsgu w,�ao s 'cel to the Workers'CompcmeBon Laws of Calif..!.. Dau i Applicant NOTICE TO APPLICANT: IL after making this CeniEca a of Exemption, you should become subject to the Wohers Compensation previsions of the Labor Codi you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affom that Nero is • answciinn landing egemy Room perfomenm of the work for which this permit is issued (Sec. 7097, Civ. C.) Lenders Name - Lenders Address I certify that I ham read this application and sou that the soon information is comet. 1 agree to comply with all city and mumy ordinances and sum laws misting to building convection, and hereby authorize represen atins of this city to enter upon the above-mcmmned Property for inspection purposes. (we) agree to ave, indcmni ly aha keep hamltss the City of Cupertino agaimt Indmithea. judgment, eves and mpcmu which may in any way same against aid City in conxqu .cc of Nc granting of this pcmit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: D so ULATIO /l^r��/r "�' 6 / Re -roofs Type of Roof Sq to ofMpplicanUConwc or Date HAZARDOUS MATERIALS DIS OSURE Will the applicant or futum building Occupant or handle hazardous material deftmd by Nc Cupertino Municipal Code. Chapter 9. 12, and Om Health and Safety ode, Sutton 35532(0? All roofs shall be inspected prior to an roofing material being installed.❑Yes taf If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which it haardnm air contaminants a dc0ncd by the Bay Arta Air Quality Management all new materials for inspection. strict? ❑ Yes 1 haw mad the huandousmeterials requirements under Chapter 6.95 of thc Califon to. Halth & Safe,,Cede, Sam. 25505.25533 and 25534.1 understand! hatuad le Wilding does not currently haw a omens. that it u my reepomildi,, on nouly de Occupal of Na rcquircmcnts whl mm txm555}}}mr as. �pa°fa ever, mcofac Signature of Applicant Date All roof coverings to be Class "B" or better oigmL r�r;.d Dam�� Aw; CITY OF �UPERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followinv infnrmatinn- i C�TContractor Signature 7-0 Date 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile i C�TContractor Signature 7-0 Date 5 F- L L apts CUPERTINO CITY OF CUPERTINO o PERMIT APPLICATION FORM APN # -32-617035" Date: 6=- 7- 0/, 1 Building Address: 7 I o� O Mailing Address (if different from building address): O L rC �tf Owner's Name: Phone #: BBOILERI Boiler <= 100,000 Btu Contracto : C License #: /JLi>5 Contact: Phone:6S6 1`YYYI;j10 Cupertino Business License#:z/O1/ `1 7 Fax: Boiler> 500K to 1M Btu Building Permit Info: Bld Elect ❑ Plumb I( Mech ❑ Job Description: Residential LAY Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: O� Occupancy Group: i BUILDING T o o ctio lrhe �rowr wee �o lease check this bo e project is a l� econd-story addition: F-1 Project Size: tandard IJP- Laze ❑ Major BUILDING Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M 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 LJ 1of3 -1—/ (/✓/ wK;1AS CITY OF CVPERTINO CUPEI�TINO PERMIT APPLICATION FORM uanti Fee ID Fee Description ree urou BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 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 Permit Fees BUILDING BPFIXTURE -Bldg Pblg Fixture PLUMBING BPGAS BPINTERCEP Gas Piping System Fee Ind Waste Interceptor PLUMBING 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 Sprinkle PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen TrapPLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATEREL 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 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT LightinE Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > 10K 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/Apparatus ELECTRICAL BREMRECEPT Rc tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 CUPEI-TING qW CITY OF CUPERTINO PERMIT APPLICATION FORM • 3 of 3 Muantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 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 Inspection BUILDING BS WIM 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 Mecb Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3