05040109 .I CITY OF CUPERTINO .:, . --r,r,'•---_._ -'— --
BUILDING DIVISION PERMIT �CONTRAGTORiNFORMATION:°-
BUILDING ADDRESS PERMIT N
FLORES REMODELING f05040109
a10112 ADELHRTD CT
OWNERS NAME: --- PERMIT ISSUED ATE
PETER & LYNNE OHLER 781 JASPER ST __0A /l9/2(1,(1S_
ONE: SANITARY NO, CONTROL NO.
(408) 298-4817
ARCHITECT/ENGINEER. BUILDING PERMIT INFO
BLDG EUCr PLUMB MECH
=oo
LICENSED CONTRACTOR
derp DECLARATION
1 hereby affirm that 1 am fanned under provisions of Chapter 9(commencing lob Description
with Section]000)of Division 3 of NC Business and Pmfcasiom Code.and my license is
mfullfolecandrffect.a3 l S-zo�P6 DECK REPLACEMENT (1ST FL)
j ? License Class f� Lis.Y
L-O Date ( Contractor t�z,a �—
'Eqqtj - - ARC'NIIECTS DECLAA f10N
�i tl-i 1 understand my plans shall he used u public ecmds
�`i 000 Licensed Pmfcssoml
3 OWNER-BUILDER DECLARATION
I I herehy alLm that 1 am exempt from the Contractor's License Law for the
-O O following reason.(Section 7031.5.Business and Professions Cad'My city or county
m which mgwfes a Permit to construct.almp improve,demolish.or repair any avenue �Z S n n
poor to its issuance,also regmres the applicant for such remit to file a signed statement c
that he is licensed pursuant to the previsions of NC Common's license Law(Chapter 9 Sq.Ft. Floor Area Valuation
04 (commencing with Section"10007 of Division 3 of the Business and Professions Code)or
y $ Nat he is exempt dominion and the basis for ire alleged exemption.Any violation of
Section]031.5 by A"applicant for a remit aubpcu the applicant w a Civil pcnahy of 3$43A8[�u3r1ber0 0 Occupancy Type
not more wit five hundred dollars($500). P Y YP
❑I,asowner of Lne polsmsy,mmy employes wiN wage asNeir sole compensation.
will do the work,and dm swmue is not mended or offered formic(Sec.7061,Business
and professions Code:The Cmuacmr'a License Law does not apply to an owmf of Required Inspections
progeny who builds orimproves dxrton,and who doessuch work htmselfof through has
Own cmpioyeW,ping or imrrochimps mid Within not euofedm leumn.for sad If,
however.olive buildingorimprosuchimisoldwiden no year of completion,Inc owmf,
budder will have the burden of proving that he did not Wild or improve for purpose of
sale).
❑I,as owner of Ice pec.704 .H exclusively sin and contracting wM bcemeC Contractor's L-
censtiun des not(Sec.9066,Business and ny who Wilds Code')The Conuacwf's and
tense law dots not apply w an Owner of progeny who sedds or improves themon,and
who contracts for such propcu with a contncmr(s)licensed pursuant to the COnvaclars
L..Law.
❑I Am exempt under Sec. ,B 8 P C for his reason
Owner Date
WORKER'S COMPENSATION DECLARATION
it I hereby Nim under penalty of peOury One of the following deel Vmmnal
I ham and will maintain a Certificate of Consent in selfnnsue for Worker's COmpcn-
sauon,as provided for by Section 37M of the Labor Code,for Lhe peffamance,of me
work for which this permit is Issued.
0 1 have and will maintain Worker's Compensation Insurance,as mqumd by Section
37M of the labor Code,for the performance of the work for which Nu peon it is Issued
My Worker's-C}nmrffe�or.a�ti�on�Insurance caannneer�and Policy number am �i
Cartier. S/ // l U 11111 pocryNO.:/4q�
CERTIFICATE OF EXEMPTION FROM WORKERS' 00 y'
COMPENSATION INSURANCE
(IDU cLion need not be cnmrlemd dthe remit is farome hundred dollars(SIM)
less)
I cefufv Non in Nc performance of due work for which this pcmn is issued,I shall nut
employ any pefsen In any manner o a to become object to the Workeri COmpensmon
Laws of Caldm
ora Day^
Appiie.
NOTICE m APPLICANT:IL arer making this Ccmfteate of Exemption,you should
become subject to the Worker's Compensation provisions of de Labor Code,you most
.JO fuMwuh comply with such provisions or this permit shall M dccmed evoked.
Zvy CONSTRUCTION LENDING AGENCY
(-+ I hereby affirm that nom is a construction lending agency for de perfomana of
C'
We work fur which this permit is issued(Sec 309],Co.C.)
o z Undies A duce
U Q 1 certify that 1 have read this application and sate that tire above mfomatmn is
Fcomet-1 agree a comply with All city and county ordinances and state laws r upon e
QU al,owngconinucuon,oil hertbyauNodaemossix.representatives of NU city to Cnwrurnn NC /
shove-mentioned 1.saw for imnify Anpurpnsca
IS. (WC)amen t,cast,indemnify oil keep harmless Nc y City ri Cupertino against
Z inemmen'tjudgments,
ci a of Recosuand expenses which may in any way aceme against sold City
CJ z w consequence of Re granting Of this remit.
t-° APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS
n
Re-roofs Q
SigmmsGyhf AppleandConvactor DM
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Re applicant or future budding Occupant store or handle harardeus material
as defined by the Cupenmo Municipal Ceti,Chapter 9.11.end Ne Health and Safety
Code. El Y.15571(x)? W All roofs shall be inspected prior to any roofing material being installed.
❑Yo Nu
Will But Applicant or future building«ca If a roof is installed without first obtaining an inspection,I agree to remove
pp s win sew n Air Qua or donnas whim g
9.11 hafaNnus air contaminanu as defined by the Bay Arta Mr Quality Management all new materials for inspection.
Dtunct+ --//
❑YCS NIL
1 have mad)tee"nouns materials mgartmenu under Chapter 6,95 Of the Cahfof
nu Heahc&Safety Cale.Satiate 25505.15533 and 25534 1 understand IbatdlM building
does not cumnLly have a enoL.Nat n is my moonsibility w Lmtify the occupant Or Be
mgwrtm exwhnthmastkmc,pnorwimu.c.r.c,.Fmw.fOC.p.q. Signature of Applicant Date
Fd a tc� 1-/—/9i—&15— All roof coverings to be Class "B"or better
Ownc uthOnmU agcni Dace
F Community Development
10300 Torre Avenue
' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT# os- /O) 0 q
16 ; / 2 R-D�LIfF✓P cZ; / /
OWNER'S NAME: O IAL01? I PHONE# 2gB ZI X1`7
GENERAL CONTRACTOR: r—Lo-j2.ja-y FAX#
I am not using any subcontractors: Z7- -) 62 _°
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
I, I Septic Tank
Sheet Metal
Sheet Rock
�I Tile I I I
Owner/Contractor Signature Date
a a CITY OF CUPERTINO
CU
CITY OF NO PERMIT APPLICATION FORM
APN # o a �,- Date:
Building Address: Mailing Address (if different from building address):
/ 0 / / 9 -#-D1L11F1D c7.
Owner's Name: Phone #:
2 's-2- 6 2 S-2
Contractor: License #:
Contact: Phone: ,2e 7 6�7 Cupertino Business License#:
U(1 A'/�f ,�L6lt.�'S' Fax:
Building Permit Info:
Bldg Q�-' Elect ❑ Plumb ❑ Mech ❑
Job Description fl_oz�16v/IVC- C�J1 t^" 26T2QialL I'Ler/Na naW-)IV
Residential ° 2t-1-pLA9 cr-- ut7 iti j` Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: .3 S-0 D �� Occupancy Group:
i
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK 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 > IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL _
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
� 3s_�°
I of3 ZS � O(/
�' /T
G CITY OF CUPERTINO
C'T'° PERMIT APPLICATION FORM
CUPEkTINO
Quantity I Fee ID Fee Description Fee Group j
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC I Comm. Housing Mit. Fee I BUILDING
BNUCOMME _I New Comm Electric I ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP I New Comm Plumb PLUMBING
I BOVERTIME Inspection Overtime BUILDING
I BPBACKFLOW I Atmospheric Vacuum PLUMBING I
BPCESSPOOL I Cesspool I PLUMBING
J BPERMFEE I Bldg Permit Fees I BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS I Gas Piping System Fee PLUMBING
BPINTERCEP I Ind Waste Interceptor I PLUMBING
BPLANCHK Plan Check Fee I BUILDING
BPLANCKADD I Plan Check Add Multi I BUILDING
BPLANCKREP I Plan Check Repeat Fee I BUILDING
I BPREPIPE I Repipe Of Fixtures I PLUMBING
BPSEWAGE I Sewage Disposal PLUMBING
BPSEWER Sewers I PLUMBING
BPSPRINK I Lawn Sprinkler/Backflo I PLUMBING
BPSTORM Storm/Rain Water I PLUMBING
I BPTRAP I Kitchen Trap I PLUMBING
BPVENT Alt of Drain & Vent I PLUMBING
BPWATER I Install/Alter Water Pipe I PLUMBING
BPWHEATER I Water Heater/Vent I PLUMBING
I BPWSVCS I Main Water Service PLUMBING
BREINSPECT Reinspection Fee I BUILDING
I BREMACOVER I A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm I MECHANICAL
_ BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY I Remodel Busways I ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN I Relocation of Furnace I MECHANICAL
BREM_FURNOV_ I R_elo Furnace> I OK btu I MECHANICAL_
BREMHEAT I Heater Installation I MECHANICAL
BREMINHOOD I Installation of Hood MECHANICAL
I BREMMISC I Misc Apparatus I ELECTRICAL
BREMNRAPP I Rem Non-Res Appliance I ELECTRICAL
BREMPOLE I Pole/Platform Fixture I ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
I BREMRECEPT I Rcpt], Switch & Outlets ELECTRICAL
BREMRELOCA I Relocation of Hood I MECHANICAL
BREMREPALT Repair/Alter Heating I MECHANICAL
13REMRSAPP I Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEI�TINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmd1 Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL I
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL_
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING 1
BSEISMICRE Seismic Fee Res BUILDING I
BSPECIAL Special Inspection BUILDING I
BSWIM Swimming Pool BUILDING_
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
�1BTEMPSVCS Temp Dist Svcs ELECTRICAL
1 BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot I ELECTRICAL
EPERMITFEE Elec 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 Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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