05050043 CITY OF CUPERTINO �` •'M af.::A?
BUILDING DIVISION PERMIT CON'"1C"OTOR INP'
URMA'TTON.,
lf.k z .x
BUILDING ADDRESS: PERMIT NO.
CALIFORNIA POWER AND LIGHT 05050043
268 WRRTAOR.99 DR
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY&65OL NO.
ARCHITEC(ENGINEER: BUILDING PERMMINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Desc
a I Mosby of Iml that 1 Am Iiavcd under pmNuom of Chapter 9(commencing ��p�\/\JO O
t� with Sttt1on mlefaf Dlvison Jaf the Huatnea and Professio sCode, mylicense is ��LEIb�
I.roll taro and efrctL 'J; GRADE ELECT PANEL '(200
j ? I.Icense Lte.N UP
Data li OS Connanlnr f• T"
ARCHITECTS DECLARATION (Lw J�
? I..dermad my plana shall he used a public records s U ! 200C
yc Licensed Professional d
OWNER-BUILDER AmptIDECLARATION BUIL 11
i$ I hereby Affirm that 1 uempt Item the RATION a License Law for the
0 o following mason.fiction 703 1.5,Business and Profession Code:Any city or county
which requires a panni,m emrslmct,alter,improv,demolish,err repair any straum
"tire prior b its issuance,also requites the applicant forsuch permit to rile a signed suunen,
NC caw he is licensed pursuant m the provisions of the Contractor's license Law(chapter Onpter 9 Sq.Ft.Floor Area Valua$ (commencing with Section 700Q)of Division 3 of the Busiaeea and Potassium Cade)or
>v that he Is sump,Nesefrom and the hub for tte alleged exemption.My violation of
Section 7031.3 by nay applicant for a permit subjecu the applicant be A civil penaby,of
3 5p11)PerO 0 Occupancy Type
no,team Nan five hundred00}
d dollars(55
O I,a owner of the property,or my employees with wages as their mle compensation,
will do the work,and the sinutumis not+ntenAed or offered for sale(Sm.704A,Business Raired Inspections
And Pmfessiom Cade:The Cmandelor's Liam Law does not ns not apply to an owner.of. q. p
property who bis llds or Improves thereon,and who dos ouch work himself or INough hire
own employees,provided that such lmpra emeau m nothesnded aroffm d fm Aala.IL
however,the building are Improvement Is said within am year of completion,dee await
builder will haw the burden of proving that he did not build or improve for purpose of
sal.)
❑1,as owner of she property,am exclusively contracting with licensed can==In
construct the project(Sec.7001,Business and Professions Cade:)The Corhaua'st..
cense law doss not apply to an owner of property who builds or Improves thereat,and,
who counsel,fat such pmjem with a conuator(s)licensed pursuant to the contractor's
License Law.
❑I Am eaemp,under See .B&PC for Nis mann ..
Owmr Data
WORKER'S COMPENSATION DECLARATION
1 hereby AM m under penalty of perjury ore of the following dalmtiau
1 haw,nd will maintain a Cardinale ofComem m self-imum for Worker's Compeer. -
1301M
tion,u provided fm by Section 3700 of the labor Code,far the performance of the
la for which this permit is issued.
1 haw and will maintain Workers Compeeafion Insurance.a required by Section
of the Labor Code,for doe performance of the work far which this permit is leaned.
y Workers Compensation Insurnce carrier and Policy number art:
rrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(Thu secauss need no,N completed if the permit Is fortune hundred dollen($100)
or hJg)
1 sanity Nat In the performance of the work f''o((which tiaia permit Is issued,L shall not
employ any p, I.&m& ginnerseaIn tb%cabje WLW f ter unaton
Laws of Calif°rntg,�r
NOTICE TO APPLICA f, u eking thisenifiosu of Exemption,you should
became subject m Ne Wo er1 Campcnadon prevision of the LAW Cede.you most
,J z forthwith comply with such provision or this permit shall be deemed revoked. '
z ti CONSTRUCTION LENDING AGENCY
(ti I hereby Affirm this ft.u•cornralinn lending aFacy for the parfnmance of
LYm the work for which this permit Is Wood(Sec.3097.Civ,C.)
QLarder's Name
=z Lenders Add=
U O I artify that 1 haw reed this application and suis that the above informatiut is
;'! curtest.I Agra m comply with all city and warty ordinances sea state laws relating te
O ISO' building construction.And hereby sothodw representatives of this city m enter upon the
t.$7 shove mentionN property fm inspection purposes
y (We)Agree m caw,Indemnify And keep humlea the City of Cupertino against
soy cn Ilabiiities,judiments.cosu And expenses which may in any any acerem What mid City
U 7 in COnsequcnc the grating of Nis iL
r7 APPLIC U DERSTANDS A ILL C MPLY TH ALL NON.POIrf Issued by: Date
SOURC E LATIONS. /
Re-roofs
SignsuriorApp)4'XATuo
OUS MATERIALS DISCLOSURE oil Type of Roof
Will the applicant or future building atopen,atm or handle hasrdous material
As defined by the Cupertino Munic( el Code.Chapter 9.12.and the Health and Safety
Code,Sector 23332(x)? All roofs shall be inspected prior to any roofing material being installed.
[D Yes 11ENa
Will than applicant are future building oceapant area equipment are devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hvsrdaus air contaminants as defaced by the Bay Ama Air Quality Management all new materials for Inspection.
Iatric'?
❑Yes Nu
I haw mAd the haardlm mAuritlsrequimmemunderCMpurh.95 of the Glifor
nu Kni"Sakt,code.Seuiam 5,2551Jand 25534.IuWmuM dmRifthe With.&
fact w faarten y Mw•urian t It O m icy m cotif tic aeupw of the
rewire n�itnmuslR 'Orionw ° ananca Signature of Applicant Date
owner ar.at a I r Data All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
OCIF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Building. Department
JOB ADDRESS: 1-123 l r� PERMIT #
(p?5 b osooY3
OWNER'S NAME: M7 C..,/Vuzc PHONE # --1olr-41-il-6 -93
GENERAL CONTRACTOR: Lq - e 0- FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical /� eI^ i t -72-04e4
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
I
a -
er/Contractor Signature Date
A1 CITY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM v
APN# � � � � � ��� Date:
BuildiAddress: ailing A dress (if different fro building address):
tb �aCrPs -C 1 1/7 o — 9 SW7
Owner's Name, C� /k • � � Phone#•
Contracto License #:
-71510
6�
Contact: hone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Descripti n• �?
Residential Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: h Occupancy Group:
i
Type of Construction: Please check this box if the project is a .
AWL second-story addition: ❑
Pro'ect Size: Standard ❑ Lar e ❑ Ma'or ❑
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/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
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CITY OF CUPERTINO
CUac
PERMIT APPLICATION FORM
E TINO
Ouantity Fee ID Fee Description Fee Group
j BMISCELL Miscellaneous Fee BUILDING
I 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
a 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 cfm 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> 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
Ah BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res App liance ELECTRICAL
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CITY OF CUPERTINO
CUPEkTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR - Theatrical Ligbting 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 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
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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