04070157 (2) CITY OF CUPERTINOax � "'�"'�'�'
BUILDING DIVISION PERMIT COIVTRA�f®R INFORMAT QN
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BUILDING ADDRESS: PERMIT N00 4 070157
22000 REGNART RD
OWNER'S NAME: PERNOTIS5URDATE
PAUL RAMIREZ
ONE: SANITARY NO. CONTROL NO.
ARCHITEC IENOWEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
O O O O
goo LICENSED CONTRACTOR'S DECLARATION Job Description
I barony affirm Nat 1 am licensed under provision of Chapter 9(commercin{ p
^¢ with Sudan 701X))of DIAMon 3 of the Business aM Profculons Code,and my license's
in fail ELECT. BOX UPGRADE
1.Z_ Licenaa Class Lk.0
' cmurector
1 Dem ARCHITECTS DECLARATION
1 undetound my plans shall he used as Public reeords
0 Licensed Pmfesaionel
OWNER-BUILDER aU1LDER DECLARATIDN
a 1 massa a(Rrm Net 1 1. exempt from the Cosion oa License Lew for the
my
p O which re reawa permit
t 703 1.5,Business and w,de seas Cade:Any city or county
$
whichrequiresWha•perost re mtnsuuctafter,nt for such
udeermitt care a sig my structure
pdormiuiensed p.alwtrquite theapplicantof Me cmurermit Uu eaigneduamment
$< (that he Comm n ing Wna menttoOMofDiaisim3 heConuac andPnseLaw(Ch )or Sq.F[. Floor Area anon
(rommencing with SatiOn 7000)of Dividers)of Ne Buanssamd Profeuiav CMe)or $800
.. Mut be u exempt Nerefmm and the basis for the alleged exemption.My violation of
Seeders 7871.5 by airy applicant for a permit Subjects the applkenr to a civil penally of APN Number Occupancy Type
not mom than Ow hundred dt,lacs($500).
Cl 1,u owner of the pmpeny,m my empmyeca with wm u Ihelrmle eompnuuon,
will du the work and immurement snotinmt dmoQemdforaslt(SmJ044,Buatteas Required Inspections
and Professions Cade:The Conuxton UQ•..Law dans not apply to an Owner of q p
property who builds o i mpmws thereon.end who dote ouch work himself or Uuough his
ownemploytas,pmHdedthanouchimpmwmmuasermtImmdr aro@sedforsak.lf.
bowewr.the building or improwment is and within oro year of rompleuon.the owner.
builder will ban the burden of proving Net he did not build or improw far purpose of
ask.).
®®I.as Owner of the Property.ser exdmiwly contracting with][Caused cneoumrs to
cILI net the pmject(See.7044.Business and Profession Code:)Tbe Conuacmr'a U•
come Law dos not apply to an owner of pmpmy whe builds or impmws thermn,and,
who emtrxem for such p njeces with a conuactods)Burned pursuant to the Counstoes
Liana Law.
01 )tt on& S eek PC For this mason
owner V
Data
13070W RKER COMPPNSATIO DECLARATION
t.a by 4BIml under pnulty of pe Ory.of the following damnMmu -
Ihaw eadwill maintain aCeniRcamofConsent toself4am fgtW tComMo.
0
lOn,as provided fa by Sudan 37000f Mere Labor Cods,for L aria of the
rk for which this permit Is armed.
I haw end will maintain Worker's Compensation Insurance,u required by Section
of Ne Labor Code.for the performance of the work fo which this permit is Wood.
y Workers COmnensadon Iwtrana carrier and Policy number am:
rder. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thmsectlon need nutbecompleted lithe permit is fume hundred dollars(SIM)
or leu.)
1 atufy that In Ne performance of Me,work for which this permit M hued.I mall nuc y
employ any person in any Mercer an r m beeome subject to the WorlOW Compensation
Laws of Califomin.Dam
Applicant
NOTICE TO APPLICANT:IL vM,making this Cerdinew of Exemption.you should
become subject m the Worker's Compensation provisions of Ne Labor Code,you must
Q Q forthwith comply with such provisions or thu permit shall W dcemvA mwked.
Z tiCONMUC ION LENDING AGENCY
[.r Ibembya@m that them sea cntutrucOmt Imam{agency fm the Perfomanauf
C gas work far which this Permit u Wood(Ser.3097.Civ.C.)
WQ Lender's Name
0.Z Lender'sAddmu
U Q 1 artily,Nal l raw mad this pplication and auto Met the show information It
LL correct.l agree to comply with all city and county ordinances and sum law totaling to
Q building comeruction,and hereby authodm mpmsenWiwe Of this city to mor unarm Me
W ysaw- for !ureases
(We)agree I.Saw,indemnify and
leap harmless;the City Of Cupen o atainsl
In liabitidca,judgmems.costs and expenses which may in any my enema against mid City '
U 7 In consequence of the granting of this Permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: D
SO G LATI
Z 4 a Re-roofs
Si{rw fApp Tan onuxetor Due
HAZARDOUS MATERIALS DISCLOSU Type of Roof
til to applicant o foam Wilding oceupantstoto o he h nus materia
red by the Ctnume.Munidpai Code.Chapter 9.13,and the cslth and Safety
ode.Sauon 25532(a)? I� All roofs shall be inspected prior to any roofing material being installed.
p ver
Will Mtn applicant of fmure building Occupant use attainment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harsrdow air conuminanu u dc0ncd by the Bay Area Air Quality Management all new materials for inspection.
7mq
istrict?
0Yca No
I haw mad the baca dnusmucrietrcqulmmenu under Chapler6.95 of the Califrr.
e Hcal"Safety Code,Sections 25505.25533 aru125534.1 undcreund thatirthe building
ata not currently haw a mnanl,that it u my responsibility to rally bete acupam of Mo
ter hithm bm=ipdarmiuumm OfaCcnlncamof Ocnpmcy. Signature of Applicant Date
r1
or madvadagenI Data All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
S�M Cupertino CA 95014
, Telephone(408) 777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDR ,n p PERA=
22 poG Re 5 b.a -I 2 vi G B/ S
OWNER'S N PH #4d >r- 7 7-5 Sr 64
GENERAL CONTRA 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
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
tr or ignature Date
a A CITY OF CUPERTINO oz�s7 CD JS—�
CUPEt�TINO PERMIT APPLICATION FORM
N# 3/ Date:
F� is t
Building Add ss: Mailing Address (if different from building address):
�Z7 C
wner'se: Phone#:
Contractor: License #:
J
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bld .6 Elect Plumb ❑ Mech ❑
Job Description: 1
Residential a Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: a 7S Occupancy Gro p:
Type of Construction: CJ Please check this box i e project is a
second-story addition: ❑
Project Size: Standard ❑ Laze ❑ Major ❑
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
3S"
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CITY OF CUPERTINO
CUPEI�TINO PERMIT APPLICATION FORM
QuantityFee 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 Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
low 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
BRENL47RHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREhIFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace > I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREN41MC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc t1 Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Rep air/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
WITYOF PERMIT APPLICATION FORM
CUPEkTINO iii
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 Inection 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
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