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04030139nee, 00 7, W. ?� Z ��O 3 U 'off' �oo F?t �FO z z C F= aC UC UC �F � L C. Uz CITY OF CUPERTINO ' ,�''-''�' BUILDING DIVISION PERMIT CaONTRAC,TARyINFO,RMATION ou,LDTNG ADDRESS: SC PLUMBING PERMIT"04030139 OWNER'S NAME: PERMIT ISSUE DATE .ONE: SANITARY 0. OL NO. ARCHITECT,ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION emby affirm a, l am licensed under provisions of Chapter Y (commencing 1 hfirm N o Jb Descrip t �® w �' with Section]000) of Division 3 of the Busire.. and Profession Code, and my licevc is ■ QYIS �i L®® infull force amertm ./2'47 > Liceot000x Class NEW GREASE INTERCEPTOR a Cunlracwr„ G APR 0 6 2004 ARCHITECT'S DECLARATION 1 underaund my plans shall M used as public records BUILDING L.icimsed Professional OWNER -BUILDER DECLARATION exempt f I hereby affirm that 11..Bump, from the Common's License Law for the fallowingrtaaon. (Section ](IJ L5. Basieo. and Professions Coda: Any city or county which wquirts permit to cpres,ho, alcor, improve, demolish, or repair um ed umm prior to its ceased p ossa myuims the applicant ror.rich Com permit m ice s signed stawmem n that he pursuant to the law(Chapter 9 Sq. F[. Floor Area Valua[ on of Division Business aMProfessions Code) or (commencing it ofDivisiooftheComsiness and (commencing exewith Section sof he Any violation of and burs for the, u exempt them from and alleged caucant .,F, 3 �4(;lll 0 Occupancy Type be subjects the applicant to a civil penalty of or to Section by any doll for not momthan (M)mit not mom Nan fia< hundred dollars (5500). 0 I, ss owner of the propmy, or my employcu with wags u Uev a01e rompenu0on, Required Inspections will do the work, and the swcture is not intended or offend for sale (Sec. 7014, Business and Professions Code: The Conlvctor's License law does not apply in an owner of propertywho buildaarimpnsv thereon, and whodmsuch work himself or through his own employees, provided too such impwvemems art not intended oroRemd formic. if, however. Ne building or Improvement Is sold within one year of completion, the Owner. builder will have the burden Of proving Out he did not Wild or improve for purpose of sale.). 0 I, as owner of one prop)., em exclusively contracting with licensed cmmosem3 w construct the project (Sec. 7011. Business and Professions Code:) The Chinni Li cease law does not apply b an Owner of property who builds or improv themon, and who contracts for such projects with a eonvacwl0) licensed pursuant o the Commerce& License law. ❑ I am exempt under Sec. B A, P C for this muon Ownu Dau WORKER'S COMPENSATION DECLARATION I hereby aRrm under penalty of perjury one Of the following declarations: I have and will maintain a common of Consent to sel0insure for Workers Compere -'ion, as provided for by Section 3900 of de labor Code, for the performance Of the work for which this permit is issued. [[QQ11 I have and will maintain Wmlm,'s Compensation Insurance.. .cup ired by Section 100 of the labor Code, for the lerfmmance of the work for which this permit is issued. My Workers Compensation Insonnce, carrier and Policy num her art: i5 Cartier. I'G INTIFIC Policy NOM OF EX WOR ERS' CERTIFICATE OF MON MOM WORKERS' ' COMPENSATION COMPENSATIONINSURANCE ' (Thu section need not M1ecompleted if Ile permit is foronc hundred dollars (5100) or less.) I sentry shut in the performance of the work for which this permit is issued. I shall oat employ any person in any ..a, u w become subjea to the Wmkeri Compcnadon Laws of California. Dau Applicata NOTICE TO APPLICANT. IL after making this Omifici se of Exemption, you should become subject in the Worker ComPcnution previsions of the Labor Code, you most forst comply with such pmvisinm of this permit shall W deemed mvoked. CONSTRUCTION LENDING AGENCY I hereby alRrm that Vert is a construction lending gency for the Performance of ' one work for which this permit is issued (Sec. 309]. Civ. C.) Lenders Hamc LcMeru Addw.. I certify that l have read this application and some that the about infotma,ion is ' cornea 1 agree to comply with all city and county ordinances and state laws misting in building construction, and hereby vuthonm reprounlativ of this city to toter upon the alhove-mcnuoned property for inspection purposes (Wo) agree to an, indemnify and keep homileu the City of Cupertino against liabilifi)s, judgments. costs and expenses which may th any way ucruc against said City in consequence Of the grunting of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGULATIONS. Re -roofs Type of Roof Signazum of ApplicaDew HAZARDOUS HAZARDOUS MATERIALS DISCLOSURE Will the applicant or Wilding occupant mom or handle material mfuwm Health az Ocfmcd by Ne Cupertino Municipal Code, Chapter 9. 12, and ,M1e Health and Safety otic., Y.35533(al] �y'Ad\ No All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the aPpfoaot or fdlure building Occupant use equipment or devices which mit hoardous air conmminanu u defined by the Bay Arca Air Quality Management all new materials for inspect,". lDtotriciliVVV [3 Yes fl1 No is myuimmcnu under Chanc ti.95ofde Califer- I have mss the harardlw/F� a Heal" afeycode, Sectio,35533 and35534.1undersuid Nalifou Nilding /, as nm cu )oily M1pse a u:namu my rtsponsihililY w nntil'y the occupont of Nc 0`� e which gWre"ionove r ertifOaolOccupancy. Signature of Applicant Date All roof coverings to be Class "B" or better owner ar aathoraed asenl Dme SEIM CITY OF �UPEkTINO C Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: y3Svc i PERMIT # d2vo OWNER'S NAME: z If PHONE # (& 91,,V-1110 GENERAL CONTRACTOR: 6. if, , FAX # _ /5 — I am not using any subcontractors: (�fzfH_� .LY lmt- Gz� 3 Signature Date Please check applicable subcontractors and complete the following information: $zU:d-- 4&�� Owner/ Contractor Signature 3ise74el 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 $zU:d-- 4&�� Owner/ Contractor Signature 3ise74el Date CITY OF CUPERTINO CITY OF CUPERTINO u PERMIT APPLICATION FORM l 3 U 37 q1FAPN # Z- Date: 3-15-c Building Address: L2im2 Mailing Address (if different from building address): Owner's Name: / f'E46W Phone #: ( G5It:') vy- 60 o100 Contractor: . 1 License #: 17� s> Contact Phone: 4(61r�J9GY /310 Fax: Cupertino Business License#: o2167 B iding rmit Info: Bldo,ej Elect ❑ Plumb Mech ❑ Job ription: Residential ❑ / �vV r Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: 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 BBOILER3 Boiler > 500K to 1M Btu MECHANICAL 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 AIL BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING U 1 of 3 CITY OF CUPEI�TINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTRYIE 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 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 > l 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/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, Marquee ELECTRICAL 2 of 3 CITY OF CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMTHEATR Theatrical Ligbting 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 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 Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 6 3 of 3