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05020161CITY OF CUPEWrINO BUILDING DlvtstoN PERMIT C �,ONTRACTOR,1 ORMATION BUILDING ADDRESS: ERMIT NO.. 5 0 2 0 16 I """05020161 OW NEWS NAME: PERMIT ISSUE DATE LAXMI K RAS ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED SDECons Job Description of CON I amCONTRACTOR I kmby affirm Nal 1 am littmed under pmvkumm of Chapter Y (commencing under p with Schon ]0110) oDivision 3 of tic Businessand Professions Codc, and my liccmc is ,rue, derreC` CHG ELECT. PANEL (200AMP) /GAS LINE s LiccnClm Lk. M Class Dam Contractor TO FIREPLACE & COOK TOP ARCHITECTS DECLARATION 1 understand my plans shall W used as public meets Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that I +m exempt from the Contractors License Law for the following reason. (Section 7031.5. Business and Riessout Cam: Any city or county which requiem a permit m cnnsomet, dtem improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed summem that W is licensed pursuant to tic provisions of the Convector's Liauc Law (Chaplet 9 Sq. Ft. Floor Area Valua$'(31r 00 (commencing with Section ]000) of Division 3 of the Business and Professions Coulee) or that be u exempt therefrom and dm basis for the alleged exemption. Any violation of Section 70]1.3 by any applicant for apsoonk subjects due applicant to a civil penalty of APN Number Occas ane T p Y Y� not marc than eve hundred dollars (ssooy. 36223043.00 0 1, u owner of the property. w my employees with wegu u their able eompenatuon, will do the work and Ne structure is not intended or offered for a+k (Sec. 7654, Bassos•.. and Prefmons Code: The Contractor's License Taw does not appy 0 an mvtmr of Required Inspecti property who builds or improves thereon, andwho doessuch work himself or through his own employees, provided Nat such improvements are nos intended woffered for sale. IL however, the building of improvement is sold within cone year of completion, the owner. builder will I tic Wrdrn of proving Nat he did not build or improve for purpose of Q/1. as owrcr of the progeny, exclusively contramins wit littnud mntrum, i. Sr•C, construct the , B Code:) The Conhereon, Li not (Sec. ]004, Business and Norassi taw doss es Wilds ban owner of Properly who Wilda or improves hereon, and consewho uchapply / C who. Lacca for such projects with a comtumrts) liartsed pursuant m he Conuumh forr Lkem ave. Q�\ Of exempt uncle a ,B&PCfor this moon Owws Dam WORKEFrSCOMPEN9911ONDSCLARLI I hereby affirm under Penalty of perjury one of he following declarations: 1 have and will maintain a Cetficamof Consent to self-insum for WutlmrsCompen- aation, as provided fee by Section 3]00 of he Labor Code, fee the Performance of the work for which his permit is issued. 0 1 have and will maim an Workers Compensation Insurance, u required by Section J] 00 of the Labor Code, for the Performance of he work for which this permit is issued. My Worker's Compensation Inwmn¢ carrier and Poli, mookr arc: Cartier. Poli, No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not W complcwd if the permit is forme hundred dollars ($m0) or LMI.) I Mm fv has in he performance of he work for which his Permit is issued. I shall out employ any person in anyman crs u nk Omambjom 1.0. Wmrkeri Compensation Laws of California. Dam Applicant /,/,� NOTICE TO AP ❑CANT: If, after making is Certificate of Exemption, you should become subject m he Worker's Compensation previsions of the Letter Code, you must foMwi, comply with such provisions or this permit shall W deemed mvakd. CONSTRUCTION LENDING AGENCY 1 hereby affirm that them is a comtmcsion lending agency for he Performance of dm work for which this permit is issued (Sec. 3019], Civ. CJ Lender's Name Lender's Address 1 «nifty dist I. have read his application and some Nat the have inter upon u u coned I agree m comply with all city and county ordinances and auto laws miming to and hereby amhons rcprrsenutiscs of this city m enter upon dm building conswel shove-mentionedprogeny for pro (We) agree to save, indemnify and keep hornless tic City of Culsertino expenses whichpurposes. agxino costs and expenses which may in any way accmc against aid City / incoisiequenc of the in consequence of he granting of his peeress. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT SOURCE EGU TIONS Issued b Y Date Re-roofs Stgmatmm ter Appl,eanucmu na HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will he apPlicam m furore W ildiog occupant swrc w handle hmardous material u defined by the Cupertino Municipal Code. Chapter 9.12. and tic Heal, and Safety Code. SCNe2sslz(.)? E] Yes &N.All roofs shall be inspected prior to any roofing material being installed. . Will the applicant or room, building =upon, use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove not hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. Dixtrico? C3 Y" [g'IMo 1 have meal the hm mlousmateriau,quirements under Chapter 6.93of he Califor- ni+Hcalh& Safety Code. Secuwu 25505,25533 and 75534. 1 understandOutliveWilding does not Contend ham • tenant taut it u my resyomibility In notify the oaup.( of the myui,mamu hmust mCi orwissuroccoraccrtifictuctrQcCupon,. Signature of Applicant Date All roof coverings to be Class "B" or better Owner or mu mored+gent ❑,m CITY OF �UPERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: 2� T e'i , 6 V � o 7.MA/✓/�, COPER-Tt 064 PERMIT # OWNER'S NAME: L4XA41 PHONE # 4D9 Ste' 46 GENERAL CONTRACTOR TA ]) FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followine information: 11, �i 10 :;s.. . 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 11, �i 10 :;s.. . Date I- L_ 14V CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM APN # '2 / a ,1 3 Date: 5VL41O5— Building Address: -2 I n%S /P)q/qu JM cF Mailing Address (if different from building address): Owner's Name: L,4�cM I K �A�STOC Phone #: 4Gg 446 Z3 19 Contractor: ,, License #: Contact: Phone: ()CMI �' �STaG/ Fax: '10 Cupertino Business License#: Building Permit Info: Bldg ❑ Elect Ek Plumb Mech ❑ Job Description:QIVvL* Residential QU44- 9NQ iem-e 4v Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: S00 UD Occupancy Group: Q- 3 Type of Construction: Uk Please check this box if the project is a second -story addition: ❑ Project Size: Standard�q Large ❑ Major ❑ Boiler> 1.75M Btu 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 IM 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 Ener Add Multi BUILDING BINVESTIGA Investigation fee BUILDING I of 3 -9 2-�� 9 aP292, �/ A CITY OF CUPERTINO CT OF PERMIT APPLICATION FORM CUPERTINO 2of3 uanti Fee ID Fee Description Fee Group 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 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 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 Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc A aratus 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 CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity 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 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 s foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3of3