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04010091CITY OF CUPEWHN0»�.> BUILDING DIVISION PERMIT CONTRACTOR`ANFORMATION R 7dsa'I-dsw'!7a,r , %EY�#Y'k4p,✓ dm,�' xh^a+hkt'evd`d: BUILDING ADDRESS: PERMIT N004010091 ER'S NAME: PERMIT ISSUE DATE NE: SANITARY 0. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MRCH a a a a LICENSED CONTRACTOR'S DECLARATION lob Description p 1 hereby affum that I am IicenuO unqGr Provisions of Chapter, 9 (commencing - with Section 7") of Division 3 of the HviuEskent Prafcuion Code, and my license is in fail LK a ii S7 39 y RESTRIP-FOR HANDICAPED PARKING LOT DAM Contract., . CONTRACTOR: PACIFIC SURFACING INC. ARCHMC`r1ikkC ATION I tend Tun;ehallhe need q Cnceteds V"EPR-B' Liccnu Pmfcssi rte OW NE. DECLARATION I herby .Item that 11. exempt fmm the Contnmah taw for tbe exempt e: Any C following rtamn. Section703 1.3. Business end Rofessiuv Calc: Any city m county which mqutres apemtil to cmmuci, alter, improve, demolish. m mpair any structure prior m its issuance, also mquircr (be applicant for such Permit file a signed statement that he is licecd punuam a the provisions of the Contrecters License law(Chapter 9 v Sq. Ft. FI a Valuat''oa0 (commencing with Section 7Mfi of Division 3 of the Business and Professions Calc) or Bud he is ...PL theufrom and the basis for the alleged exemption. Any Yelf2don of Section 703 1.5 by any applicant for a permit subjects the applicanuo A civil pentlty ofAPN eupan Typ not more than fin hundmd dellen (5500). _ _ ❑l,uownerof NepmMny,ormyemploycawlNwa uJmirxlecmnpenudan. 32633109 00 Required Inspections willdothework,andthesuucmreisnotimmndcdoroRee rorsate(Sce.?W.Business and Professlona Cade: The Canmmors Lune law does not apply As an Owner of pmpeny who buildaar improve themon, and who time such work himself or through his own employees, provided that such improvements art not intended oroRercd for sale. If. however, the building or Improvement is said within one year of completion. Ne owner. builder will have the burden of proving that he did not but to or on prow: for purpose of mm.). ❑ I, as Owner of the property. am exclusively contracting with licensed contractors to construct the ymjen (Sec. 7014. Business and Prafouion Code:) The Conlractorn Li. cense taw does not pply x an owner of property who builds or improwa thereon, and . ' who contracts for such projects with a eonhaemRs) licensed pursuant to the Contracmh License taw. 0 1 um emmpt under Sec. , B & P C for this reason Dem - WORKER'S COMPENSATION DECLARATION I hereby affren under penury of perjury am at the following exclusions: I he end will roMmila a CeniRcam of Covent m x16Wum fm Wartrts Cmmpcm cation, u provided for by Section 3700 of the labor Code. for Jia performance of the work for which this permit Is issued. ❑ 1 haw and will maintain Worker's Compensation Insurance. as required by Section 3700 of the Labor Code, for the performance or the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number art: c 'er Poll o. WS/�17Lf3)63 CERTIFICATE OFEKEMfm N MWORKERS' COMPENSATION I RANCE musaaction need not be computed if the lermh Is farom hundred dallan (5100) or Ice) 1 certify that in the performance of the work for which Nis Permit is issmd, 1 shall not employ any person in any manner an u_ he become subject to the Workers' Compenallon Laws of California. Data Applicant NOTICE TO APPLICANT: If, after making this Cenificaw of Exemption, you should became subject to the Workers Cumpevation provision of th. labor Cldi you muss ' faMwiN Comply with such provision or this permit shall be deemed ranked. - CONSTRUCTION LENDING AGENCY I hemhy ufllrm that there is a constnctian lending agency for the Perfurmaott of tint work for which this permit is issued (See. 3097, Civ. C.) Lender's Name lander',Addmm I sorrily Nu I ban read this application and sum the, the above information is correct. I agree to comply with JI city and county ordinances and sn a law, relating to holding constructs.., and hereby euthonw o pmsenutiwf of this city ve enter th nn IM above-mentioned property for inspection Purlmses. /l (We) agree to sow, adcmni fy and keep hamlets the City of Cupertino Against liabilities. judgments, cosh and expenses which may in any way accrue against mid City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE ATION . Re -roofs Type of Roof "O•o S'gn uttiol'Applicanuconusectur Dam HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building Occupant store or handle intention material u ec0nd by the Cupertino Murat ipal Code, Chapter 9. V2, end the Health and Safety c. SchOm on 25533(a)? All roofs shall be inspected prior to any roofing material being installed, ❑No If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant Me equipment or devices which telt haianenus air com eounanIs dofincd by the Bay Arta Air Quality Management all new materials for inspection. Di mid? ❑ Yv u I haw mad the hunnlous materials requirements under Chapter 6.95 of the Califon nia Hcalth & Smcty Code, Scceons 35505,35533 and 35534.1 undcmand thm if thc huili ing does not currently haw a teem,'he t It is my rcaponsibiltty nodfy the occupant of the m tai ch' met rte C......C.C.rnrc oraapancy. Signature of Applicant Date - L°'0V � � All roof coverings to be Class "B" or better Owner or Authorized agent Me: CITY OF CUPERTINO t'z�'m'"- aks�, �adh';^5y>A.+�'•.'^ti�+ -;'' ''�n " - -- BUILDING DIVISION - PFR CONkTRACTQREINFOR-M #2.u'aa`a . 'S. 4. YY:M1a#.�`L �9'§`.•Po' oda+` 5 �. w+..k BUILDINGADDRESS: PERMIT NO 04010091 _ NER'S NAME: PERMIT ISSUE DATE ONE: SANITARY 0. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION JobDescription I hereby affirm that I am licensed�r provisions or Chapter 9 (commencing, with Section 7") of Division 3 of the Bus' and Profossits. Code.ral my license is infull 1. offices Litt f, S7 39 � RESTRIP-FOR HANDICAPED PARKING LOT Dae O CONTRACTOR: PACIFIC SURFACING INC. ARCHITECumncCr ATION 1 sunt Ian lir used c.,am, K -- Liccnu Pm(wai rte OWNER -BUILDER DECLARATION 1 hereby .Rete Law for y 11. exempt from the Contractor's following mason. e: Any ccense 710 1.5, Business end Code: Any city or county on l eCodon which myuiress....Roll to improve derecli iu tiler, ire repair anyxWmort requires the rorsuh xermittcar ce s,Law Chapter I Insult. slcenseee,alasmgo d rex oap.licantoof far NCII.CrmlllaLicense, of theeBusiessand tmencigwith Sq. FL Floor Area Valua[�o 000 Proklaw(Chatter9 (commencingSection 7 )a(Disiov of the Business and Cam ung with Section 70nd a(Division osis (cat or he I, f r on. My Nn he is excret, th0rt(rom and dm beau for Ne ellcged Cxempd0a My vlalatlon of APN Number Occupancy Type Section 7031.5 by any applicant for a remit subjects she applicant to a civil penally of not mom than five hundred doll.. (5500). ❑I, as owner of Ne pmper,y, armycmplayces wish wagesushcir sole comjenulion, 32633109.00 Requi ns tl ns will do Ne work. and shesuuaum is not intended aroffered fouale (Sec, 7Ddq Business and Professions Cods: The Contractor's Liam Law does not apply 10 an owner of pmoory who builds or improves Neeson, and whodoessuch workhimulf or through his j twn employcrs, provided Nal such Improvements are not intended aroffered forule. TL 1 however. the building or improvement Is sold within arc year of completion, the owner• builder will have Ote burden of proving that he did not build or Impmw for purpose of saleJ. ❑ h u sower of the Pmp ril, am exclusively contracting with licensed conreciors to canton the pmjccl (Sec. 7044, Business sad Prefcssions Code;) The Contmemes Li- ^'- catte Taw does not apply m an owner of property who Wilds r lmprows demon, and, who contracts for such projects wish a canwcso (s) licensed pursuant IF the Conuaclo's Liccnu Law. ❑ l am exempt under Sec . B B P C for thH recon weer Data WORKERS COMPENSATION DECLARATION 1 hereby nation under penalty of perjury am of the following EedsmimV ❑ I haw and will meinuin. ccruncam of Conunl to ul6Wum for Workers ComNn- utiun, ax provided for by Section 3700 of de Later Cade, far du performance of flux ' work for which di$ permit is issued. - ❑ 1 have and will maintain Worker's Compensation Inxvnna, u refused by Section 3700 of the labor OvIc, for de pcfformance of the work for which this pored, is issued, My Warkers Compensation Insurance carrier and Policy number art: C or- poll o. l711(T 6 CERTIFICATEOFEXEMPnON MWORKERS' COM PENSATIOf I RANCE (This section need not W completed If IW Parch is for one hundred dollars ($I00) or Ices.) 1 Maury dot in the perrnrmance of de work for which shin Permit is issued, I eh ll not - employ any pecan in any manmr an an to hecomc subject to the Wohere Compensation Laws of California. Dau Applicant NOTICE TO APPLICANT, If. after making dis Ccnincau or Exemption, you should become subject to Of Worlecra COMM tion provision of the labor Code, you must forthwith comply with such provisions or this Permit Mall be deemed revoked, CONSTRUCTION LENDING AGENCY I W teby aMTm that then is aaomuuctian lending agency for torformarcc or drm walk (or which this permit is issued (Sec. 3097, Civ. C.) Leader's Name Lender's Address I es nify do 1 have mad this application and sate that the shove information is COMCL I agree to comply with all city and county ordinances and sues laws relating to building construction. and hereby authorize representatives of this city to enter upon the ahovmmcationed property for ins ocdon purposes /I (We) agree to saw, indemnify and keep ha mese drm City of Cupcnino against ` Ilabilides.judgments. costs and expenses which may in any way acme against said City in consequence of the granting or this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE. Re -roofs Type Of Roof !DATION Sgn umof Applicand ontractur Date ��/9� HAZARDOUS MATERIALS DISCLOSURE V - Will the applicant OF future building Occupant store or handle hazardous mucrial u dcnned by the Cuperino Muni ifial Codc. Chapter 9.12. and firm Health and Safely Cod Sccdon 35333(e)? All roofs shall be inspected to any roofing material being installed. ❑Yn Ne, u prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant of relate banding «capant use equipment or devices which mit hanfdous air Camara as dcOned by the Bay Area Alf Quality Management all new materials for inspection. Duarte'? [3 Yes u ve I horead the harardaus materials requiumcnu under Chapter 6.95 of the Calirm. nil Health dr Safety Cade, Seedun 25505.25533 and 35534.1 undersuad dm if the Wilding dans not currently have a ¢nano Out it is my rcaponsitelity mery the OMupant or the uyui m chm ar melt' nnissuancc ofaCcmfic of Occupancy. �r f`_�p Signature Applicant Date dg1 of 2d All roof coverings to be Class "B” or better Owner or amhori'rcd ./gr.`-i`� D„e i I "J CITY OF CUPEkTINO Pte•—•+ w 03090178 CITY OF CUPERTINO* PERMIT APPLICATION FORM APN # Date: 326 - 33-/09 1 -20 -04 Building Address: /0555 DC- ANZF, G IVCk • CU�'-�Na Owner's Name: Phone #: p 255-H/06 Contractor: License #: / P✓+u C c $� YPC•N iNc. 6 S 2 39 Contact: Cupertino Business License#: Cla,.A Lat �2I�n FNF97 62z�1 B ding P rmit Info: $ld Elect ❑ Plumb ❑ MeGh Job cription: esidential ❑ l er 1 /}q PGIz D Sq.Ft. Floor Area: $/Sq.Ft.: BCONSTAX Construction Tax Cost of Project: Occupancy Grou 6 BUILDING Type of Construction. Con. Tax for BQ Zone n Comcv,k 12K, 4, 541a,,� BCONSTAXH 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 > 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 BMITIGATC Comm. Housing Mit. Fee BUILDING I of 3 'Z(� 2,7 2/7.7( CITY OF CUPERTINO SCITY OF CUPERTINCO PERMIT APPLICATION FORM 2 of 3 Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res 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 Repipe 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 BREAUU-1AN 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 Fumace > 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 2 of 3 cin o CUPERTINO OCITY OF CUPERTIN040 PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group 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 Sips, 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 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BMISCELL Building Misc Fees BUILDING 3 of 3 t � !.y f: v m z a GG"" 1 k s"k 1f i71 t