03050068 CITY OF CUPERTINO gr''`i'/k�•,y+yamz *} r°'
BUILDING DIVISION PERMIT *'v�'•12''(� �A )',) f "' .
BUILDING ADDRESS: BOB BERGER PERMIT NO 03050068
10439 ANN ARTROR ANTP,
OWNER'S NAME: PERMTT lYf 15/2 0 0 3
OB BERGER
NE: SANITARY NO. CONTROL NO.
ARCHITEC IE IGINEER: BLDG BUILDING PERMIT INFO
p 0 O PLIC O
aIOO LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby afOw Net 1 am licensed under pmvisions of Chapter 9(Commencing
with Section 70(10)ofDivlefan 3 ofthe Business and Professions Code.and my license U
N mmBtmmeand ene ELECTR. PANEL REPLACEMENT
j N oZ�„ Licenm Clw Lk.tr f1AAll //Y. tl tC 0
3 6 Dao
ARCHITECTS DECLARATION
u m�'�c fie+ -v�u
I Underwood my phns shall be used ss public weards MAY 2 7 2003
G Licensed Professional
OWNER-BUILDER DECLARATION
I 1 hereby affirm that 1 am exempt from the Conlraco`3 License Law for the
00 following memo (Sccdun7031.3.Busi•...andProfesdunsCedo:AnycityUrcounty BUILDING
$ which requires a permit o Cdnsmam,alter,improve,demolish,ar¢Poll any structure BUILDING
Vl
prior to its issuamo,also requires lhd applicantorsuch permit o file.signed sommenl
£ that he I.fictursood ptersom,m Me provisions of Me Contractar's License Low(Chapter 9 Sq.Ft. Floor Area $1N648tion
i2 $ (commencing with Section 7000)of Division 3 of rte Businoutund Professions Cook)Or
that M is exempt therefrom and the basis for s m alleged exemption.Any volafiM1 of
SeNon 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of 3 3+&&8Qu-id3er0 0 Occupancy Type
not mom than Bve hundred dollars(000).
❑Lu owner of the property,Or my employcca wit,wages u their sale eompewtian,
will do the work and Ne someone is not intended or offered nor Sale(Sm.7041,Business — BE
and Prefeselmo,Code:The Conuacor'a License Law dues Col apply in an Owner of 501 - FINAL A ENERGY
propeny who builds or improves thereon.and who incomes work himself or through his
meramployma,provided that such improvements amnot intemled oraQered forssle.11. SOS — FINAL ELECTRICAL
however,the building or improvement is mid within ane year of completion.to wnar-
builder will have the burden of Proving Nal he did not build or improve far purpose of
sale.).
❑1,as owner of the property,am exclusively contracting win licensed conuacon to
construct the project(Sec.7W.Business and professions Cotler)The Contractor's Li-
CIWI w docs not apply to an owner of property who builds or Improv thereon,and,
Who
fle far.. pmjeMwinaconuaclor(s)limnwdpunuantmthe Cm=WeS
Lr/russ Law.
lame rnpl c. .B&PCf thi,. a
r J
wmr Date
CO EN ATION DECLARATION
I hereby aRhm under penalty of perjury am of the following declarations:
I Raw and will maintain a Cerdrirete of Consent to self-Insum for Wo oo'sCompcn-
tylion,as provided for by Secdon 3700 of rte labor Code,for rte pdRowenm of the
wan,for which nia permit is issued.
❑1 have and will maintain Worker's Compensation lamnnm,as required by Section
3700 of rte labor Cade,for rte performance of the work fm which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Poliry No.:
CERTIFICATE OF E(EMFnON FROM WORKERS'
COMPENSATION INSURANCE
Cnis section need not be completed if rte Ix:not Is foram,hundreddolhrw(3100)
or less.)
1 certify that in the performance of the work for which this permit is WOOL l shall not
employ any pe on in an man sg become stubjmuo the Won,eri Compenv0on
Lows of CeM�l`aSD .��
Applicant -
N0em s I la ting n' osions of the
Exemption,you should
become subject y rte W an ons or Mis provisions of rte Isom Code,you must
,J,'� forthwith comply with such provisions m Nice Vomit hall b,dcomed mwkcd.
OCONSTRUCTION LENDING AGENCY
F 1 hereby alrmn that dere B a construction lending agency for rte performance of
a? the work for which lois permit Is issued(Sec.3097,Civ.C.)
W Q Lender's Name
.4`7. Z Lender's Address
V 1 cenlfy that 1 have read this application and state that to above trunno don Is
D. building l agree to comply with all city and county MMand Crete laws relating o
building construction,ad hereby outcomerepreseUoUM Of of Nia oily c enter upon the
W asovc(W)aged property for Inspection purposes
(Wc)agree o vows indemnify and keep harralessm the City of against against
In liebllltias.judgments.costs and expense which may in anyway mime agatnstmid City
U2 in consegmnce of the Yonling of tis permit. J
sem• APPLICA UNDERSTA S AND WILL COMPLY WITH AL ON. INT Issued by: Date
UL /��
Re-roofs
U
API' or De
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building accupantstme or handle haeadous material
Us,donned by the Cupertino Municipal Code,Chapter 9.12,and the Healdl and Safety
otle.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes C3 No
Will the applicant m future building amupam um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit harsrdous air,contaminants u Jcnmd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ONO ,
I have mad the haran oss maorialsruquimmonts under Chaporii orrteCalifor-
niaHmlth&SafetyCede,Sccdons25505.25533 md25534,1 understand natlf ties building
Jura mol eurtenlly how a tmanl oat It u my mspons@ill y m notify w mcupant of the
n ich 1 me daroisavance cera Comic, cu arta. Signature of Applicant Date
U
ar arixed as, Dal6 All roof coverings to be Class"B"or better
CITY OF CUPERTINO o u
CUP TYOF O PERMIT APPLICATION FORM o 3 - -
J1hPN # Date: J , 5 O
Building Address: i c>(45
(4J /j,)A
Owner's Name: d tJ t 1 r Phone#: got
3
Contractor: License #:
Contact: Cupertino Business License#:
fi�211�
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Descriptions 50A ta 2.bo td
Residential ® Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: (000-o O Occupancy Group:
Type of Construction:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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
BMITIGATC Comm. Housing Mit. Fee BUILDING
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CITY OF CUPERTINO
CUPEt�TINO PERMIT APPLICATION FORM
QuantityAdak Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee . BUILDING
BMNEWNR JIM New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMNM New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCON2 P New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
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
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
BREMFDCT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace> 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
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CITY OF CUPERTINO i
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ED Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch& Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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 13LILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection 13UILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit 13UILDING
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 PlumbingPermit Issuance PLUMBING
PPLBG PlumbingFees foot PLUMBING
ZADDCHG Address Chane BUILDING
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