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03120125 F., ITY OF CUPERTINOBUILDING DIVISION PERMITILDING ADDRESS: ANTHONY WHITE PERMIT NO 03120125 i0NE NER'SNAME: PERMIT ISSUE DATE : SANITARY NO. 9'19rl� C ONTROLL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH °00 LICENSED CONTRACTOR ❑ CONIRSDECLARATION ECON ZFI hereby affirm mal 1 am licensed under Pidons Of Cham «9(commencing Job Description W with Sc[liun)IXt))af Division3tfda Btisineuaof Professions Cndc.and my license is ® _gym mfullf«cass effect. FIN a' t> ED _qz umllin=a Ile.. 2 NEW WINDOWS ��a@MI!/Fp1Al o_a °aa comncOLD PERMIT #14664 WAS EXPIRED 3a+ pp ARCHITECTS DECLARATION ARATION -I Iund«nanJ my plans shallWused as public rasndv Ini.l (a gOoA JaU JHIY O L 4 G� Licensed Pmfcnsional OWNER BUILDER DECLARATION 1A <T I hereby affirm that I am exempt room Ne Contraaoh License Law for the �p ®1.®A' �0 o following reason.(Section 7031S,Business and Professions Code:Any city of county ®�/ K m which requires a permit to construct.alter,improve,demolish,or repair any structure priono its issmnrmitlsurequi.the anplierom f«such permiuo rlcasigned sutemenl Ya0 hot he is licensed imutom to the provisions of ho Cworch,,'a U..Law(Chapter 9 Sq.Ft.Floor Area Valuation $0 ice$ (commencing with Section 1000)of Division 3 of the Business and Professions Codc)or _ mat he is exempt therefrom and the basis for me alleged exemption.Any violation of Semon]031.5 by any applicant for a pem,it subjects the applicant to a civil penalty of APN Number Occupancy Type not more than fire hundred dollars(s500). Pane Y YP ❑I,u owner ofthe progeny,«my employees with wages ss their cele compensation. 31633065 . 00 will do the work,and Ne swcmte isnot intended orottcred forsale(Sec.70a4,Business and Professions Code:The ConuactoA License law docs not apply to an owner of Required Inspections progeny who buildsor improves thereon,and who d«esuch work himselfor through his Own employees.provided that such improsmenu are net intended orortered for sale.If. however,the building or improvement is sold within one year of completion.the owner. builder will have the burden of proving that he did not Wild or impsoac for purpose of sale.). ❑1,as owner of the propony,am exclusively contracting with licensed contractors to consumer the ymjem(Sec.1066.Business and Professions Code)The Contractor's Li . rue L.O.dose not apply to an owner of progeny who Wilda or improves therton,and. who contracts for such projects with a cuntraaof(s)licensed pursuant o the Conuactofs bicense law. - 0 1 am exempt under Sec. B&P C for this rtavon - 9w', 'TOW 1F Ifs' DueIZ q03 KER'SCOMPENSATION DECLARATION I toothy affirm under Penally of perjury one of(be jll NIng declarations: 1 have and will mmmutin a Ccnificue of Consent to self insure for Workefs Cumpen- suion,as provided for by Section 37W of the labor Code,for the Performance of the work for which this permit is issued. 1 hast and will maintain Worker's Compensation Insurance,as required by Section 37W of the Labor Code,for the performance of he work for which mus Permit is issued. My Workcfs Compensation Insurance carrier and Policy num her art: Cartier. Policy No.: _ CERTIFICATE OFF EMPITON FROM WORKERS' COMPENSATION INSURANCE (Thissectionneed not ecompIctid ifrbc permit isfaronehundred dollars(SI00) loss.) 1 ceNfy that in the performance of thc work for which this permit is issued.I shall out employ any person in any man/cryo arfy.hccQo�s�jec`o dm Workers Compensation Laws of California. ////��,,SS 33 Applicant Aro �(t f 7� °FT^me TO APPLICANT.If,after making Certificate of Esemption,you should beSL(pe mbjat to the Worker's Compensation previsions of Nc Labor Curie,you most z foMwirh comply with such provisions«Nis permit id all be deemed arcked. zCONSTRUCTION LENDING AGENCY I hemby uRrm that there is a construction lending agency for the Performance of G'7 the work for which this permit is issued(Sm.30Y7,Civ.C.) (+] A Undch Name D z Lender's Address V O 1 ccnify that 1 have read this application and Sam that the above information is I,. f coned.1 agree to comply with all city and county ordinances and sure laws relating to 0O building construction,and hereby aumorne«prescnutiacs of this city to color upon the above.ms judgments, progeny for inspection purposes FQ. (We)agree Ip save.indemnify and keep handless the City of Cupcnino against h inconsequenc of the coarsing of this Cartons which they in any way accrvc against said City V z APPLICANT UNDERSTANDStAND Permit. COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREG Re-roofs gnatum of ApplicanUConuacmr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building Occupant store or handle haralloes material as defined by the Cupertino Municipal Cope.Chapar 9,12,and the Health and Safety oak.Screen 25532(a)? ❑Yea stn All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air contaminants ss dcfrncd by Ba Bay Arca Air Quality Management all new materials for inspection. isuict? ❑Yea XfNu 1 have rtad the hava minis materials requirements under Chapter 6,95 of the Califon his Health&Safety Code.sector.25505,25533 and 25536.1 undersand Nat if the Wilding does not currently have a tenant,that it 0 my maponsibility fir nou fy mo"a part of the mquiamcn.which mus,be net prior w issuance of a CcnlOcam of Oce alter. 'Signature of Applicant Date - GN G(J lL 3d O fir cpm rued agent /, rfaic All roof coverings to be Class"B" or better Sin-- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO APN# 3 ( 3 Date: 0 — n 3 Building Address: Z o o (o I Fo 12cs-r A ✓C L) p L---f2--r I NO Owner's Name: Phone#: Contractor: , , Ow Ne-yz, License #: Contact: Cupertino Business License#: Building Permit Info: ./� N� N�0 a.i -Y Bldg LzY Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential ® I N 12 a o 2 2C' " im O o l2 Commercial ❑ Sq.Ft. Floor Area:b�j G $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: 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 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 BMITIGATC Comm. Housing Mit. Fee BUILDING ,# aq z I of 3 i 7 7 Sv p( - CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO 10 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 BOVERTIME 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 Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING AIL 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 BREMAIRIIAN 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 Fumace > 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/Ap2aratus ELECTRICAL 2 of 3 m_ CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEP,,TINO Quantity Fee ID Fee Description Fee Group 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 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BMISCELL Building Misc Fees BUILDING 3 of 3