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04080185CITY OF CUPERTINO F� BUILDING DIVISION PERMIT ` C,OWRACTQV BuaDINGADDRESS: CUPERTINO VILLAGE ASSOC. PERMIT No. 04080185 OWNER'S NAME: PERMIT ISSUE DATA ONE: SANITARY N TR ONOL NO. ARCHITEC (ENGINEER: BUILDING PERMIT INFO t 'B Da ELECTy� P UMa MECH ! O LICENSEDCONTRACTOR'SDECLARATION Job Descri I hereby affirm Ihn 1 am limed under provisions of, 9 (commencing under O ,, Ce ta. with Section Diviaien 3ofthe Btteinesaan0 Profcssiana Codc, and my license is d.1of I. fall .Cla anderceLt. Class Lk. p TEMP. POWER FOR KARAOKE pggy��L ffi'Nldt� r O Zir Date- recter Dam Con DELL ARCHITECTS DECLARATION 1 understand my plena shell M used as public records Q, 1 ■�yv�� I L e ' I N Lleced Professional OWNER-BUILDER DECLARATION D V yr V I hereby .(Sero 1 exempt from the Contractor's License Law for the following rcpeon. (Sadat 7031.5. L$ Business and on 1. tape Codc: Any city m county which requires a permit improve, ri Improve, de any structure es re uir he applialtar.cant h Permit n e a sig that hor e requites lhovisio so for suchp on'sLiees, Loed statement iutensedp puralssuant that Sq. Ft. Floor Area Valuation witpuuuanitotheofDivisionitheheBusinessaLimomlaonsCodmr9 (commencing Gxlc) per n 3 of the Business and Profesme. Meet aisecept theron efrom Any aper for Ne alleged eumpdon. Any vielel Ily of and I basis r exempt ranrtfrom and gallon7031.5 any subjects Ne applicant io or mecivil penally of 3AENVOintl>er00 Occupancy e EYP reddentforapeemir ft.lby not mart dun five hundred dallua ($500). P Y ❑ I. as owner ofthe properly, or my employees with wages as their sole compensation, will do the work end Ihmtrunum isnot intended proffered forsale (Sec. 7066, Business and Professions Code: The Connector's Lime law docs not apply to an owner of Required Inspections property who bul Ida or ice proves thereon. and who does such work himself or through his own employees, provided that such improvements are atinuended creamed formic. if. however. the building or improvement ismld within one year of completion, the owner. builder will have de burden of proving that he did not build m improve for purpose of _ sale.). ❑ I, as owner of the company, am asclusively contracting with licensed combustion; to construct the project (Sec. 7046, Business end Professions Cade:) The Contractor's LL come Law does not apply to an owner of properly who build, or impmvm thereon, and who contracts such projects with a conuacior(s) licensed pursuant miles Coma torn e Law. I am axe rq undu Sec. , B &�P q1110, Nls//p /mjon O.V I Dem tS'T`G y WO COMPENSATION DECORATION I hereby emrm under penally of perjury one tsf the (allowing dedpeeuom: _ I have and will maintain a C.nifluunfConsentio self-insum fur Workers Cempen. moan, as provided for by Section 3700 of the labor Code, for the performance of he week foe which this permit I. issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3100 of Me Labor Code, for the performance of Ne work for which this permit is issued. My Workces Compensation Insurance carrier and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (nascence nand notbemmplcud tithe permit is forone hundmd dollam ($IIX) or les&) I unify that in to performance of Ne work for which Nis permit is issued, l shall not em ploy any Forma in an manners sobec Nbicct unlike Workers' Compensation Laws of Califmm'. Y Applicant• n� NOTICE 7 PLICA�N1., 10, r making this Certificate of Exemption, ym, should become subject m the Wpekeu Notation previsions of de Labor Code, you must forthwith comply with such provisions or On permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 thereby am. that there is a censtruelinn lending agency for the perfmmmoo of dm work for which (hie permit is issued (Sec. 7097, Civ, C.) Lender's Name Lender's Address I notify that I have read this application and euro thn de above information la correct. l agree to comply with all city and county ordinances and seats laws relating to V building consuucdon, and hereby authonza representatives of Nis city to enter upon Ne aImVC-mentioned for inspection (We) agree to an, indCmnify ad kap harmless the City of Copece ro, against liabilities. j and Cxpempe which may he may la any Way aCCNC against said f.'lly graLL race of mitCil In LpnSegYC11CC Of the $lallllag of IVIS permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Dat SOURCE RE I ! (l Re-roofs Type of Roof Srgumdre of AppBanvconoacip Dam HAZARDOU TERIALS DISCLOSU Will Me applicant or future building occupant store or handle havardous matenai U defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety ' Case, &adon 2ss3x(an 0y. V't No All roofs shall be inspected prior to any roofing material being installed. Will thc applicant or future building occupant ase equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove mil hazardous air contaminants m dcEncd by Ne Bay Area Air Quality Management all new materials for inspection. District, t]Ycs Nu 1 have read the hvaednus materials requirements under Chapter 6.95 of the Califon ria Health A Safely Code, Sections 25505,25533 and 25574.1 undcrmnd thea ifthc building does not currently have a mnanr, Nat It r my respomihdity as notify the occupant of the requiremcn ch melpnortatssanceefuCenifmamof rap y. Signature of Applicant Date 0 All roof coverings to be Class "B" or better o n raumpnsedasen, Q Post -It* Fax Note 7671 I)atG # f pa es To iT oTIAjo Frorn TT _« «k( co �, VIdA66— Phone# Phone — 3)«_Ism Fax —2 ,44� > 0 \y� / \ � > r 0 � r v 0 > ct) Post -It* Fax Note 7671 I)atG # f pa es To iT oTIAjo Frorn TT _« «k( co �, VIdA66— Phone# Phone — 3)«_Ism Fax —2 ,44� \y� / \ � v ct) Post -It* Fax Note 7671 I)atG # f pa es To iT oTIAjo Frorn TT _« «k( co �, VIdA66— Phone# Phone — 3)«_Ism Fax —2 ,44� � ƒ v ct) >1 C avo CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM p z , -bg o I of --- Quantity Fee ID N # Date: PLOTHER O 0 L Mailing Address (' differe from b ilding address): Building Address: V9. v 15 Z 0 MECHANICAL Owner's Name: c7e Phone #: MECHANICAL Contractor: License #: MECHANICAL Contact: I VrrT Y Phone: 5v._3—I,-p-U Fax: S z7— v S Cupertino Business License#: MECHANICAL Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Boiler> 1M to 1.75 M Btu Job Description: —7 Residential El(&m P1z,+a ftz rL Commercial ❑ BBOILER5 Sq.Ft. Floor Area: 1=02 K I kA $/Sq.Ft.: BCONSTAX Costof Project: Occupancy Group: Type of Construction: Please check this box if the project is a second -story addition: ❑ Pro'ect'Size: Standard ❑�Lar�O�MaorO�__ BCONSTAXBQ Quantity Fee ID Fee Descri tion Fee Group PLOTHER Other A liances MECHANICAL OILERl EtBBOILER3 Boiler <= 100,000 Btu MECHANICAL OILER2 Boiler > 100K to 500K Btu MECHANICAL Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler >1.75MBtu MECHANICAL BCONSTAX Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for B Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL WI1Construction BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Ener BUILDING BENERGYADD Ener Add Multi BUILDING BINVESTIGA Investigation fee BUILDING * �, 6 7J'Y I ars /�r,0a7 CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2of3 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 BOVERTIME 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 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 BREMAHUTAN 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 BREMR.ELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 I CITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmd] 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 Inspection BUILDING BSWIM Swinuning 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 AIL • 3 of 3