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05060010CITY OF CUPERTINO BUILDING DIVISION PERMIT ,4CONTRkC-TOR4NFORMATION '; Td�9cs.Y.hf ...fie .tt.`d.TM:a>�T rvin �.� .ry-31^Ar 41:.{ 9u1 WING ADDRESS: CLARK ELECTRIC CORP PERMITNG05060010 OWNER'S NAME: PERMIT ISSUE DATE NE: SANITARY O. CONTROL NO, ARCHITECT/ENGINEER: BUILDING PERMIT INFO BB EO PLUMB MEOCH i� LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby arlim that 1 am Howard under provisions of Chapter 9 (commencing P with Section 7IX10) of Division 3 of thc Businruand Profesdona Codo. and my licence is In full form and effect Lkenha CI Lk.« INSTALL 5 RCPTLS (IT' ROOM) Date (n�(Contruwr THCH FfTSI)FOLAIRATICY i I, I understand my plans "I be used an public rt . Licensed Pmrwional OWNER -BUILDER DECLARATION i I hereby affirm that 1 am eacmpt from OO, Contractors License Law for IN j O � following moon. (Section 7131.5, Business and Profession Cade: My City or county /N�� `j� I .P, which nequims m a permit comment. alter improve, demolish. O repair any nmckm prior to its issuance. also requires the applicant for such perch to Hie ulgned suementJ thathe laticcnmd punuantlothe provision of Ne Camrmuri Lkcnm Law (Chapter 9 Sq. Ft. Floor Area :/ { I/ Valuation (commencing with Section 7000) of Division 3 of she Buaineaaand Profession Code) or that he Is exempt therefrom and On but, for the alleged exemption. Any violation of Occupancy I'�IDLII'Crn 0 V�� Type 3 hL Section 7031.5 by my applicant for m Permit subjects the applicant k a civil penalty of not mart Nm five hundred dollars (M). 01. u owner of the property. Or my employed; with wages n their role compensation, ` // //. ` will do the work structure On scture is ml intended O offered forsala(Sm. 7044, Business l r�aa � �Requlred.Inspeetions and Profession., Code- The Contemnors L)aue law dead, not apply k an owner of property who dmuuchwoin MmselferlArough his such nprmdwM yeds, ..ided Out mushimps ems fm nk.IL ownemployees,pmgor year ocmpletiru buwercA theWildingdo orimprovementuhalt wllhinoro)earermmeassfo.Neowner. i pi mid within bu0der will Mrc Ote burNn of proving Out he did ml build O Improv far purpose of talc.). ❑ 1, u owner of the pmpenY. am "elusively contrmding with Iittued centrhaun to comnuct the project (Sec. 7044, Business and Professions Cada:) The Commandoes Lt. come law does not apply to an owner or property who builds at improv Nemon, and who contracts for such projects with a eonuacmr(0 licensed punont to the Contrmmrs License Law. El 14. morpt under Sec. , B& P C for this moan Owner Date WORKERS COMPENSATION DECLARATION I hereby afrirm under penalty or pedury one of the following declensions: 1 haw and will maintain, CCelRcate of Consent GoselMnum for WorkeesCmnpen- Oon. u provided for by Section 37e00 of On labor Code. for the Performance of the work for which this permit is issu. An and will maintain Wmkers Compevtie an Insurance, u required by Section3 of to lalmr Code. for the performance of the work for which this Permit is bound. My Workers Compewtion Insurance carrier and Policy number art: Carrier..S�in 1 2 u PolicyNa.: r.'i S 7 Z- 100 tt CERTIFlCATE OF EKEMPrION FROM WOR—' K' _R0 COMPENSATION INSURANCE (This scctim need net ummplcted times pemit Is foram hundreddollan ($100) nr less.) I certify Nat In the performance of the work for which this permit Is issued, l shall not employ any person in my manner m as in become subject to theeW rkcrecompemalion Laws of California. Dam Applicant NOTICE TO APPLICANT: IL after making this Certificate or Exemption, you Mould become subject in the Worker's Componadon provisions or the labor Cum you must Oforthwith comply with such provision or this permit shall be dcemcd nomium. CONSTRUCTION LENDING AGENCY IMreby affirm that Olen is a construction lending agency for Ote performance of - the work for which this .it la issmd (Sec. 3097, Civ, C.) Q Lenders Namc z Landers Address Q 1 certify that 1 have mad this application and teak that the mon Information is CONGO. 1 agree to comply wit all city and county ordinances and main laws relating In building construction, and hereby autharim representatives of this city to cnkr upon the above-mentioned property for Inspection Purposes q (W.) egret m arc, indemnify and keep harmless the City of Cupertino against Ilabilidesjudgmenu,coms and expenses which may in my way moue against said City in of the granting of his rmit. tAND APPLICANTGUNDERSTANDS WILL COMPLY WITH ALL NON -POINT Issued by:S4(2� Date SOURCE REGULATIONS. Re -roofs Signature ofApplicsoutfiContrasciorDate HAZARDOUROU S MATERIALS DISCLOSURE Type of Roof Will the applicant or future building aceupanl nom or handle hoWous material ss defimd by tite Cupful.* Municipal Code. Chapter 9.13. and the Health and Safety , Oc onyu us33(,37 Oyu rys u All roofs shall be inspected prior to any roofing material being installed. If a.roof IS installed without firs[ obtaining an inspection, I agree to remove Will the applicant or future building occupant um equipment at devices which Ihavumou air conuminants u dcOncd by the Bay Area Air Quality Management all new materials for inspection. ic P ❑Yea Lynes IntlaHcalih Ihew ran the ban ous materials requirements under Chapter 6.95ofthe Celifor- Ser yCode,Smdou35505.3533�Md25534.1undenkndthmRthebuilding not cum ly haw • kne I, 4t is ps�j e/ponlhility m nadl'y Na Occup., of the 'i re on hichmum rioI. cora bNilneskeracn G. Signature Applicant Date / of All roof coverings to be Class "B" or better o Tar, or Dak CITY OF CUPERTIN.x-I PEAL rONTRACTnR INFO BUILDING DIVISION ¢*q -.D•a,, t ....+5�,.O BUS I.DINC ADDRESS: CLARK ELECTRIC CORP PERMIT N'05060010 OO SO F)OO ZO NER'S NAME: ('P.PTTTq _3469 ITICTOR 2T PERMIT ISSUE DATE 1071 /2005 PHONE: ' SANITARY NO. CONTROL NO. ARC HITECTIENGINEER: BUILDING PERM IT INFO BLDG ELECT PLUMB MECH Q Q Q 0 LICENSED CON-IRACTOR'S DECLARATION Job Description I hereby affirm Nal I am limned under provision of Chapmr 9 (commencing with Section 7 ,Xd of Division 3 of the Business and Professions Code. and my license is Lfull and effect - e INSTALL 5 RCPTLS '(IT' ROOM) mr"forte License Claes Lieu Dam [ /r c Canuacmr A ARCHITE R DECLA ATIO 1 understand my plans shall W used u public recp s � p ���� ITC■�� Licensed Professional OWNER -BUILDER DECLARATION ' 1 hereby .(Seco License Law for the 11. exempt from Nc fessors Co : re recon. on 703 1.5, 5, Business and Professors Code: Any city or county which Permit t demolish. fic repair any which requiresapermit mennswealcor.nt 0Y� V -2005 nnn tatement for such Pannus cense signed cmcm sthor eits censed0.also for suh Perlia g Sq. Ft. oorArea Valuation dumenttothelhovisid of uanessan Inmlaw(C ormr9 essand Indications vi Code) or incingscdpursuanttoNcpmviviouofor ftBusiness (commencing with Section bastion 3 of the - that M Is erg Alleged Nal he u ezempl Nercfrom and the buts for the alleged Gumption. Any violation of gra and tof he Sec tion ]031.5 by any applicant for a permit subjects the applicants m a civil penalty of 3 Occupancy Type not more than five hundred dollars (5500). ❑ I, As owner of the property, or my employees with wages As their solo compensation, e DS Required Inspections will do the work. and the structure is not immndcd orolfercd (.,ask (See 7(It4, Business and Professions Code: The Convazmes License taw dors not apply m an owner of q P proneny who Wilds or imptovcs thucon,and who doessuchwork himadfor through his own employers, provided that such improvements Are not intended oroRered for sale, if. however, the building or improvement is sold within one year of completion. Ne owner - builder will have the burden of proving that he did not Wild or improve for purpose of 1, as owner of the property, am exclusively contracting with licensed convectors to consumer the project (Sec. 7044. Business and Professions Code:) The Contracter's Li - come, law docs not apply as an owner or property who Wilds or improves Ncman. and who contracts for such pol win a comracmr(s) licensed pursuant o the Cons actor License taw. ❑ 1 am uempt under Sec. . B & P C far this mason mer Data WORKER'S COMPENSATION DECLARATION I hereby affirm under Penalty of perjury one of ted following declarations: I ham and will maintain aCertiGmm of Consent to self -insure fm Wund ehComped- sadmn, as provided for by Section 37W of the LAW, Code, for Ne per turnurm of IW work for which this permit is issued. W—and will maintain Worker's Compensation Insurance, u required by Section .3 of the Labor Code, for the Performance of the work for which this Permit is issued My Wormes Compensation Insurance canner and Policy number au: Cartier. -S—t-nTa= FZ, sem, p Policy No.: (.'3 S 7 3 — wa: CERTIFICATE OF EXEMFnON FROM WORKERS' COMPENSATION INSURANCE This section mood nos W completed if the Permit Is furore hundred dollars (SIM) or est.) I comfy that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manncrso as to become subjen m th� rkeri Compensation Laws of California, Date Applicant NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should Veeome subject to the Worker's Compensation provisions of Nc tabor CMB you must ' faMwiNeomPly with such .rnvisimu or this ,.I, shall be deemed newmd. CONSTRUCTION LENDING AGENCY 1 hereby lending agency for the Perfurman<e of thi that there is which s ed (Sect3 ch ' Mc work for which Nis permit is issued (Sec. J097, Civ, C.) Lender's Namc . t.cndcrs Addtess 1 certify Nat 1 have mad this application and some that the starve information is " correct i agree to comply with all city and county ordinances and sum laws relating to building convection. and hereby authorise representatives of his city to enter upon the _ shout -mentioned property for inspection purports (We) agree to save, indemnify and keep harmless the City of Cupenino in Iiabilidu judgmentaxosls And expcmes which may in any way accrue against said City ' in consequence of the granting of this Permit. " APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE REGULATIONS. Re -roofs Type of Roof Signature of ApplicaDam HAZARDOUS Will Ne applicant or future building occupant morescore or handle Health Add u defined the Cupertino Municipal CMe. Chapter 9.12, and the Health and Safely m Me. Sc❑ctiea sss32(a)? t ,.m Yes + All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will led a licamtmr rmlmre Wlldin pp g occupant use cyvipmcm or deviea which emir hazardous air contaminants As retired by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes Iyf Nu 1 have read the hanMtmss mamrialsmquircrecnu under Chopmr6.95 of the Califon ria HcaIN & SafciyCodc, Smumu 25505.25533,am125534. 1 understand that ifthe Wilding Jou not cmrstaly hale a mnant th }ilia tipansibilvy to notify she occupant of she require ort.wlnkhmust W el dorm emra mfieamoraem er. Signature of Applicant Date All roof coverings to be Class "B" or better Ou f,nt - rcramNmr . Dam. �Eq�k S 1 (020 1 `vrirc AWe Cl �T�2ov • �CJ�pw T\tel c���-� RECEIVED., e JUN 0.1 21105 2�N Qhtoh'r'O t.�ew t_t VCu tT, ,40�-i'Pr6)(k erCL-v 47A{t-e' M LZ OFFICE copy �. I T 1 I L(o 2c �.tew N oTe Lfn 202 aHe eeck 4e0tcate-Q c -it ce �T4 C,p"pLeX veep?—FktLe � a a� t_i 6 tl Zo R ti P G_khc_T_ 4L 4Lt1r«.T PnNeL Zv Q,c(p MALQa I'G. New Cly -f.0 iTS to I� 111 4 O Ul 7f 00 N a 00 W 4 lR o �e o. CIj �1 V A � e^ a"> i > '6 MaM oeeeBounceeaa vv© �e eaaaaaevv000�� �I i v �■■uu■mn■ as' mm m Ism -- - ---- --- - '6 MaM oeeeBounceeaa vv© • CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN . 36941005.00 DATE ISSUED.......: 06/01/2005 RECEIPT #.........: 29829 REFERENCE ID # ...: 05060010 SITE ADDRESS .....: 10201 TORRE AVE # 200 SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ...... OPERATOR: conniew COPY # : 3 OWNER CERTUS ADDRESS ..........: CITY/STATE/ZIP ...: CA RECEIVED FROM ....: VIRGIL CLARK CONTRACTOR .......: CLARK, SUE L LIC # 19532 COMPANY ..........: CLARK ELECTRIC CORP ADDRESS3469 VICTOR ST CITY/STATE/ZIP ...: SANTA CLARA, CA 95014 • TELEPHONE (408)988-4358 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL --------------- .-------- -------------------------------------------------- BREMPOWER POWER UNITS 1.00 47.96 0.00 47.96 0.00 BREMRECEPT NO. OUTLETS 5.00 6.00 0.00 6.00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 53.96 0.00 53.96 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ OTHER 53.96 M/C TOTAL RECEIPT 53.96 VOICE ID DESCRIPTION VOICE ID DESCRIPTION --------------------_____--- -------------------- --- 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL 0 zf"�. � r"+'�ks ;{ � `�� ./�ir iii kcs. � '_ ♦a � U � ;. COlVIMERCIA (INDUSTRIAL INTERIOR • CITY OF NlIMPROVEMENTS?COVERSHEET CUPEfi;TINO Assessors Parcel Number: Name of business. f E IZ \ �-t. S Proj ect address. �04Ao I TvYf .eve L,.412PvT1�x, (-M S. .T env Contact person. I/ t &e F' -V -C , Phone. �c -u? efO 7- V t,, 2 o Current use of space. Proposed use. Building construction type. o Fi= �� A - C' V.6 Occupancy Group(s) Occupancy Load. • Square footage of remodeled area. �T Is the building equipped with:. Fire sprinkles? N; Fire alarm system? � N • Number of floors in the building? yr On what floor(s) is work being done? �2- Yj 4 Brief description of work. (,5 ( kc=ap Ael-� S Code editions: 2001 CBC (Y - N)2001 CFC (Y - N)2001 CMC (Y- N) 2001 CPC (Y - N)2001 NEC (Y - N) Effective 11/1/02 Are there any chemicals/hazardous materials to be stored at site? Y -(jFq If above answer is yes, provide a list of materials and quantities. If job is involves food service, provide 3 extra plan sets for Health Department review. Commercial Plan Review Process Work BookPage -11- revised 4/28/04 CITY OF OCU CUPE. RTINO • CITY OF CUPERTIA PERMIT APPLICATION FORM APN # Date: Fee Group BAPPLOTHER Building Address:i Mailing Address (if different from building address): O 2D I TO Ir VT ve-, -S )�oc � A?-r-rI00 Owner's Name: 'I—C- N a N CIF-P-T"u S Phone #: NI� BBOILER2 Contractor: License #: CLARI, E.Lec-TtG C r c: to 679 693 Contact:. f ' Phone:4ag- qgg-tt2_6g Cupertino Business License#: �i S 3,2 V [1 t G( atrlL Fax: - p I Building Pe 'flit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: 1 NSTq 1/At u ,� c Residential ❑ Commercial 5 Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Projec eo Occupancy Group: BUILDING BCONSTAXBQ Type of Construction: Please check this box if the project is a BCONSTAXH second -story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ BCONSTAXR Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI 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/ConTm/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 1 of 3 ���7 SRO CITY OF CUPEINO 0 CITY OF CUPERTIA PERMIT APPLICATION FORM 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 BOVERTEAE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE PbIg 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 TraR 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 cfin 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 > 10K btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platforni Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP I Remodel Res Appliance ELECTRICAL 2of3 CITY OF CUPEkTINO ATY OF CUPERTINO 9 PERMIT APPLICATION FORM 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 BTEMPPERA? Temporary Bldg Permit BUILDING BTEMPSVCS Teirp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elee Permit Issuance ELECTRICAL. MPERMFEE Mechanical sq. 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 ZADDCH 3 Address Change BUILDING LJ 3 of 3