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05020130 CITY OF CUPERTINO W�77 ..�. * "�. '` " ✓� BUILDING DIVISION PERMIT CONTRACTORANPORMATION . BUILDING ADDRESS: PERMIT NQ 5 0 2 013 O v OWNER'S NAME: PERMIT ISSUE DATE 1 av' .ONE: SANITARY NO. CONTROL NO. ARCHITECT ENGINEER: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH LOp LICENSED CONTRACTOR'S DECLARATION O O O O wF I hereby affirm that I am licensed under and Professions of Chapter 9(commencing Job Description ih� with Section7 i(U)ofDivision 3afthe Budncss and Pro@ssiuns Code,and my liccns.0 "`are; Inrmlmrceandeno. ,� gu7y� GAS LINE TO COOKTOP S vj? Licu.0c Lic.N� 4-0 Dam Co. / ARCHITECTS DECLACONTRACTOR: APS ROOTER RATION y z< 1 understand my plans shall be used as public records aLicensed Professional `in 5 OWNER-BUILDER DECLARATION 'i M I hereby affirm that I am exempt from th.Contractor's License Law for to 0 0 following reason.(Section 713 1.5,Business and Professions Code:Any city or county y3 which requires a permit ms emnmru s.slur,improve,demolish,or repair any structure prior it,its issuance.also oul 1M applicant for such permit m Gu a signed summem fscthat he is licensed Pursuanuoth.Provisions ofthe CommcwrsuccvcLaw(Chame,9 Sq. Ft. Floor Area ValuatiGtP8 2 5 e t-$ (commencing with Section 7000)of Division 3 of the Business aM Professions Code)or Out he is exempt Orrefmm and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy not more man five hundred dollars(s50ux P Y Type pl,aowuer of the ProRnY•«mY employees wire wage as mein sole compenaton, 36216022 . 00 will do the work,and the structure is not intended oroffeed(orale(Sec.7014,Business and Professions Code:The Contracmrs License Law does not apply to an ow«s of Required Inspections property,who builds or improves thereon,and who does such work himself or through his own emPwysea,provided mat such improwmcnts art not inuMW oroRertd tarsals.If. however,the building or improvement Is Sold within ase year of completion,the owner. Wilder will have to burden of proving that M did act build or improv for purpose of SAM). ❑1,AS owner of the property,am exclusively contracting with licensed comuactors to construct the pmject(Sec 7(14,Business and Professions Code:)The Contrxemri Li- cence Law it=not apply in an owner of property who builds or Improves thereon.and, who contracts for such projects with a ennuactogs)licensed pursuant o the Contractor's rL' s Law. pJ l am exempt on&,See ,B&PCfp,thU owner, Da O WORKER'S COMPENSATION DECLARATI N I hereby afro under Penalty of perjury one of the following declarations: I haw and will maintain a Cenifieste of Consent An self-insure for Worlee'sCompen- tion,a pmvhm for by Section]700 of the Labor Code.for me perfomunce of the w ork for which this permit is issued. 1 have and will maintain Workers Compcnsadan Insurance,a required by Section of the Lobar C.M.for the po fommna of the were for which this Permit u issued. y Workeri Compensation Inumma carrier and Policy number are: rrier. Polity No.: _ CERTIFICATE OF EXEM MON FROM WORKERS' COMPENSATION INSURANCE (Thu section reed not Wconpleud if the permit is forams hundred dellars($100) or less.) 1 cerdfy,Nat in the performance of the work for which this pooh is issued,)shall not employ any person in any mansmrsn AS in hccomn subject m the WorkersCompenaton Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption.you should Winne abjcet in the Walker's Confession.provisions of the LAW,Cod.,you muss wJO forthwith comply with such provisions or this p.rmitmall 4 deemed revoked. z y CONSTRUCTION LENDING AGENCY (•+ l hereby Affirm,mat then is a construction lending agency for the peffumhare of C 9 the work for which this Permit is issued(Sec.3W7,Civ.C.1 1 Lenders Nam. 7 z Lenders Address U Q 1 emsify that I have read this application and sum that the show information is c«eeL I agree to comply with all city and county ordinances and sue laws elating in 0 building consllU[tion,and hereby authorise repmaenufies of this city to enter upon use V) ahovc-es,Judgmomed pmperty for inspection proposes n, (We)agree w saw,indemnify and keep harmless the City of Cupertino against N I.cmite;Judgmcnu.cwtsand ex penseaoolt. may in soy way eccmc against aid City t.1z inconsequenceof On APPLICAlTr UNDERSTANDS AND per mit. ~ SOURCE GULATT ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �A� ��0� Re-roofs Signature oMpplicanUContractir Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occu duumme or handle haiardous stands, AS defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety Code.Otyeess 255]2(x)? All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtainingn inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which ap mit ha ardous air comaminants b refined by the Bay Area Air Quality Management all new materials for inspection. Id. istrict, ❑Yes Nu 1 have mW the haardhws materials requirements under Chapter 6.95 of to Califor. ix Health&Safety Cade,Sections;25505.255]]and 25534.1 unMrsund that ifthe building not cuncndy have•o nam,that it u ory,responsibility w un til,the occupant of thc mel pdorwissuance oraofa Ccrtfrca��cuo% Signature of Applicant Date wns,an aumotad agent D,m All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue - Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 BUPEkTINO Building Department JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE # GENERAL CONTRACTOR. / FAX # I am not using any subcontractors: /�Glir✓ /�P'—O.S Signature Date Please check applicable subcontractors and complete the following information: 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 �_ Owner/Contractor Signature Date (Q- CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM N# Date: i d a i�os Building Address: Mailing Address (if different from building address): Owner's Name: Phone#: Contractor: License#: g3,29V3 e-tys 4670er Contact: Phone: 4WF 71/--527 upertino Business License#: / Fax: Building Permit Info: Bldg ❑ Elect ❑ Plumb IHS Mech ❑ Job Description: 4� -IWnC -/rya77r? ^✓ lei— Residential Qr Commercial ❑ Sq.Ft. Floor Area: S/Sq.Ft.: Cost of Project: 6P00 Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition:-- ❑ Project Size: Standard LTJ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 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 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 Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1of3 ��' � C(,-:alull Its CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM 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 Stonn/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 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BRENU URN Relocation of Furnace MECHANICAL BREMFURNOV Relo Fumace> 1 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 A Hance ELECTRICAL 2 of 3 CITY OF CUPERTINO CUPERF 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 BS WIM 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 PPERNUTFEE Plumbing Permit Issue PLUMBING PPLBG Plumbin Fees foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3