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04050065 CITY OF CUPERTINO ^R%77777777777P: 777' BUILDING DIVISION PERMIT CONTRACTOR=IN FORM6"N BUILDING ADDRESS: EDWARD L MULLINS PERMIT No 04050065 OWNER'S NAME: PERMIT ISSUE DATE KRISHNA K ONE: SANITARY NO. CONTROL NO. (408) 929-5524 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG BLECT PLUMB MECH �op LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licamed under provisions of Chapter 9(Commencing Job Description nZ1 with&Chun 7rXK)ef Division 5ofthe Box.and Promsdam Coo,andmy liecomis m f�Imoan If az uLle.g -7 9-12 CHANGE COOKTOP TO GAS LINE Daconlraaar ARCHITECTS DECLAgAT10N anJ m plans shall be used as publi ords SLicensed Pmfcuional i OWNER-BUILDER DECLARATION F I hereby.('fete than I emm exempt from she Contracted e:Any law lot lbe p o fallowing mason.(Section 713 o1.5. t,itheas and Pmfessinli Cour:Any oily or mousy $ which myuiroa a permit 1.reenres be,aIle[imprtrsu h [mala ore a si,mygned structure Frit prior m its iensed p also requires pmvisi applicant for coadmi Irmo[caste Law(Cha mem (commencing wait pSesuant moa pmmsiam ofmeGOntmnmdlAame Lw(Chapscr9 - Sq.Ft.Floor Area Valuatlo0 $ meth[ exempt Soofroodmdthon 700M Divisions of me Business and Professions Any Cal e)of Net he V exempt Nemfrom and the bss6 far Ne alleged exemption.Any violation of Seeuan 7031.5 by arry.ppliiant Cor.parmil subjects me applicator in.civil penally of 3 93W34ltBtfier0 0 Occupancy Type not mom Nan five hundred dollar(5500). P Y YP ❑1,as owner of the property,or my employees with wages as Noir sole compensation, will do the work and Ne.wcrute is natimemmd moRered for (Sm.7044,Business and Professions Cade:The Caomcmr's Liana law dies torr apply b an owner of Required Inspection a property who buildsorimproves themon,and whodoes.uch work himself at through his own employes,provided Not such improvements tae not Intended ma0ered rteaale.If, ®® however,the building or Improvement is sold widen one you afeoropmuce.me awar- builder will have the burden of proving that he did not Wild or improve for purpose of sale J. ❑L u Consumer the p of Ne property,,B esdus and concocting with:)TheeCrontrmbrs t. E]1.athe project(Sec.70aa,Business end Profracii ns Code:)The Concocted l to cane law docs rnot such Poa m m owner of property who Wilds or improv demon,and. ®� noo� who Law do(orsuchprojects winerontranar(O licensed punumtro the Contractors and ` License law. O 1 not exempt under sa. .B At P C for this moon Iwner Dam ®�:+� WORKER'S COMPENSATION DECLARATION 9� 1 hereby affirm under penally of perjury arc of the fallowing declantions, 1 have and will maintain a Certificate of Consent self-imum for Worker's Compmn loon,u provided for by Section 3700 of me Labor Code.fm de performance of Ne ork for which mi.permit is issued. I have end will maintain Worker's Compensation Insurance,ss required by Section 00 of me labor Code,far lid performuux of Ne wart far which Nis permit is Wrote. y Workers Compensation Insurance carrier and Poliry number am: rtier: Policy No.: CERTIFICATE OF EKEM MON FROM WORKERS' COMPENSATION INSURANCE (Ibis section rrsA nos Ire completed if[be permit is Intent,hundred dollar(SIM) or Ices.) 1 certify,that in to performance of me work for which this permit is issued,I shall Dot cmployaby pemopp inany m no u comesubjecuo the Workeri Compmation Lava of Califantid�V -�"� '-)�r'S NOTICE ,YAPPUCANT:If.after making this Certificate of Exemption,you should modam'sdfiJem m Cha Worker's Compcvalion pmviAom of rte Use r Code,you muss ,J O foMwith comply with each pmvistnm or this pormitshall be doomed revoked. Z r. CONSTRUCTION LENDING AGENCY 'f-s ate+ I hereby aRnm nn thea is a construction lending agency for do perummmm of CL, rte work for which this permit is issued(Soo.5037,Cl,C.) W Q Lender's Name z Lender's Address U Q I certify Nn I have read this application and.tale Net dm shove information is IT. comma I agree to comply wish all city and county on isunm and sum laws rtlaung an O V building convection,and hereby authoom representatives of this city to toter upon me liaavcmentioocd property for Inspection purpewhich m. gym (We)agree to save,indemnify and keep bumless the City of Cupertino against Tag Iiacoisequence fthecastsandofpemesmay in my way income against said City V 7 Aconsequence of UNDERSTANDS of this Permit. �7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE0. GULATIONS Re-roofs nature ofAppliean✓Contraetor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will No applicant or room building occupant mom or hendte huardovs mateoal as defined by the Cupertino Municipal Code.Chap er 9.12.and me Health and Safety We.Srouan 2saz(an All roofs shall be inspected prior to an roofing material being❑Yea 8 P P Y g g installed. Will me.pplicmt or fuwm Wilding occupaor me equipment or devim which If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air Contaminants ss defined by the Bay Area Air Quality Management all new materials for inspection. District? 0 Yes t�/lrT I have mad the he7amous materials requirements under Chapmr6.95 ser Ne Califon nia HuiN&Safety Cadc So dons 25505,25553 and 25534.1 understand had Iron:building dots not currently hem•tenane nm It is my numenchilisy w notify the axup.,of Ne men me a which Cour IV at poor ho arenaar.Certificate orOcera Signature of Applicant Date Owner as adsd agent D, All roof coverings to be Class"B"or better CITY OF CUPERTINO ' CITY OF PERMIT APPLICATION FORM CUPERTINO qpkPN # -3.5- Date: •s�Jo��Q Building Address: Mailing Address (if different from building address): 7,011 Owner's Name: Phone#: Contractor: License#: 7;Z-7 ay Contact: Phone:yQ$ qa¢S-c-a y Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect ❑ Plumb -E Mech ❑ Job Description: c�on V6r't C.cao P- Residential 2' �p Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: - Cost of Project: t Occupancy Gro u : Type of Construct Please check thF ❑e project is a second-story addition: OrqjectSize: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILER1 Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler-> 500KIo 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 lof3z �s 7r / z�� CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantitv 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 I Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Stonn/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 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation ofFumace 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 2of3 CITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group 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 i BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific 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 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 • ZADDCHG Address Chane BUILDING ' I i 3 of 3