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03100011, 04060206, 04090025moa Y� CV Z njt :404 Y �l a 0 00 kmKA 7J N FZ< 5a 3 0 z FY'UCr -�' R� Q az UC L:. E OCrC a U CITY OF Ci1I'EItTINO *7��r-3� C� ` d� �tt BUILDING DIVISION PERMI BUILDING ADDRESS: PERMIT NO. 03100011 OWNER'S NAME: PERMrf ISSUE DATE PHONE: SANITARY N0. CONTROL NO. SGS OFF 3 ARCHITi ECSIENGINEER', BUILDING PERMITINFO kG✓t BLDG ELECT PLUMB MECH (r' cllo o D D LICENSED CONTRACMWS DECLARATION Job Description 1 hereby affirm that I am licensed under provisions or chapter 9 (commencing with Section 700D) of Division 3 of the Busincas and Pmfcssions Code, and my license Is dtffecL Lie. It LicenlseClasand NEW RETAIL/RESTAURANT/OFFICE Date Contractor ARCHITECTS DECLARATION 1 understand my plans shall be used as puNic records Licensed professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt hum tke Conaacmr's Uccnsc taw for rhe fallowing reason. (Section 70315, Business and Proressiuns Code: Any city or county which requires a permit to construct, alter, impruve, demolish, or repair any structure Prior to its issuance, also rcquires the applicant forsueh permit to file a signed statement that he is licensed porsuanttothe provisionsorftcocrmaaesLimitseLAW (chapter 9 Sq. Ft. Floor Area vat30n (commencing With Section?0DD)ofDivision3orthe BusinmsandPror,onsCade)ar that he Is exempt therefrom 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 3 �1�I8`�tn$er Q Q Occupancy e 1} y T 'p not mom than five hundred dullars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections will do the work, and the structure is Cot Intended of offered forsalc (Sec. 7144, Business and Professlons Code: The Contractor's License Law does not apply to an owner Of propeny who builds orimpravts thereon, and who does such work himself or through his awn employees. provided thatsuch Improvementsare not intended oroffared for sale.If. however, the building or improvemea! Issold within cceyear of completion, the owner- builder will have the burden of proving that he did not build or improve for purpose or sale.). 1, as owner of the property. am exclusively canlracting with Oceased contractors to co eon the project (Sec. 71144, Business and Professions Code) The Conaactor's Lt. cense Law data not apply to an owner of property who builds or improves thereon, and. who contracts for ouch projects with a conuaetor(s) licer=d pursuant Lathe. Contractor's License Law, C1I am exempt and Sea , B & P C for this reason Date �s 1 Fort WORKER'S COMPENSATION DECLARATIOi� ,�// I bereby affirm under penalty or perjury one of the fo1111ff-, Z'g declaraflons: 0 ShaveandwDlinainrainaCenifimieafConsentwself-iassurefnrWorker'sCompen- sation, as provided for by Section 3700 or the Labor Coda for rhe performance or the work for which this Permit is issued. ❑ I have and will maintain Worker's Compensation Insurance. as required by Section 3700 of the Labor Codc, for the performance of the wort for which this permit is issued, My Worker's Compensation livnirance tamer and Policy number are: Carrier. Polity No.: CERTIFICATE OF EREMPISON FROM W ORKERS' COMPENSATION INSURANCE (Thissecdon need AOL beeomplcted Irthe permit is for one hundred dollars (S100) or less,) I certify that in the performance of this work for which this permit is issued, l shall not employany person in any mannerso as to becomesubject to time Workers' CCmptrulation Laws of Califmrda. Datc Applicant NOTICE TO APPLICANT: if, alter making this Certificate of U mption, you should become subject to the Worke{s Compensation provisions of the tabor Code, you must forthwith comply with such provisions or this permit shall be dermad revoked. CONSTRUCTION LENDING AGENCY I hcmby anrm that there is a construcdon Iendingagcncy for dXperfwmanm of the work for which this permit is issued (Sec. 3097, Civ. C.) Leader's Name Lcadc:'sAddress I certify that 1 have read this application and state that the above information is ' cotmcL I agree to comply with all city and county ordinances and state laws relating to building construction, andhcmby authorize rcprrscmatives of this city to eater upon the above-mcntiancd pnopertyfor inspectionpurposeL (Wc) agree w save, indemnify and keep barmless the City of Cupertino against liabilit3u, judgments, costs and expenses which may in anyway accrue against ad City in consequence or the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date REGU SOURCEONS, Re -roofs Type of Roof z_1 O �� S' arta Applicant/Conunctor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12. and me Health and Safety Code. Scction25532(a)? Oyu AN.All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future buiiding occupant ase cquipmtne or devices which emit ha%archers air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes 'ro I have read the hazardous materials requirements under Chapter 15.95 orw califor- Cia Health &SafetyCodo, Sections25505,25533 and 25534.1 understand thnif the building does not Currently have a icnan4 that it is rely responsibility to aoccupant of the _ require cnIsWhich Must bemet prior wissuanceofaCertifica o[Oc panty. • Signature of Applicant Date 254 All roof coverings to be Class "B" or better 0 r era orized agcat Date - a4F CUPERTINO JTY OF CLTPERTING PERMIT APPLICATION FORM oo q, o�l00��1 APN #,561.F,�j — 6 Fee Description e: lo -01-03 Building Address: % 770 5ILev-eq s Cr -Cele Uol- MECHANICAL Owner's Name: )Ever5RAC 'ET, 4,1? Bldg Permits . foot Phone 7WWPe YOB 3 y3 -/,W eek 73`/l Contractor: Boiler <-- 100,000 Btu License #: n P wx*,r p/,4l%� Boiler > 100K to 500K Btu MECHANICAL Contact: Boiler > 500K to 1M Btu Cupertino Business License-#: B ildirig P� 't Info: Boiler > IM to 1.75 M Btu 1 ld Eect ')—P umb 14ech C- escription: Residential ❑ ,� Construction Tax Commercial Sq.Ft. Floor Area: `25666 Ind/Off/Comm/Quasi $/Sq.Ft.: Cost of Project:v �-� Occupancy Group: 2, Type of Constructio% Hotel and Motel ---r l BCONSTAXR Constax – Resi/Mobile Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <-- 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler > IM 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 B Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax – Resi/Mobile BUII,DING BELEC 1000 Elec 600V <-- 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BEWESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING J3` (- 7 I of 3 ��1r�7 -{ 'ITY OF CUPERTINO CITY°F PERMIT APPLICATION FORM CUPEI,TINO 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 13NUCONIMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUM= New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTIME hWection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERIVIFEE Bldg Permit Fees BUILDING BP=URE Pblg Fixture . PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUU-DING BPLANCKREP Plan Check Repeat Fee BUILDING 13PREPIPE Re i e Of Fixtures PLUMBING 13PSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING 13PSPRINK 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 BPWIMATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfin MECHANICAL BREMAM AN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFM Lighting Fixtures ELECTRICAL BRENMAM Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace > 1 OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BRENENHOOD Installation of Hood MECHANICAL BRENWSC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2 of 3 fau" C1TY OF CUPEkT1NO 2ITY OF CUPERTINO PERMIT APPLICATION FORM Quanti Fee ID Fee Description Fee Group 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 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 S ed& 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 r, BUSLIC Business License BUILDING cod ELECTRIC Electrical sq foot ELECTRICAL EPERNIITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERNQTFEE Mech Permit .issuance AMCHANICAL PERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 ui4 CITY OF CUPEkTINO Buil JOB ADDRESS: A/ P07X�#Cf - FW J P 7d s s 6-f dl I1 -Y OWNE_R'S NAME: 4---f1C - GENERAL CONTRACTOR--, fizci4'7 lam, ez Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 ing Department PERMIT # PHONE # �,��,C/s�►-�Gc rXo � -� 6 n*,3 , FAX # "aY ?'02 a�3d.S� I am not using any subcontractors: Signature Date Please check a-Dulicable subcontractors and com.Dlete the following information �2 Dy`d 7-6 el Owner/Contractor Signature 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 �2 Dy`d 7-6 el Owner/Contractor Signature Date Jun 01 06 08:39a Mark Nelson 510-655-8128 P.2 PROJECT: LOCATION: 1a7R0 STEVENS CREDEK BLVD, CUPERTINO. CA 95014 �`�,"""// SUBCONTRACTOR LICENSE # EXPIRATION DATE A & E PAINTING 27688 03-28-07 A R S MECHANICAL 22004 05-31-06 ALOHA CABINETRY 27434 08-31-06 APPIAN ENGINEERING 25775 06-30-05 ARBORWELL 25207 02-28-05 BAY AREA ASPHALT 26130 09-30-05 BLACKWELL GENERAL ENGINEERING 25830 07-31-05 CENTRAL CALIFORNIA INSULATION 557 12-31-05 CIARRA CONSTRUCTION 25308 03-31-05 DELTA BAY WATERPROOFING 25445 04-30-06 GATEWAY LANDSCAPE �� D7 26000 08-31-05 HARD ROK CONCRETE 26187 03-31-07 I NSU L -FLOW 26973 07-31-06 1 JONES PLUMBING�IbeP25835 07-31-05 LE DEIT & SONS GLASS 26901 06-30-06 LEGACY ROOFING 24091 06-30-06 MODERN MECHANICAL 25822 07-31-05 OLIVEIRA PLASTERING 27095 08-31-06 REGEVIG ROOFING 23169 05-31-06 SCHINDLER ELEVATOR 13056 12-31-05 SILICON VALLEY DRYWALL / 26570 01-31-06 SUER MASONRY 11 26294 11-30-05 WALSCHON FIRE PROTECTIO 25576 05-31-05 WONG ELECTRIC 20368 04-30-05 CITY OF CUPERTINO BUILDING DIVISION PERM BUILDING ADDRESS: OWNER'S NAME: EVERSHINE PHONE: ARCi1ITECVENGINEER: v C LICENSED CONTRACTOR'S DECLARATION or l hereby affirm. . that 1 an, licensed under provisions of Chapter 9 (commencing U with Section70(]0)orDivision3oflheBusinitsandProfessionsCode•andmylicenseis n in full force and effect. a Lice= Cfass Lir, k 4— p Date Contractor_ Lit ARCHITECTS DECLARATION � �.a U I understand my plans shall be used as public records a u. Licensed Pfofessional OWNER -BUILDER DECLARATION d1 hereby uffirm that I am exempt from the Contractor's License Law for the cc following reason, (Section 7631.5, Business and Profcssiuns Code: Any City or county X m � which requires a permit to construct. alter, improve, demolish, or repair any structure tiz y priario its issuance, also requires the applicant For such permit to file a signed statement < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapocr 9 mF- o (commencing with Section WW) of Division 3 of the Business and Professions Code) or that he is exempt Iberefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant rot a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 1, as owner of the properly, or my employees with wages as their sole comperuation, will do the work, and the situcture is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Cantaetors Licerise Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employers, provided that such improvements are not intended oroffered for We. If, however, the building orimprovemenl is sold within one year of completion, the owner. builder will have the burden of proving that he did not build or improve for purpose of We.). . Uf 1. as owner of the property, am exclusively contracting with licensed contractors to kobtruct the project (Sec. 7044, Business and Professions Cade:) The Contracmr's Li- cense Law does not apply to an owner of pmperty who builds ar improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec.y--b, , B & P C�foorr Ns reason 0 err ,0`"Z—� �re �V—Z rj-UL WORKER'S COMPENSATION DECLARATION I hereby of min under penalty of perjury one or the following declarations: ❑ ihave and will maintain aCeriilimmofCansealtoselifdnsurcforWwkcr'sCnmpcn- sation, as provided for by Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the pcdorinance of the work for which this permit is issued My Worker's Compensation Insurance carrier and Policy numherare: - Carrier Policy Nm: CERTIFICATE OF FxF1v1 mol,; FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the Permit is for one hundred do][= ($100) or less.) I certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to hecome subject 10 the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: ]r, after making this Ccrificam of Exemption, you should become subject to the Worker's Compensation provisions of. the Labor Cade. you must forthwith comply with such provisions or this parfait shall bdeemed revoked. z .. CONSTRUCTION LENDING AGENCY r y E -r I hereby affirm that thele is x construction lending agency for the perCurmancc of .> the work for which this permit is issued (Sec. 3119?, Civ. C.) Iii A Leader's Name Z Lender's Address U 0 1 certify that 1 have read this application and state that the above information is VZ H correct. I agree to comply with all city and county ordinances and state laws relating to 0 V building construction, and hereby authorize rcprrsematives of this city to cnterupon the U above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City ar Cupertino agaimst ,raj] liabilities, judgments,costsand expenses which may in any way accrue againstsaidCity V z in consequence of the granting of this permit. h� APPL(CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Signature of/Applicant/Contractor Data HAZARDOUS MATERIALS DISCLOSURE Wili the applicant or future building occupant store or handle hazardous material as dermad by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑Yes �No Will the applicant or futurc building occupant use equipment or devices which Cmil hayardous air contaminants as defined by the Bay Area Air Qua]ily Management Disuicl? [:]yesKNu I have read the harardnusmalerWs requirements underChapicr&95 of the Cali for- niaRc2hh&Sakty Codc,Scelions25.505, 25533md255.34.Iundcaiandlhatifthc building does not currently have a tenamt that it is my responsibility to notify the occupant of the requirements whit us be �mm!etrp�riorr to issuance or a Certificate of Occupancy. we Owner or authorized agent Date PACIFIC GENERAL CONSTRUCTIkyUMITNG04060206 510)713- PERM71' LSSUE DATE SANITARY NO. CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB � o 0 Job Description DEFERRED ELECT./MECH ORIG. 403100011 (SHELL ONLY) q. Ft. Floor 36906009.00 Required Inspections Issued by, Re -roofs Type of Roof Occupancy Type All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better (a CITY OF CUPEkTINO I 'ITY OF CUPERTINO PERMIT APPLICATION FORM D< C/D APN # Date: bG 016 Building Address: 111 %1k.1FTp1Y7e 6 Mailing Address (if different from building address): 70 Owner's Name: Phone #: Pb- 3 y3- 40 ' - 73W MECHANICAL BBOILER2 Contragtor: I pga License #: Contact: Phone: 570- X7j- 3116 Cupertino Business License#: r7ark Fax: BBOILER4 Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech Job Description: l Residential El� e ed�C %�ic�f t 3 Aly? Commercial Sq.Ft. Floor Area: $/Sq.Ft.: 256W Construction Tax Cost of Project: 1300100a Occupancy Group: Type of Construction: se check this box if the project is a BCONSTAXBQ 44nd-storyaddition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ BCONSTAXH 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 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 > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING I of �� 3 carr oF, CUPEkTINO `ITY 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 BNUCONEVEM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIlI E 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 BPSPRIlVK 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING _ BREMACOVER AIC Unit > 10,000 cfin MECHANICAL BREMAMHAN AIC Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUS W AY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMP-MOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL. BREMPOWER Power DevicelApparatus 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 a . ` CITY OF CUPERTIN( CUPEkTINO 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 Ins�ection BUILDING BSVaM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL r- BUSLIC Business License BUILDING' ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPER)ETFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZA.DDCHG Address Chane BUILDING 3 of 3 goo . w p �ZU C.) z a OyV we 4 �p0 ym� tKit — v. t-ze a CC z c 5- U C UC V. F 0� FCL Uz 4 CITY OF CUPERTiN4 Ilu1LnlHc RrvtsloHPERMI- CTOR4 BUILDING ADDRESS: PACIFIC GENERAL CONSTRUCTI NMITNG-04 0 9 0 0 2 5 OWNER'S NAME: PERMrf ISSUE DATE EVERSHT PHONE: SANITARY ONTROL NO. ARCHITECTfENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm [hat I am lknased under provisions of Chaplet 9 frommencing P with Section 7000) of Division 3 of the Business and Professiuml Code, and my license is in full fortLicenseCl%sdcffect. Lie.B REVISION -SITE PLAN/PLUMBING Data Contractor ORI G PERMIT #03100011 ARCHITEC'T'S DECLARATION I understand my plans shall be used as public records NO NEW PERMIT ISSUED Licensed professional OWNER -BUILDER DECLARATION ' 1 hereby alYren that J am exempt from ft Contractor's License Law for the following reason. (Section 703 L5, Business and Professions Code: Any city or County which requires a permit to construct, altar, improve. demolish, or repair any structure priar[n its issuance, also requires the applicant rursuch permit to file asigned statement thathe is licensed pursuant to the provisions of lheContracloT's license law (Chnptm9 . Sq. Ft. Floor Area Valuation (commencing wilh Section 7000) of Division 3 of the Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number OCCU anC Type P Y YP Secdon 7031,5 by any applicant for a perm)t subjects the applicant to a dv_il penalty of not more than rim hundred dollars ($500). ❑ I, as owaerof [he property, army employers with wages as their sole comperU"don, will do the work, and the structure is nor intended or offered forsale (Sec. 7044, Business 0 0 9 0 0 Required Inspections and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employers. provided thatsuch improvements are not intended oroffered for sale. If, however, the building or improvement is sold within one year or completion, the owner. builder will have the burden of proving that he did not build or improve for purpose of sale.). 1. as owner of the property, am exclusively conLmcdng with licensed contractors to cdnstruct the project (Sec. 7044, Business and professions Cede;) The Contractors Li. cense Law does not apply to an owner of property who builds or improves thereon, and. who contracts for such projects with a eanuactor(s) licensed pursuantto the Contractor's License Law, ❑ I am exemptdd� , B & P C for this reason �u f/Sec Date U —J)7_71 / WG KEWS COMPENSATION DECLA I hereby arf m under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certilicze orCemsent to mf f -insure for WorkerYCumpcn- sation, as provided for by Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. ❑ T have and will maintain Worker's Compensation lnsurance, as required by Sectiou 3700 of the Labor Code, for the performance of the work forwhich this permit is issued. My Workces Compensade n Insurance carrier and Policy number arc: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION 114SURANCE (This secttaa need not be completed if the permit is for one hundred dollars (S 100) or less.) 1 certify that in the performance of the work for which this Permit is issued, I shall not employ any person in any manner so as in become subject [a the Wo kers' Compcnsation Laws orCalifomia. Date Applicant NOTICE TO APPLICANT% If, after making this Ccnifiicate of Exemption, you should become subject to the Worker's Compensation provisions of the LatiorCode, you must . forthwith comply with such provisions or this permit shall In deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance or the work fur which this permit is issued (Sec. 3D97, Civ. C.) Lrndcrs Name r Lender's Address I certify that I have mad this application and state that the above information is ' correct. 1 agree to Comply with all city and county ordinances and state laws relating t0 building construction, and hereby authorize representatives of this city to enter upon the there -mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabili les,judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGULTION �J JJ7 Re -roofs Type of Roof Y'gnature 6f ApplicanLIContractor Date HA,ARDOUS MATERIALS DISCLOSURE Will the applicant or rutum building occupant store orhandle hazardous marcrtal as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Cade, Section 15532(a)7 QYes No 1 All roofs shall be inspected prior to any roofing material being installed. " If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building ocwpaal use equipment or devices which emit ha7Ardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. Districl7 ANN ❑ Yes I have read the hazardoosmaterialsreyuiremrnLs undcrChapler 6.95orthe Califor- nia Health nr Safety Cade, Sections 25505,25533 and 25534.1 understand that ifthc building y we o cupanl o[ the d[.Cc we CarYCa[ly have a Tenant, that it is my rerpan$]hiJlry to�_'_MvLyt _ rcquirem nts which must met prior to issuance of a Cer iri m Signature of Applicant Date ' �y All roof coverings to be Class °B'r or better Der or auth fiZed agent k-111 CITY Q CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM APN # 36q, o6-oo g 00D/a Date: Gl - 07 -- O Y Building Address: MlggllFT121 qce Mailing Address (if different from building address): 1 X17 7a SP, -ens C!-,r-eA11.r1. Owner's Name: Phone #: 65diy ae d �r e fT 2-A y09 3y3-100PfXl� Contractor: Pac r -c (relLein?l CcnaS uc License #: G 37Va2 Contact: Phone: Do-,a9y-31/6 Cupertino Business License#: i emk -41--15e `T`c,� 5,�g er Fax: Boiler > 500K to 1M Btu Building Pen -nit Info: she// Bldg ❑ Elect ❑ Plumb Mech ❑ rob Description: a - 5�u, y '��y. - 1 /�-evj5lt l 3' e' p/un f -P errs �kn11 i Residential ❑� f �U 1� PrcdC� / Commercial Sq.Ft. Floor Area: $/Sq.Ft.: - L a s add BCONSTAX Cost of Project: PO pOd Occupancy Gr up: Type of Construction: se check thx roject is a BUILDING e and-sto addition: EJ Project Size: Standard ❑ Large ❑ kaj or ❑ BUILDING Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERl Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 10 OK to 50OK Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL 13BOILER4 Boiler > 1M to 1.75 M Btu MECHANICAL BBOILERS Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING 13CONSTAX ad/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 Elcc Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 t 'A �,,VVV G1TY OF CLIPERTINO "ITY OF CUPERTING PERMIT APPLICATION FORM Ouantitv Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMIVEM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTWE 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 BPREPLPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Stonn 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 ofm MECHANICAL BREMAIRHAN A/C Units c= I0,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > 1 OK btu MECHANICAL BREWMAT Heater Installation MECHANICAL BREM NHOOD InstaIlation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Apphance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL 13RENMEPALT Rep air/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPEi-T1NO N"ITY OF CUPERTINC 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 13SC13LVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING 13SVir1M Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Terap Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERNUTFEE Mech Permit Issuance MECHANICAL PPERNUTFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3