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03050021m0 Z' ��A flE 2 Fal HZ� CITY OF CUPERTINO Z ,y+ Q Z 0 y Z �--� BUILDING DIVISION PERMIT CpNTRACTOR)[NF'ORMATION BUILDING ADDRESS: 12002c; rP.T)AR TRP.P. LAMP. SHEPHERD SERVICES PLUMB IN Eagan NO03050021 OWNER'S NAME: 10121 IMPERIAL AVE "'W7`56/2003 CK & BETTY NE: 4085597160 SANTTARY NO. CONTROL NO. ARCHDRCTIENGiNEER: BUILDING PERMITINFO BLDG ELECTO MICH Q O LICENSED CONTRACTOR'S DECLARATION Job Description I hereby same that I am Ikeved under provisions of Chepur 9 (commencing p with SOcdoni000)af Diviilon3ofthe Bu"inw P fessimm Code, and my license is in roll torte and _Ies,1,7G Lleg o / INSTALL HOOD, GAS COOKTOP/CAP ELECTRICAL on Lkenm Clw _ Date l Cayl Cf S D FINAL.�E® rsund my plan shall MCPS public micard, - MAY 0 8 2003 Licensed Pmkadmnal OWNER -BUILDER DECLARATION I hereby eaitm that 1 exempt from Ute Conxrnmor, n taw for the : A c muga. (Section 7831.5, Buaircu and Ro(esilon Code: Any city or county maso 1. . which require" •patron re construct, alter. Impose, demMbh, ore. sig any Structure whichmi cement the o for such Permit inriles,Lnedatstemenl poor Nits tensed c,ilsomquims the GammNsandProelAw Sq. Ft. Floor Area inions of the (Chapter9 thenheis lkevut section Nth) or Division 3 of the end Code) of of Diut% (commencing with Sanchrum f egBusinessxe on. Any Nal he 4 exempt tiremttotn and die bub for the ilkged exemption. Any violation of and 31Aff%n aibcr0 0 Occupancy Type Section 7031.5 by any applicant for a permit mhjects the applicant to a civil penally of not more Nm five bundled dolhn ($500), ❑ I, u awes of W propmty. or my employcu with wages u Neh role compewtion. - dInspections will do Ute work, and themumure I,notinitMW ormeeted lee oak (Sec. 7011, Buslrcu i and Prore neons cads: The cmutemes him Law does rot apply N an owner of 102 - PIERS property who builds or i mpmses themmn, and who dou,uch work himsel f or through his awn employes, provided Nal such improvements am not intended melfcrtd for ogle. E. 103 - UFER however, the building or improvement to sold within one yeu of complexion, to owner. Wilder will have the burden of proving that he did not Mid or imports for purpose of 104 - REBAR sak'1. 105 - ANCHOR BOLTS ❑ 1. u owner of the property, am exclusively contracting with licensed cons ims N 10 6 - SEWER & WATER com uet tite project (Sec. 704/, Businw and Professions Cade:) The Connector's Li ante Law does not apply N an owner ofpmperty who builds m improv lhemon,and, 202 — UNDERFLOOR PLUMBING who convects for such pmjecta with a cormacum(0 licensed perswm m the Committees License law. 203 - UNDERFLOOR MECHANICAL ❑ I am exempt under See . B & P C for Nis reason 204 - UNDERFLOOR FRAME Owner Data 205 - 301 - UNDERFLOOR INSULATION ROUGH PLUMBING WORKER'S COMPeNSATION DECLARATION I hereby air= under penalty of perjury au of tits following declaretiana: 302 - TUB & OR SHOWER I haro andwilliminwn acert ricamofeanumtmmlr.inaumfm WarL-e$Cmpen- orlon, u provided for by Section 3700 of the labor Code. (of the performauo of the 303 - ROUGH MECHANICAL work for which this permit is issued. 304 - ROUGH ELECTRICAL ❑ 1 have and will msimain Workers Compensation Iwrmce, u required by Section 305 - FRAME 3700 of the Labor Cade. for the performance of the waft for which Nis permit is Issued. My woe rs Compewtin iwrsna Amer and Poll umber are: 306 — HOLDOWNS Carni S7Y1-ls f's�a✓� PoliryNa.. IS'}SSoJ-Mo3 307 - INSULATION CERTIFl COEOP SATIONON FROMWORKERS' COMPeNSATION INSURANCE 308 - SHEETROCK mus,ectimt need not he completed lf0u permm is formic hundred dollars (SIM) 309 - EXTERIOR LATH lir less) 310 - INTERIOR LATH I artily that In the performance of the work for which this Permit is issued, l shell not 311 SCRATCH COAT employ any person in my mannerist u m became subject to the Workers' Campenutian - Laws of California. Date 313 - 501 - ROOF NAIL FINAL ELECTRICAL ENERGY Applicant NOTICE TO APPLICANM If. afut making NB Cenificste of Exemption, you should become subject N Ilse Worker" Compensation provision of tits tabor Code, you most 502 — FINAL PLUMBING ENERGY forthwith comply with such provision or Ibis permit shall be deemed reversed. 503 - FINAL MECHANICAL ENERGY CONSTRUCTION LENDING AGENCY Iher Net Nem isaed(Secti0lending agency for the performance of 504 - FINAL BUILDING ENERGY which work which Nle permit busucd (Sec. 7097, Civ. Cd 505 - FINAL ELECTRICAL Na Lender's Name 506 - GAS TEST I<adet"Addreal I cenify Out I lute read this application and Nu Nn the shave Information is 507 - FINAL PLUMBING cone« I agree N comply with all city and county ordinances and "use Iowa testing N building couwcdon.and hereby authodte representatives of this city to enter upon the FINA MECHAN CAL ahovomendoned property for Inspection purposes O 9 F I N against (Wo) lime u chem, indemnify and hap burnifleassm the yCity of against liabilities, jndgmmu.coauand expevu which mayor anY way accrue giln,tuid coy 5 G -� in cotrseganee of Troy ggpp Nis Permit. APPLICANT U fD AND WILL COMPLY WITH ALL NONPOINT Issued by5 WORKS Date spuace /c, "a3 Re -roofs Type of Roof SI u f pBcan o HAZARDOOUr S MATERIALS OISCLOSUR Dau Willtheapplicmtnofotum building acupmtnomor handle maudil Health" u deOuM by Uu Cupertino Municipal Cade, Chapter 9.13. and the HcilN and safety code. SeNezss33(aj? All roofs shall be inspected prior to any roofing material being installed. Y Yet ❑�No If a roof is installed without first obtaining an inspection, I agree to remove Will the applicmt of future building Occupant wen equipment or asoma which mil harardous air munitions u defined by the Bey Area Air Quality Management all new materials for inspection. istrict? 13 Yes &No I have mad the but pusmun as requirements under Chapter 6.95 of the Califor. 1�6wncr ia lkalth&Safely Code hurt 05,35533and35534.1understanduatirxhe Wilding no1 corm ulyfav e D ' t� 14 my responsibility to noul'y Ne ¢c.pml of the �s ubemantsw l[it Cm E m wuanemn Certificate of oil�m Signature of Applicant Date o All roof coverings to be Class "B" or better arisd.gent �.D �t CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM o ) o s" u-0 2-/ W Quantity Fee ID APN # / / , O D / I Date: �?ZL73 BAPPLOTHER Building AµP17ess 00 2 s C v � £DAR TRf£ CN MECHANICAL Owner's Name ISNikAw IS�,1 a(rJr� 4 Q Phone #: yog SS9i/6o BUILDING Contractor: n -CNCN,EcCw g(z cf s License #: C,60?t 3 c zo J -3c MECHANICAL Contact: CJ (c L I R.+., n Cupertino Business License#: MECHANICAL Building Permit Info: Bldg ❑ ]ect Ph4b Mec Boiler > 500K to 1M Btu Job Description: Residential ❑ G� r BBOILER4 Sq.Ft. Floor Area: $/Sq.Ft.: BBOILER5 Cost of Project: Occupancy Group: BCONSTAX Type of Constructi : BUILDING W Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERl 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/Con m/ uasi 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 feeBUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING Z1 7 ?0 _ 1of3 2( Y, 5-1 CITY o CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 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 BNUSFD New Single Family Res BUILDING BOVERTINM Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pipe 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 > 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 2 of 3 alTYV CUPEt�TINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rcptl, 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 BUIL G BSEISMICRE Seismic Fee Res BUIL NG BSPECIAL Special Inection 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 PPERMITFL lumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3