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04100021CITY OF CUPERTINO CONTRACTOR INORMATIO�Nd., BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 04100021 OWNER'S NAME: PERMIT ISSUE DATE GE L 2 qft11 ONE: SANITARY NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO _ BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description thereby affirm Wt l am licensed under imvisfons of Chapter 9(Commencing —' wits,,' ")af Dw.ad fthe Businsnand Pr inns Code, and mYliceve is imm� J¢maande n 2� '-'----- - - -- CHANGE SERVICE LicensCClma A, a D coons Cori CONTRACTOR: ALPHA GENERAL ELECTRICAL ARCHDEC'S DEC N understood my plans Mall M used u puhli oris Licensed Professional OWNER-BUILDER DECLARATION I hereby ofrom that l am exempt form 0. Contractors License Law for the follnwing moon. (Section 7 W 1.5, Business and PmRaiona CWc: Any city or county which requia permit m com ct. alter, improve. demolish, or repair any Moncton, res Sq. Ft. Floor Area Valua PH., to its issuance. auo ecquina the applicant far such Permit to file a signed s stement Canmumrs License law chapsn 9 Nhe is licensed Pa...' to the provisions of the m (commencing with Secron'1") of Division l of the Business and Professions Code) or ,1000 that M is uempt therefrom and the breis for Ne alleged cumption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type nut mom than fin hundred dollars (S5OOL 35926045.00 I with uNev sol. cont cation, I.•, owner or she y poy.aw gra pe pmpeny,am 10aa,wner or Will do Ncwadc ande: swcturtisnutsLicemse a1firedwdo for Re wired Ins ections q P hot Apply. and Profusions cad.: The ca law dors 1f an awtgr Of weak is i t osu ther.on, and w: AM notih work himffered for ughWe hif. thencon. and Property who buil provided aron.rcd for We. If. Own ledOf suchimis own cmr. / Lire Withini pr mid vnlsarnne year however. Ne building or improvement is sold within one year or completion. Nepose Of builder will have t: burden of proving out be did not build or improve for Purpose of We.). ❑ I, as owner of Ne property. am uclusively contracting with licensed eanuumrs to z -x construct the pmJCet (Sec. ?OW, Business cad Profusions Cade:) TM ContrKmr'.t Lt. can= law docs not apply man owner of property who builds or iMMO M Merton, and, who contracts for such pmjccu with a,muractor(s) licensed pMAMMto thc ContoctoM1 License law. I am exempt un4r See . B k P C for this Tenon Owner Dam - WORKER'S COMPENSATION DECLARATION 1 hereby grim under penalty of perjury one of IM following declarations: lfor Warkeh Compon. ainin • CrnifiCote of Consent (a u6insure 1 ave and will mu smian, u provided for by section 7700 of the, labor Code. for the p.rfearmance of de work for which this permit is issued. ❑ I have and will maintain Worker's Compemadon Insurance, n requited by Section 7100 of the labor Code, for Ne pmformome of Ne work for which this permit is issued. My Workers omperuadan lnsunmme corrin endPo mberart: br % O Poliry / CERTiFlCXEMPr1NFRA WOR ERS'S' INSURANCE COMPENSATION NSURANCE fThuuetion need not Mtempleted if the permit is for-onc hundred dollars ($101) or lest) I CCnify Nat in the performance of 1M work for which data Permit is issued. I shall not employ any person in any mannerso as An become subject to the Woftra' Compensation Laws of Califomia. Dam Applicant NOTICE TO APPLICANT: IL altar making Nis C.nificM, of Esempnion. you should :Came subject As t: Wmscr's Compenudon provisions or N. ohm Code. you mut .', foMwidt comply with such pownicu or Nis permit shall ac deemed revoked. - CONSTRUCTION LENDING AGENCY I herchy affirm that Nem is a construction lending agency fm th, perfurmence of the woic for which this permit u issued (Sec. 7091, Civ. C.) underS Name Leader's Address a Nis application sNet above information u 1 I ttnee Nat I have rend Ned Sum building 1 once to comply with all city and county ordinances and sum laws miming he building construction, and hereby auNome representatives of this city to enter Upon the a:vomennionod properly for inpdc r n puToaes. L (We) agree m save, indemnify and loop harmless de CinY of Cupertino against O Iiabili0u,judgmen¢euts and expenses which may in MY way accrue against said City in consequence of the granting of this Permit APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLN N.POINI Issued by: Date SOURCE m Re-roofs Type of Roof tgnmumo plicanUComracror/ HAZA"o MATERIALS ISCLOSURE am til l occupant More Or addle hacalf, applicant ser forum bpal Co Md Safer As defined by the Cupertino Municipal Cade. Chapter 9.11, end the HcaIN and Safety y d Code. Section Iss7xa)+// All shall be inspected prior to any roofing material being installed. roofs ❑Yu XINo If a roof is installed without first obtaining an inspection, I agree to remove Will t: applicant or future Wilding Occupant use equipment or devices which .mit hmardnu air Contaminants As defined by Ne Bay Area Air Quality Management all new materials for inspection. District? ❑Yes rN. / ?have read Ne aaa ousmate als requirements under Chapter6.95ofthcCalifor- ntkalNkSafny COde,Sxtiom 25505, ]5573 am12557a.I wdcssuM NmifNc Milling does man Currently a Conant that it a my maponsihility an notify the oauPanl of the Date equimmcm normtntrane a r.cemrmamoraapan Signature of Applicant "•�� All roof coverings to be Class "B" or better caner ser am:dmd.,cut m CIT OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM APN # J / D Fee Description Date: /O Building Address- _ Mailing Address (if different from building address): Owner's Name: BBOILERI Phone #: , BBOILER2 Zarl— 2 � Contractor: BBOILER3 License #: Contact: Phone: Cupertino Business License#: MECHANICAL Fax: O 3.a(J' Boiler > 1.75M Btu Building Permit Info: BCONSTAX Construction Tax Bldg ❑ Elect 0 Plumb ❑ Mech ❑ Job Description: Residential Vr ,— Commercial ❑ Sq.Ft. Floo Area: _ $/Sq.Ft.: o2pn0 BUILDING BCONSTAXR Cost of Project: BUILDING Occupancy G up: O ELECTRICAL BELEC1001 Type of Construction: ELECTRICAL Please check e project is a Elec Svcs 600V <= 200A ELECTRICAL second -story addition: ❑ Pro'ect Size: Stand az Laze ❑ Major ❑ BENERG 7 D Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > I OOK 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 > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY EnergyBUILDING BENERG 7 D Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 273JC� �t, 2X-32- CITY o CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2of3 Ouantitv Fee ID Fee Description Fee Group IMP 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 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 rinkler/Backflo PLUMBING BPSTORM StomVRain 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 cfrn MECHANICAL BREMAIRI-IAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BRENIFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BRENR RAPP 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 R air/Alter HeatingMECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Maz uee 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 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 Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING - W 3of3