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03120007
CITY OF CUPERTINO BUILDING DIVISION PI'rRMOCONTRAC`*TORINFQRNn" F LD;NG ADDRESS: ANCHOR CONSTRUCTION PERMITNO.03120007 NER'S NAME: PERMITESSUEDATE OHM NADLER 4 N. NORFOLK ST_ 12 /02 /2003 NE: SANITARY NO. CONTROL NO, (650) 346-4508 CHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH CJ ±oo LICENSED CONTRACTOR'S DECLARATION m 1 Many affirm that liana am d under provisions of Chapter 9(commencing Job Description £<Edh S with 7")of Division 3 of the Business andriuns Code.and my Because is ?amu, in hill fn¢ avj Clean.Cl TV— / Cie.as .f," BATHROOM REMODEL - 12.-, fARCHITECTS DEC ION C a U I undamand my plans shall M used az pub c me e u.t, Licensed Processional ;ice OWNER-BUILDER DECLARATION z<T. I hereby affirm that I am exempt from the Contractor's License law for the 0 o following rausm.(Section 7031.5,Business and Profcssiom Coda:Any City or county 5$E which mgwres a permit it,construct.alter,improve,demolish,or repair any structure ire prior 16 its issuance,also requires the applicant for such permit to file a signed statement iC that he is licensed pursuant to beprerismnsofthe Contractor's License Law(Chapter 9 Sq.FL Floor Area Valuation el- (commencing with Section 700()of Division 3 of UC B USness and Professions Code)or that he is esempt therefrom and Be basis for Ne alleged axemElion.Any violation of Section 7031.5 by any appli.1 for a permit subjects the applicant m a civil penalty of 3�.�ffiN32BIBer 0 0 Occupancy not.Tore than five hundred dollars(SM. P Y Type o I.as,owner or EEC property,or my employees with wages M dreh sole compensation, will do the work,and the swctum is not intended or offend for sale(Sec.7044,Business and Prorcuiom Code:The Conuactars License law dors not apply to an owner of Required Inspections proOwncnywhobuildCm]mphaves t=animprandwM are ssuchnot in work or rer edthmate his LT—ffl howemployvs,ping or i prove ent is improvements ear ded OfCmoRemd the 1J+'� lapiy�y tea® �uilder thebuildingor improvementressold within one year or eomovefo.Ne owner- 6 builder will have dte burden of proving that M did not build or improve for purpose of site). JAN 6 q ❑1,re,owner of ct sec.70,am exclusively eontraming with licensed oonuacmn i- as GOO construct the project(Sec.10 n Business and Professions Code:)DEC Convectors rad Li- Canada law cOcs not apply m an with a of pmpcny who builds or improves thereon.and ey who contracts for such projects with aconrnnor(i)liccnmd pursuant to the Contractor's BUILDING [I I rom Law. ab0 k� . ❑I am esempt under Sec. .B&P C for Nis meson Came, Data WORKER'S COMPENSATION DECLARATION I Mmby aRom under penalty of perjury oa of rhe following declarations: bass vnd will maintsin a Cenifiom of Comem to self-insure for WorkahCompcn- bra,u provided for by Seniors 37.of the labor Cade,for the performance of the 11 OFk for which Nis permit is iuucd. ❑1 have and will maintain Worker's Compensation Insurance,a required by Section 3700 or UC labor Code,for dm parr Ocmara Cir the work for which his panni,is issued, My Worker's C.prpeJsar n�lnsunntt career end Polity number am: Fl t�ZL4G��-✓s.r_[ ��oriJJryry No.: / CERTIFICATE OF EXEM�fI FROM WORKERS' . COMPENSATION INSURANCE (This mninn recd not M comptetcd i(tM permit is foronc hundred dollars(Slip) or lass.) I certify their in the performance of the work for which this Permit rs issued,l shall not employeny,person io any manner an as tP kenne bjen mdse Worlmos Compensation . lawj of California.Dare Applicant NOTICE TO APPLICANT:IL after making this Cenifica a of Exemption,you should become subject to the Worker's Compcmadon pmvisiom of the labor Code,you mus, J ,z forthwith comply with such provisions or this Permit shall be,deemed revoked. zCONSTRUCTION LENDING AGENCY r T hereby effort Nat Nene iso comtmetinn]Coding age.,far tM pe,furmana of W'LC On,work fruwhich Nis permit is issued(Sec.3097,Co.C.) 0 4ndcr' Name =z Landers Address 1 U Q I certify that 1 have rod this city and county and aisle,bas rbc above ws relation is - ly (~ miming I agmc to comply with all airy and county oNimnas and Cott lads relating to buildingend hcmbyaodtorimra,isu of this city menhirUpon theUaon-memtioned Property fin inspection purposes. �a'y (We)agree to save,indemnify and keep harmless the City of Cupertino against h liabila djudgmrhe to and eaPemeamit. they in anyway accroe against said City U Acon tic c of the gmntin o! is permit. SOUL�A or D WILL COMPLY WITH ALL NO -POINT Issued by: Date t S � a I2-� G Re-roofs vt c o hasnUComranor Data HAZARDOUS MATERIALS DIS11X1 Type of Roof Will one applicant or fmuro builJing occupant shire or hantlle hasertlous material as doGncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and safety Code.Section 25512(a)? _ ./ All roofs shall be inspected prior to any roofing material being installed. ❑vee [9A Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove I hnrardnus air contaminants n JcfncJ by,be Bey Area Air Quality Management all new materials for inspection. ❑Yes I hvvcrt the haaaNrws malaria"my ma tsunikr Chapterfi95 ofthc Califon ria Hralnits eryCodc,Sections 25Ni5.25 l J gJ4.lundcrsund thairthc building does nota ml raw•re yyylll l Lha (f,'Shility m notify tM me pant of Ne mgnlmme It' [�,1 a 1/ rthric a C N y. l/J,�- U (s Signature of Applicant Date neroraamoriy. Sant D„e All roof coverings to be Class "B”or better =�fir- - WITY OF CUPERTINOP CUP TYOF O PERMIT APPLICATION FORM Ask N # Date: Building Address: pp Owner's Name: Phone#: ontractor: cmc nse#: Contact: Cupertino Business License#. Atux ( a� wild Permit Info: B1 Elect ❑ PluMech ElJob ascription: Wr (-Rd'sidential � Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Projec : Occupancy Group: Type of on ruction: jP 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 /71 BELEC200 Elec Svcs 600V <=-200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Ener Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housin Mit. Fee BUILDING 1 of 3 WITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP 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 rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfrn 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 A —r — ELECTRICAL BREMNRAPP Rem Non-Res A liance ELECTRICAL BREN20LE Pole/Platform Fixture ELECTRICAL 2 of 3 + , OITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREMPOWER Power Devi ce/A aratus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Sips 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 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 12 EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 i i /VeZ y PLAN SHALL RE"N ON v THIS c1 � THIS !04 AY ALL l�� DIJWNG cot4imcnO". TM CIV 6B W,% A OWE ja%) g10Ntuof dns ands aletim s pd dre6c 5 © en ke a yachanRasat'Ss lc 1CAt[: � � without wCtY^ Cupcftina: on 'a 3 Capt., lanE and sPe�FEica ,d �inS of this p� pscm�t Of oot s;onn y�5�,E �hyeldaflon cE tntu law. I c ` r "-, RECEIVED 0 2 2003 • Y. - - i o tce i vS l 6 v I