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03060187 CITY OF CUPERTINO ' ' R •?:- n.=ti ` `�' r' s:: BUILDING DIVISION PERMITCONTRAT(IRnIINF.ORMATION BUILDING ADDRESS: PERMIT N00 3 060 18 7 OWNER'S NAME: PERMIT WUE DATE SANITARY NO. CONTROL N0, ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �Op LICENSED hot( CONTRACTORS DECLARATION hap _ lob Description 4�i 1 hereby affirm that 1 em licensed under provisions of Chapter 9(cnmmcncing P <� with Scnion 70gllof Di ision]af NCBu' .v and Professions Code,en�llccnm is fig< mFullmre C�yv BATHROOM REMODEL a License Cl L c.s o Dam Cumrse� � f CONTRACTOR: DEVERA CONSTRU�diQIti ARCI3ITECTS ATION I unde6l J mY plant shall W trod s7. tic records )oat k a Licensed Pmfcssiontl p 3 O� OW NEm exempt DECLARATION Contractor's ontr ON License - AUG 2 �� LOOJ COO hereby ng meso .(firmSec 11. exemptfrom thefeminaelor!cAnyc Lew forth. COO follwhich requires; cccii toc construct, Bmincu and vefmsinrmh,in Any city or county which requires a permit to construct.aheq Improve,demolish,m repair any structure 5�y prions its imuance.alsumquiresthe applicant forsuch permit to File asiened statement �0 that he is licensed pursuant to pmvicions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area _Mtt@000 at he is exempt and on Di isf rnr(W Business ori on.Any vi Cilie)ser ;? $ (bat he is exempt therefrom end(W Euu far the alleged exemption.Any violation of wr,fn,a,i, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 3�laY VLLf Uler00 Occupancy Type nut more than fire hundred delta.($500). P Y YP ❑I.K owner of the progeny,or my employees with weges as their tole eompenutlon, will do the work,..it Ne structure is not intended or offend forsat.(See.7040,Business and Professions Code:The Contractor's License Law does not apply to an owner of 101 — FOUNDATION gInspections property who builds or improves thamon,and who does such work himse for through his owncmployces,prov(ded that suchimprovarr ems aranotimendeduroffered foruic.If. 102 — PIERS however,the building or improvement is sold within one au of completion.the nwner- buader will have the burden of proving that he did not Wild or improv for purpose of 103 — UFER sale.). ❑1,as owner of the proper,am exclusively contracting with licensed contractors to 104 — REBAR construct the project(See.7pa,Business and Professions Code:)That Contractors U. 105 — ANCHOR BOLTS. come Law does not apply to an owner or progeny who Wilde or improves themon,and 106 — SEWER & WATER who commcls for such pmjecu with a cmm�clm(s)licensed pursuant to the Contractor'. License Law. 202 — UNDERFLOOR PLUMBING ❑I am exempt under See .B h P C for this reason 203 — UNDERFLOOR MECHANICAL Owner Data—WORKER'S COMPENSATION DECLARATION 2O4 — UNDERFLOOR FRAME I hereby affirm under penalty of perjury one oflW fallowing dooksikins: 205 — UNDERFLOOR INSULATION I haveandwill maintain a Cenifee of Consent to self-insure for Worker's Compere 301 — ROUGH PLUMBING cation,u provided for by Section 37W of the Labor Code,for the performuce of the 302 — TUB & OR SHOWER work for which this permit is issued. ❑1 have and wit]maintain Wurk.rs Compensation Insurance,as reyu]md by Section 3 03 — ROUGH MECHANICAL 37W of the labor Code,for too performance of the work for which this Permit is issued. 304 — ROUGH ELECTRICAL My Worker's Cron pens�atioin Insurance carrier and Policy number are 305 — FRAME C (JG'fct QM� Policy _ ` ER'rJ.F1FEXEMPI70N1WORKERS' 306 — HOLDOWNS ZWINSATIONINSURANCE 307 — INSULATION or ase)('Tots seen.need or rte completed ifdue permit b for one hundred dollars IS 100) 308 — SHEETROCK 1 cervi fy that in the performance of the work for which this permit is Issued.I shall net 3 09 EXTERIOR LATH employ any person in any manner so as to become subject a the Workeri Compcmation 310 — INTERIOR LATH Law of California.DamApr311 — SCRATCH COAT Law ant NOTICE TO APPLICANT:If,a0er making this Camilcam of Exemption,you should 313 - ROOF NAIL become subject to the Worker's Compensation provisions of the Labor Code,you must .Jz forthwith comply with such PrnvbloaOr(his permit ahaBIt,deemed mrnkcd. 501 — FINAL ELECTRICAL ENERGY zo CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY (hereby affirm that them is a construction lending agency for theperfurmuccof 503 — FINAL MECHANICAL ENERGY a w�+ the work for which this permit Is issued(Sec.3097.Civ,CJ W O Leader.Natne 504 — FINAL BUILDING ENERGY =) Z <mdersAddrea 505 — FINAL ELECTRICAL U O I certify that 1 have rod this application and state that the above information is 506 — GAS TEST B COMCCL I agree 10 Comply with IN city and county o dinuces and s0m taws relating to OU Wilding construction,and hereby authorize repreareat]rra or this city to enter upon the FIN PLUMB( G w above mentioned property for inspectlo urpoxs. d (We)agree m aro,code and cp harm(.-to City of Cupertino`gains( 0 8 F I L to liabllilin,judgmcnu.cmu expense ich may ire L,accmc against said City 5 U z in ce tae ser thi it. PLICANT UN TANDS WIL MPLY WITH A NON-PINT Issued by:5 NG Date d . SOURC GUL ONS. a2fi PUBLIC WOR Re-roofs IYre.f C nn Kl.f Dale / HAZARDOUS MATERIALS DISCLOSURE Type of Roof e applicant or future building Occupant store or handle havardous material .fined by lie CuMnin,Municipal Code.Chapter 9.12.and the Health and Safety Cale,Section ° 25532(a)?? _�/ All roofs shall be inspected prior to any roofing material being installed. yes t0'^ Will the applicant or Future building acupant use equipment or device;which If a roof is installed without first obtaining an inspection,I agree to remove hazardous air contaminants as darned by Its Bay Area Air Quality Management Disurh:7 all new materials for inspection. Yes (,Qla0 , I have ehaardnu alai reyuiremcnu under Chapter 6.95 of the Glifoo- ni.Hm SafeyC ,SK' m25 5,25533 ud25534.louden nd thmifdte Wilding doee'not curren0 o ark t U is my reepomihilitY m testily a(ccupant of the vyuimmcn nth us brwissuuceofaCcNr of esu Signature of Applicant Date Own m agent Date All roof coverings to be Class"B"or better G CITY OF CUPEWFINO • � `� r..'`a� �` �'• a ' BUILDING DIVISION PERMIT faCON�RAC',tOR NPORMATIr BUILDING ADDRESS: PERMITND03060187 OWNER'S NAME: PERMITISSUEDATE NE: SANITARY NO. CONTROL NO. ARCHITECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH J00 LICENSED CONTRACTOR'S DECLARATION wF I wroby affirm that]am liaaced under provisions of Chapter 9(commencing Job Description �i'r$ with Section] Bof Division Sof NC Bu i s.and Professions C oro On Nhear.is "> Irare Beat' /�95 / a /ter BATHROOM REMODEL bLiccnsc CI Llc.M_r! c—, Dam - Contractor�y _ ti'Sr CONTRACTOR: DEVERA CONSTRF 1 E0 ARCHITECTS dnDr6��1I,,AARATION I.nfa d my plena shall w toed u'lVEhiic accords pU AUG f� s LicensedProcssinnal Ut7 2 1 ZUQ9 OWNER-BUILDER DECLARATION a y 1 hereby cram that 1 am exempt from the Contract.,'.License Law for the ❑O following reason.(Section 71131.5,Business and Professions Code:Any city or county <m which requires a permit at construct,alter,Improve,demolish,or repair any structure gu III priono its issuance,also requires the applicant for such permino rile a signed statement £ � that he is licensed pursuant the provisions of the Contractor's License law tChaPmr 9 Sq.Ft. Floor Area t 000 y jcommancing with Station 7060)of Division 3 of the Business and Professions Cork)or y that he Is attempt rotation.and the basis far the alleged exemption.Any Ard.tlon of Section 7031.5 by any applicant for a permit subjects roc applicant to a civil penalty of 3 MNIOu lbuO 0 - Occupancy Type not more than fin hundred doll..(1500). L ax owner.Rhe pmpeny,ar my cmployeas with wages as their ale compensation, will do the work,and the sumaure is not intended or offered rorsale(Sec.7044,Business and Professions Code:The Committers License law dna not apply to an owner of Required Inspections progeny who holds or aprons thereon,and who doessuch work himselforthrough his 101 — FOUNDATION own employers,provided that such impmscmees ane not intended proffered for sale.If. 102 — PIERS however the building or improvement is sold within but year of completion,the owner- builder will have the burden of proving that he did not wad or barren for purpose of 103 — UFER ale.). D 1,as owner of the property.am exclusively convecting with Examined contractors to 10 4 — REBAR consumer the pmject(Sec.7014,Business and Professions Code)The Contractors Li- 105 — ANCHOR BOLTS. come law does not apply to an owner of Frippery who wilds or improves thereon.and. 106 — SEWER & WATER who contactsfor such proa jects with a eanvnags)licensed pursuant de,hCommerce, Llceoo L.w, 202 — UNDERFLOOR PLUMBING D l am exempt under See. .B&P C for this rtaon 203 — UNDERFLOOR MECHANICAL Owner Data 204 — UNDERFLOOR FRAME WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the fallowing deelanriou: 205 — UNDERFLOOR INSULATION have aadwlnmaintain.Cen0lemaofConsent toself.inampar WnrkcraCompen. 301 — ROUGH PLUMBING .tion,as provided for by Section 37M of the labor Code,for the performance of the 3 02 — TUB & OR SHOWER work for which this permit is issued. D 1 have and will.ainmin Workers compensation Insufance,as required by Section 3 03 — ROUGH MECHANICAL 3707 of the labor Code,for tw pe4Ormance.f the work for which this peamil is issued. 304 — ROUGH ELECTRICAL My Worker's Compensation Insurance carrier and Policy number art: 305 — FRAME cdmm�r,/�✓CfC�z�'Gd'/Y/f Poftr /��(TG/.�_�✓�`' �O — CERjIFICATp,.QFEXEMPTION W001f RKERS• 6 3 306 - HOEDOWNS / ENSATIONINSURANCE 307 — INSULATION (This section need not wcompleted if the Permit is for one hundred dollars($100) 308 — SHEETROCK nr less.) 1 cenify that in the eforcrance of the work ter which this permit is issued,I aha.net 309 — EXTERIOR LATH employ any Person in any manners as to become subject o tbawofkeri Compensation 310 — INTERIOR LATH Laws of Calif..[..Doc Applin. 311 — SCRATCH COAT NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 313 - ROOF NAIL become abject to the Worker's Compensation provisions of tum labor Cods you must p2 forthwith comply with such Provisions orthis Permit ahall xdeamedranked. 501 — FINAL ELECTRICAL ENERGY zoCONSDICIIONLENDINGAGENCY 502 - FINAL PLUMBING ENERGY IhemhyaRrmthatthcre111caatuctionlending agency for ft coloratura or 503 - FINAL MECHANICAL ENERGY W' >' the work far which this permit is issued(See.3(197,Civ.CJ W im Undoes Name 504 — FINAL BUILDING ENERGY �- g1. lender's Address Z 505 — FINAL ELECTRICAL U U O I cenee that I have read thirty and county sum that the above laws emoting is 506 — GAS TEST f" corted.l agate to comply smith all city end county oNinanas and sate lawn relating to V buiwn-nommardi.n,and hereby athorizerepmsematinsOf this city to eater upon Ne "NPtIG.hove-(W.)a gre Property for iaPtaiO p)acpha(Wc)egrce to.ossa,indetftmd cep hasmlas roc City of Cupertino against 0 B L 3 Iiblides,judgmcnu,cosuap4cercns.ghich may in epy way ecame agonsuoid City 5U 7 to onaequenmarthe ga pingfthfmI6/ DalePLICANT UNO TANGS WIL MPLY WITH A L NONP-INT Issued by:5 SOURC REGUL ONS. ' " =3514 PUBLIC WORK Re-roofs vert of c on annr Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Il�icant or future building Occupant smoc or handle hazardous material y efncd by the Cupertino Municipal Code,Chapter 9.12,and be Health and Safety Code,Section 25532(.)7All roofs shall be inspected Prior to an roofing material being'Installed.❑Yes [OK.' Will the applicant or future building Occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove it hazardous air annuitants as befntl by the Bay Area Air Quality Management all new materials for inspection. tauter] -- DY.. G}nu�/J I have mat haand ar!mrielirtyuirenwnu under Chamer6.95 of Ne Califor nix HeoldlSafcty�c,Sec' a15.505,25533 and 25534.1 understand that ifdte wilding rlocinot eurtcndam y o a thbt itumro ypoaihilitymnoufy the acupant of at or ch a ac( 'ortu issuance or CcniOc mof, vane 3 Signature of Applicant Date o m.6in 1 rn . tat nam All roof coverings to be Class"B" or better `k a &Y OF CUPERTINO CITY OF PERMIT APPLICATION FORM O 6'0 & CUPERTINO N# 6Zj, I Building Addr s: GG��7 V .S—C7 Owner's Name: M S lest- Z Phone #: D� r -- //l/G Gr 57J- s Contractor: ILicense#: �E!/��1 0PJNf(-V-&1C7(011/-C cO 40 !z S Contact: Z{D ,/ Cupertino Business License#: /--Z) S b' Buil 'ng_Permit Info: 1 CBldgC9f,) Ele P umb MechAW escription: Residential ❑ Commer al Sq.Ft. Floor Area: $/Sq.Ft. Cost of Project: Occupancy Group: 757 Type of Constructio : Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Pennit sq. foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K 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 <= 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 z 2313 / 1 of 3 6 i ATY OF CUPERTINO • CITY 0 CUPEf�TINO PERMIT APPLICATION FORM 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 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 Sewers PLUMBING BPSPRINK Lawn S rinUer/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 A/C Unit> 10,000 cfm MECHANICAL BREMAMIAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFDCT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace 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 2of3 6 amCITY OF CUPERTINO CUP TYOFINp PERMIT APPLICATION FORM u 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 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 PPERNIITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3 ........... � O •��� (�0�� � _ESD . . � Qc- in.h w 'V SLI ;.{' •. .P b�'.x'�:i�.."�4.F '1�ry[, •(������ E MY ON �. t--� 1l(l'iivr o A'4ES l — � �in s AND 0 DIN 51GNFD= specifications —I This sat o` an. ,id aPac —t all times and it is hor alteration: