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05050053O Z4 W, W U Q s a CITY OF CUPERTINOVIA '"""�`''` . BUILDING DIVISION PERMIT #COWWRACTQRNFOIAT7UN BUILDING ADDRESS: PERMIT N005050053 5050053 OWNER'S NAME: PERMIT LSUE DATE ONE: SANITARY k05. iftOL NO. ARCHIIECDENGINEER: BUILDING PERMIT INFO BO EO PLO MEOCH ip LICENSED CONTRACTORS DECLARATION Job Description i meaing 1 hereby effort that 1 am licensed under provision, of Chapter 9 (mm with Section 700r.dDivision 3afthc BmineuW Prefuelav Code. and my licenacla t 'Z i— UcevmCluaindeaect. ` Lic.d REPLACE A/C UNIT Date Conuenar CONTRACTOR: ACS 1 u RATION Iunderstand myplans Mallheneed upublccaccords NO PERMIT FEES FOR CITY JOB Licensed professional OWNER -BUILDER DECLARATION i E I hereby .niece that L em exempt from she fess oactofc Licence Law for the t O ii following rcaxon. (Section 7(131.3, Business and Cale: My City os county S improve. docun, which r its fino,Wo • n, 2110 m coassUHMS t e, alter. improve, is permit t or acalr any stractstatemrc ent permit filcacigned statement the Applicant forthe Sq, Ft. Floor Area Valuation tprior hm heitaccusa0.amercquiree dwhemlkemdpuewavmthcProvision, on t< c � 3aluCanusinemalcemldw(CltaPter9 (commencing pt thection 7000) of ft Division r th al eg einassend on. Any visCMe) or that he u exempt therefrom and the bun, for dm aliened esemPdm. Any violation of that he s APN Number Occupancy Type Saban 7031.5 by ury applicant for a permit subjects dm applicant to a civil penalty of not mom than Ove hundred dollars ($500). O 1, u owner of the prapmy, m my mpioym withwps u Neo rotemmpemdm, Required Inspections will do Newark and the smuctum unminmloada offered forsale(Sec. 7044, Business and Profesuiov Code: The Caricatures Liam Law dad oat apply m an W. of q P peopmy who builds car improws Hereon. and who Eoeauch work himsel f car through his now employees. provided such improvemenminove are deut formicthe Q e ofomo@rctl pr year owner. builder NcbwthenbrlmpmverovinghaltwithinarcKarofmmoveforNeower- �� builder will haw dm burden of proving that he did rwt build or improve far purpose of FIIV F ole.). �(/iaL ❑ 1. as owner of the propmY am exclusively connectins with Earned mntracmra m construct On, pmject (Sec. 7044. Business and Profusions Code:) The Conuacros's Li- cove Law data m ower not apply an of property what builds or improve deamon, and, .�/ s,rvrs� `� LII' I who contracts for such projects with a comracta(s) licensed pursuant m the Connatofa License law. i em ase on a/th_is p n jI Ij 03 Cwpn � � Dam 7 Owner // J O 1{n��J �■eLYe ®I IflfBilil�`➢VDp WORKER'S COMPENSATION DECI.ARATION GSY ^*I{j� I hereby affirm under penalty of perjury aro of the following declarations: I haw end will maintain a CeNOamaf Consent to self -insure for Worker's Camper. t en. u provided fa by Section 37W of the Labor Lade. for the performance of the 1M031."00 ok for which this Permit is issued. 1 haw and will maintain Worker's Compensation Insurance. u required by Section of Ne ldba Cade, for Nrmancee perfoof dre work for which this permit ie issued. y Workefs Compensation Innunnce eerticr and Polity number w: rt{ee Polity No.: CERTIFICATE OF EKEMPnON FROM WORKERS' ' COMPENSATION INSURANCE (This motion need mlhecompleted ifthe Permit Is fluoro undrcd dollam($100) or lm) 1 certify that In the performance of the work for which this Permit is Issued, I NJI not employ any person in any manarso as to become subject m the Workm' Compensation Law. of Califomie. Data Applicant NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must ' forthwith comply with such provisions or Nmit shall be dcemed coolant. O CONSTRUCTION LENDING AGENCY , r~ i hereby affirm Nat Nem is a convection u nding ageecy far the performance of > the we,k for which Nm permit is issued (Sec. 3097, Cih, C.) Name QLender's landssAddress Z - O 1 certify that 1 have read this application end sum that the above leformedun Is torten I agree as comply with ell city and county oNi.s and sum tows rclNng to building convection, and hereby anNodre representative of this city to oma upon the show -mentioned PmPeny for inspection purism s. i27 4 (We) agate to taw, imdcmnify and keep hanmses dx City of Cupertino against CI) liabilities, judgments, costs and expenses which may In any way same against said City Z, In comgucece of the granting of this permit. APPLICANT UND RStiyAN/ypq�A'NDD WILLCOMPLY WITH ALL NON -POINT Issued by: Date j— ir�, SOURCE REGU Re -roofs Sisnalurc of HAZARDOUSData MATE RIALS DISCLOSURE Type of Roof handle hauaaterial Will Ne applicent or future building occupant r9,1 hNus m u ticOned by Ne Cupertino Municipal Code. Chapter 9.13.. and Ne HUIN and Safety ni Cada. Section 25532(e)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yrs Own If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use ryuipment or devices which It huudnu, air mmminants as &road by the Bay Ama Air Quality Mansgemcm all new materials for inspection. isulcR ❑Yrs Q+K—" I hew mW On hanamoutraamriau requirements um@rCWpter6.95 of the C.lifor. me RmIthB Safety Code,Seebreu 25505,35533 and 25534.1 undersund rhatifthe Wilding dean rot torten ant. thertlt u my responsibility in ratify dm occupant of the mqulmmen met 'artoissuan a em cepa - Signature of Applicant Date C/ All roof coverings to be Class "B" or better Owner or authorized agent Data I aly CUPERTINO up CITY OF CUPERTINO PERMIT APPLICATION FORM 0 -r -z f-�'`�� APN # 32-b 2-l _ 2?— 02.Z Fee Description Date: S—/1 -0S Building Address:Mailing 2 (I Address (if different from building address): STe✓, s G✓'ee h' Owner's Name: Cl I 0� CvPe�liho Boiler <=100,000 Btu Phone #: 777 ' 3Z72— z7ZContractor: Contractor:n C -S Boiler > 100K to 500K Btu MECHANICAL License #: �? 10 (6 7 Contact: S Pen«rIq?r Phone: q2-- ( 2 P Fax: y7 ?q35 BBOILER4 Cupertino Busin ss License#: Building Permit Info: BldgEl Elect Plumb —/ LTJ Mech L� Job Descriptio Residential Re tt c e AC Vitt i Commercia Sq.Ft. Floor Area: BCONSTAX Ind/Off/Comm/Quasi $/Sq.Ft.: Cost of Project: Con. Tax for BQ Zone BUILDING Occupancy Group: Type of Construction: BUILDING BCONSTAXR Please check this box if the project is a second -story addition: ElPro'ect Size: Standard F-1Laze ❑ Major ❑ BELEC1000 Elec 600V <= 1000A QuantityFee 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 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 F -A ,%)'D�QY � his 1 of C CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 din MECHANICAL BREN AIRHAN A/C Units <= 10,000 din 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 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 Appliance ELECTRICAL 2 of 3 . 0 CUPERTINO 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 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 PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING • 3of3