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05040051 CITY OF CUPERTINO a �s =rro' E "w"^ x y"I ''�"` "•' " *f BUILDING DIVISION PERMIT =xCOiVTRACTORaINF®RMATION: '•iTs"Nu,F. ., ;x ' r w,�C6� ..v `?a ,A',i, BUILDING ADDRESS: PERMIT N0. AAA FURNACE & AIR CONDITIO ING 05040051 M PERMIT ISSUE DATE ONE: SANITARY 12 OL NO. ARCHITEC rENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 900 LICENSED CONTRACTOR'S DECLARATION JobDescri [Ion u6 1 beery affirm that I am limen ed under Pmm vivans of Chaplet 9(comencing -,n.� n p U wish Section7000)of Division 3 of the Business and professions Calc.and my license is r ° r vWai L full force and p(re I, enc a =pz ua.soc C: / REPLACE FRUNACEL&,ADD A/C, %J Dam��Co.DSC . w GAS LINE FOR OVEN, FI PLACE & DRYER ARCHITECTS DEC RATION I uMcrtunJ my plans shall be used As pudic records S ie 2155 . ;a� Licensed Professional 1 OWNER-BUILDER DECLARATION r iI I hemhy affirm Nal I am exempt from the Contractors License Law for the 00 following reason.(Smarr 703 L5,Business and 9ofe&siom Code:Any city or county x$ which reyuima a permit to convect,alter,bnpmve,dens"ish..1 rep of any mucron m-'^ pdorm its ismance.also rrquimsthc applicant farsuch permit mfik aligned ammrcom F'S< the,he is licensed punu uano the pmiom visof NC ContractoriU..Uw(Chapter 9 Sq.Ft. Floor Area Valuatypg000 �Fa (commencing with Section 70Xb of Division 3 of the Business and Professions Code)or b i 3$ that he is exempt therafem and the bees 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 Type not mom Nan five hundred dollars(SSW). C]I,As owner of the property.or my employers with wages As Ncir sole wmpetuadan, 36928033 . 00 will do the wart,and the avenue is not intended or offered for sale(Sec.7001,Business and Professiav Calc:The Camseemes Licence,law does not apply to an owner of Required Inspections progeny who builds orimprovcs thereon.and who doessuch work himsevorthrough his own employees,provided that such improvements art not intended at offend for sale.IL however.the building or improvement is sold within one year of completion.the owner- builder will have the burden of proving Nat hat did not build or improve for purpose of Ask I. ❑1,As owner of the property,am exclusively contracting with limned mntracmrs to contract the project(Sec.]OCA,Business and Professions Codc:)The Contractor's Li- cense law duct not apply in an owner of property who haida or improves Norton,and who contracts for such pri with a com ettor(s)licensed pursuant o Ne Contranors License law. ❑ I am exempt under Sec. .B At P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under Penalty of perjury ane of the following declarations: I he ve and will maintain a Certificate of Consent lin self-imam for Worker's Compere sail..,as provided for by Section 37M of the labor Code,for the performance of the work for which Nis permit is issued. Lhave and will m,johno Worker's Compensation Iwrana,ss required by Section of the labor Code,for the performance of the work for which this permit is issued. My Worker's9Compensation nIIns uranee carrier and Policy number art:_ Carrier: ss/Ole_ ri/A � Policy No.: $ Pk-V4 RTIF CATS OF E%EMPnON FROM WORKERS' !— COMPENSATION INSURANCE (Thu section need not be completed if tie permit is!oras hundred dollars(3100) or les&) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner m as m become subject to be Workers Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:IL after making this Cenificare of Exemption,you should become subject to the Wo leer's Compensation provisions of the labor Calc.you mots Z forthwith comply with such provisions or this Permit&halt be deemed revalued. z CONSTRUCTION LENDING AGENCY [-+ I hereby affirm that then is a c.nstrominn lending agency lot the performance of IZ the work for which this .it is iuucd(Sec.3097.Civ.C.) 0 Under's Name O Z lender's Address U O 1 really that I base tend this application and sure that the above information is " P torten.I agree to comply with all city and county onchances and sun laws relating to 0U building convection,and hamby authorim npnsenittives OTthls city to enter upon the �[!1 above-mentioned property for imNcdon purposes. (~ 6 (We)agree to save.indemnify and kap harmless the City of Cupcninr against N liabilities,judgments.costs and expemm which may in any way accrue agaimLmid City U Z lin consequence of the granting of his permit. ^` APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUCEREGULATIONS. _ O Re-roofs Signature ofApl!16QC � 'O1fD HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupant uon or handle lux oM ous material as defined by the Cupertino Municipal Code.Chaper 9.12.and the Fiction and Safety Cadc.Section 25532(a)± All roofs shall be inspected prior to any roofing material being installed. ❑you t!1 No Will the applicant or future building Occupant use equipment or dcaas which If a roof is installed without firs[obtaining an inspection,I agree to remove it ha anhms air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection. imict7 ❑Yes 91No 1 have mad the moa drmamamdals requirements under Chapter6.95 of the Califor- nia Hwlth&Safety Code.Seeuon25305,25533 and 25534,1 undersand that ifthe Wilding Jas not currently have a mama that it is my esponsiolity to notify the accupam of the rcquGiy-97.nkswbmh matt be mel pour to issuance Of a Cenificae Of Occupancy, Signature of Applicant Date "�`''9K� Q4Ur , All roof coverings to be Class"B" or better Owner or autWnaod agent Dan .� Community Development t 10300 Torre Avenue yfr% Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408) 777-3333 �UPEI�TINO Building De artment JOB ADDRESS: PERMIT # QS-07�Wj'/ 1051elz 4X5- d52ti ,o lvv OWNER'S NAME: �, - PHONE # ;2 3 - /;7,70 GENERAL CONTRACTOR: ' FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followinginformation: 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 �, m�� -A ,✓��c�,�.c O�Dom'o.s^ Owner/C�onfractor Signature Date CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO APN # Date: �� D3 a - cIP o� Building Address: Mailing Address (if different from building address): J- L R Owner's Name: n Phone#: K v Con ctor: License#: c c 6 Con act: Phone: 2fJ-�v Cupertino Business icense#: H Fax: FYI Building ermit Info: Bldg ❑ iElect Plumb pl Mech Job Description: Residential ❑ Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: /oOpo m Type of Construction: R e v/nQ�t Please check this box if the project is a pi second-story addition: • �Yc/ Project Size: Standard& Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to IM 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<= IOOOA ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 GQ ?'- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO 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 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 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 cfrn 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> IOK 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 liance ELECTRICAL 2 of 3 GQa- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO 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 Plannin LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3of3