03070094 CITY OF CUPERTINO . '*'- � w"�• 'a s w.a,-z " '�
BUILDING DIVISION PERMITCONTRATOR INFO�RMATIO
BUILDING ADDRESS: PERMIT N0.03070094 3070094
OW ER'SN ME: PERMITISSUEDATE
JNE: SANITARY N CONTROL 11.
NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y00 LICENSED CONTRACTOR'S DECLARATION 7bDescri tion
1 hereby affirm that I am licensed under previsions of Chapler 9(commencing op
with Section] )ref i xionJof the Business gitQ�frufc snore do rad license is
�� in fun forte once ✓ 1F9
CHIMNEY REBUILD NALEK3
�_ ueensclaat^' � m.M
Delo COaIOCbr
A xlTecrsO LA 1 CONTRACTOR: NOBLE CONST.
Ise untlemanJ my plans shall kusedupu rtmrds JUL 2 8 2003
� U r
O� Licensed Pmfeuinnel
OWNER-BUILDER DECLARATION BUILDING
UI Dasa G
I hcrcby alarm that I am cxcmpt from tPr Contractor's C :Any c Law for the L f 1�u
a e o folloWhich Mgrireti I (Section 703 1.5,Business and improve,
demolish.
Code:Any city nr county
m which its issuance,
a permit to connmck ellop improve,demolish,ore signed statement z�^ pat he slicenadpurs ant in resthe the
ovisioaorthe Crl c mantorpoicensre ae ovicllomcd
(commencing with
Srstion 70 �nre Division
or the Braetoriul Prae IJw(Chapur9 Sq. Ft. Floor Area Valuat x$000
pl-$ (comm is exempt
pth Scclion VOlnd of Division]Ntkeged exemption.
Any
CMc)ser
.. Nn io is exempt tkrefum and or aper for she subjects
the ell icant t.Any l r(hoon of
not Section7031.5
by any 36Yb!N;9i4cr00 Occupancy Type
not mare Nen ave hundred dolhn(5508).
❑I,a owner of the prepcny,or my employees with wages u their sole compenurian.
will do the work.and the structure is not intended oroffemd for sale(Sca]8a4,Business Rid Inspections
and Professions Coec:The Contractor',Licatue C are
Law deoa not apply to an owner of p
progeny who builds or improves thereon,and who does such work himself or through his 101 — FOUNDATION
own employees,provided that such improvements am not intended in offered for sale.If, 31Z - CHIMNEY REBAR & STRAPS
inthe building or improvement is uld within one year of completion,Ne owner
huadnwill ban she burden ofmoving wthedid nor wudorimprove for purpose of 514 — FINAL PUBLIC WORKS
ole.).
El 1,a owner of the property,am exclusively contracting with licensed contnmors to
conswenhe pro' (Sec.""a,Business and Professions Cade:)The Contractor's Lt.
came Isw drum t pply to an owner of pmpeny who Wilda or improves Norton,and
whne Tracts r ch projects with acentnctor(s)licensedpureuanOotk CealOetor'a
LI se Law r
lam x funder Sec. ,B&PC far lhltr
Ow a, Deese D
R OMPENS OND RATION
I hcrcby on under penally o 'ury one of the fa owing declarations:
I have and will maintain a Ceniacate of Consent to self-insure fm Workcr's Compere
1031.1(s)
ion,u Provided for by Section 3]110 of the Labor Cnee,for the Performance of tM
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section
of the labor Codc,for the performance of the work for which this permit is issued,y Wnrker's Compensation Insurance artier and Policy numkr am:
nicr. Policy No.:
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not k com c if the parmit is for no nominee delta.($IW)
or Ices.)
I certify that in the perm ancc the work for this Permit is nonce,)shall not
],,you acnein mann uln kco c jcd mthe Workcri Compcnse8nn
Laws of California I
Applicant
N ICE TO APPUC W f, It r m in his Ceniaato o matt.1.011.111.121 you should
kr bjeel to the or,i Co n, lien provisions of c bon CMc,you mull
.J�
to I comply who tach prnvisin r this permit than d med revoked.
ZO CONSfRU ON LENDING AGE Y
[-� I hereby affirm that there is comructinn lending agency forthe performance of
the work for which this permit is issued(So,.3(137,ON,C.)
lL) Q Landon No
z Lem,
V 1 certify that T howcomply
read this application and sine that she above informative is
U 0
correct. enif locomply read
city and county a dNinanceune atalo information
relating to
OU building construct i on,an Crthy authorlle Rpmacoladve.of this city to color upon the
atwve-memiunedp try inspection purposes.
UzgL (We)1g to sate,1 damnify and keep harmless the city of Cupertino against
liabiliticc,judg cns,camand swhich may in any way accrue against said City
in ennwqu of the gradin rf thi rmit.
'^ APPL) A NDERSTA S D WILL COMPLY WITH ALL N -P01 T Issued by: Dale
50 KC LATIONS
Re-roofs
S amrc of Applicant/ IOLIm a
ZARDOUS MATERI S❑ CL SURE Type of Roof
Will the appli tour futon building cope Imre or handle havardous muerial
a dcOnee by the C nine Munmi 1 C pier 9.11,sed the Health and Safety
Code,secdes las un All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or future building=upon(use equipment or devices which If a roof is installed without first obtaining an in I agree to remove
it haeardnus air contaminants in dcancd by the Bay Arca Air Quality Management all new materials for inspection.
I
m,icR —/
❑Yes I[ `
I have madth avallous malorials requirements under Chapter 6,95 of the Califnr
Hmlth&Safety Me,Seevom25 533 see 255M.Iuocknsod son if he building
rs not cunemase amon".)h t is my responsibility to notify tk Wc,71 of the
quimm�3. ich most me rill in...of.CeriBmm of Decorum Signature of Applicant Date
u mriz cm / Dat 3 All roof coverings to be Class "B"or better
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM -
CUPERTINO
APN # Date:
Building Address: Mailing Address f fferent 6m building address):
Alto
Owner's Name t) e#: '1
Contractor: i
Contac A P e: 'd-05 6 Cupertino siness License#:
F
uilding t Info:
Bld lect E3Plumb ❑ Mech ❑
Job De ption:
ential ❑ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: t Occupancy Group:
%0 a
Type of Const
ion: Please check this ox if the pr ' ct is a
" second-story additw .
a
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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
BBOILERS Boiler'> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX lnd/OfVComm/ uasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> I OOOA ELECTRICAL
BELE 200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
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
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 Repipe Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent 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 Fumace MECHANICAL
BREMFURNOV Relo Furnace> I 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
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?t! CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM '
CUPEkTINO
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 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 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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
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