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04100077 CI'T'Y OF CUPF;RTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION . d awE ?zyxyt`;: AtifreXe;,4 ..' Psi . BUILDING ADDRESS: PERMIT�.4 9121 BARNHART AVE OWNER'S NAME: PERMIT ISSUE DATE HOME LIFE TRUST 10/12/2004 NE: SANITARY NO. CONTROLNo. ARCHITECUENGiNEER: BUILDING PERMIT INFO BLDG 0 ELS PLUMB MF.CH 0 0 0 LICENSEDCONIRd under provisions DECLARATION F❑ I hereby affirm That 1 am IveeBJ undersedPr "(Chapter v(commencing Job Description with Scnion (Nq7 fD' inion]of me Businnsj Professions Code.and my license is ^`H mmn5re it �6"'N UPGRADE (1) BATHRM FIXTURE/ELECT. '�� u"" eyL m WINDOW REPLACEMENT o Dam Comitant 4T ARCHITECTS DEC L-A ATION Y u I neat nil my plans shall W used as pubu,records 3 o G Licensed Pmfessinnid ` i 3 OWNER-BUILDER DECLARATION ay 1 hereby affirm that I am exempt from the Comranoi s License Law for the n a following re...,(Section 7031.5,Business and Pndessiom Cade:Any city or county K m which requires a permit to construct,aluo.improve,demolish.or repair any structure prior to its issuance,also rel the applicant for such permit to file a signet statement 'xc that he is licensed pursmnuothe pmviaonsofthcContmamSLianscLaw(Chipter9 Sq. Ft. Floor Area Valu i OF (commencing with Section 7000 of Division3ofthe Busineaand Pmfess;nns CnJe)ur i 3 Nat he is exempt therefrom and the basis for me alleged exemption.Any violation of Section 7031.5 by any applicantfor a permit subjects the applicant to a evil putalty ofpp�r�7yr�be Occu anC T e not more than five hundred dollars(s5D0k 3750904.3 . VO P Y YP 1,as owner.RM1e pmpeny.or my employees with wages a m,ir sole=ampensati., will do the work,and Ne structure is not intended chattered Parsee,(Sea.7044,Business and Professions cod,:The Contactors License law does not apply to in owner of Required Inspections propeowncrtywycos.rive;mprnveuch impr,entlwhotloessuctende or offered his FINALE pa ® ownerty whoc.pds or ed immateuchimp,and who arenet ssuch work oroalfc,too.ith his ItlI p{/y/�p®[l[ir]a however.the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not Wild or improve fur purpose of see.). Cj 1,or owner of the pmpcny,Int exclusively contacting with licensed=ulmolu rs I. MAY t3 Zppg construct the pmjea 00 (Sec.70 ,Business and Professions CWc:)The Conua=mr's Li nae Law does not Imply to an owner of property,who Wilds or improves thrum ,and N Oil �amtraw. for such projecswith ammracmr(s)licenedpursuanuo NC Convenor's ��1 �V®� Lean,,taw. {'I(t��� am exempt under Sec. B A PC for this reason stabows Owner Dam WORKER'S COMPENSATION DECLARATION I hereby affirm under pemlly of perjury one of the fallowing declarations: I haw and will maintain a Certificate of Consent to self-ensue for Worker'uCompen- satlan,a provided for by Section 3700 or the labor code,for the performce anof be .,it for which his .it is issued. ❑1 have and will maintain Worker',Compensadnn Insurance,as required by Section 3700 of me labor Calc.fw the performance of Ne work for which this permit is issued. My Workers Compensation Insurance carrier and Polic numhcr are: Car p _ C::9 CERTIFICATEOFE.=A l l ROM WORKERS' . COMPENSAPID'NINSURANCE (This section need not he Completed if the prim it is for one hundred dollars(Sl FBI or less.) 1 certify hot the p,rut rfli ee of the work for which this Permit is issued,1 shall not mployan),perso110 a yit ney�n ;come subj=coo the Workers'Compensation Laws aft'Am. r6 W Apple am NOTI E eO APPLICANT:If,after m g is Cen;licale of Exemption,you should b sore bjcct ro the workers Com rovisions of the lalmr Conk,you mum .J0 (o mplywithsueh provisions or this permusball W deemed revoked. Z CONSTRUCTION LENDING AGENCY j-a Iherebyafirm Nm there isarnnslruNnn lcnJ;ngaFeney l'ormeperformanecof 01 the work frrrhich this permit is issued(Sec.7897,Civ,C.) Q Lender',Name U Z Lcndcr'1 Addruis etifys J Q I ccnee Nat 1 have read this city and coun and star,Nat the abort ws elstian is v/ C:) come(.l agree m complyand with by city and county ordinancesvesof and stmt laws rel Pon me �U aWbuilying,ononed prn.Ind hereby authentic of this city tocnkr upon me Dq liaave-mc judgra reL c si for inspection purposes. (~ (We)agree m save,indemnify and keep harmless the City of Cupertino against % incomarqurica of ,gain and ing of thisesmit, may in any way accrue against said City 1 ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR EG L IONS. � lsnamre orApny= c n r �ek Re-roofs HAZ RDOUS MATERIALS DISSI.OSURE Type of Roof Will the applicant tar future building Occupant store or handl N haizuus mamdul az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Chdr,Section 25532(.)? ❑Yea tf4a All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building munpanl use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove R hazardous air contaminants as defined by the Bay Arca Air Quality Mmmgemcn, all new materials for inspection. vitt? ❑Yea RtHo I have mad me haardous materials requirements under Chapter 6.95 of the Califon old Health&SafelyCalc,Scamms 255115.25533 and 25534.1 undersand that if the building does not currently here a tenant,mat h is my responsibility m ha dly rhe sxrupnt of m= M�q�rcyu'rtM1,ae,lxmet prior t,,;aaanc, nn cU.S . non=x Signature of Applicant Date �d l Owner s aamomcJa I Data All roof coverings to be Class "B"or better CITY OF CUPEizTINO i� BUILDING DIVISION PLR HC�>-,TTRAC INFOR ON." BUILDING ADDRESS: PERMIT p04 1 00077 121 BARNHART AVE INER'S NAME: PERMIT ISSUE DATE HOME LIFE TRUST 10/12/2004 PHONE: SANITARY NO. CONTROL NO. BUILDING PERMIT INFO ARCHITEC-PINGINEER: BLDG ELECT PLUMB MECH 0 Lop LICENSED CONTRACTOR'S DECLARATION Job Description Fp 1 hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing P 7 W with SmdMl7W(Bof Division3of Ne❑moxotxe pPrnfessions Cnde,andmylicensc is _gym mfuopnr dr«r 7� UPGRADE (l) BATHRM FIXTURE/ELECT . Doen Lir." WINDOW REPLACEMENT v q p p Dase TS DECle CC M I '1 / Ak �� ¢F hq ARCHITECTS DEGL-ARATION 1{F u ///U\r Y a 1uagra,and my plans shall be used as P.5 o,rccmds i 0` C� Licensed 11 ru"innat OWNER-BUILDER DECLARATION MAI t3 2005 1 hcrchy infirm that I am exempt item We Contractor's License Law for rM1e p o following aasoa.(Satin 7031 S.Bushels'and Prufrssiov Code:Any lily or county ym K which inquires a permit to balancer,drier,improve,demolish.or repair any structure poor ah its issuance.also requites the applicant for roth permit to rile a signed statement Val U. 1 ees t-�a that he is licensed pubmanUO the pmvisionsof the Cononton's License Law(Chnpmr9 Sq. Ft. Floor Area 0FG (commencing with Scoom.7IXN1)Ol Division 3 nine Businexvund Professions Cudo)nr ou that be is exempt Wcofrom and the basis for Ne alleged exemption.Any vinlmion of Section 7031.5 by any applicant for a permit subjects the applicant Io a avil penalty of pp N T I Occupancy Type not team Nan five hundred dollars(SSW). 37 5 0 9 0 4 3 bel 0 C3 i,a owner Of the pmpcny,or my CMPIOyrrs With wages as their aide compensation. U wills Ne Work.and We structure is not intended o offered farsell(Site.7044,Bal bass and Professions Code:The Contractor's Liccnse Law docs not apply to an owner of Required Inspections property who builds or improves thrown,and who does such work himself or through his Own employers,provided that such improvements are not intended or offered for sell.If. however,Ne building or Improvement is to wiNim one year Of completion.NC MW... builder will have the burden of pmvi n6 Wat he did not build or improve for purpwx of sale.). ❑ 1,as owner of Wr property,am exclusively contending with licensed contractors to consumer the pojed sin.7044,Business and Profusions Code:)The Contractor's Li. cave raw dos not apply to an owner of property who builds or improves thereon,and, who contracts for such projects with a contractors)licensed pursuant to the Contactor s License Law. I am eaem pt under See. ,B Al P C for this reason Wall Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penally of parjusy one of the following dcclaraimic ❑1 have and will maintain a Certificate of Consent to sel Linsum for Worker's Compen- sation,a provided for by Section 37W of the Labor Cuda,for We pvfomanm of the work for which this prrmit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 37W of Wr Labor Code,for Ne performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Poltc numhor are: C� Pd CERTIFICnTE OF E%EMITI,q ROM WORKERS' COMPENSATION INSURANCE Colis section wed not he completed if the permit is foram hundred dollars(SIIXp or less.) 1 ecnify thin in rhepednr 3Tvmr of I work for which this peon it is issued.1 shall nut employan wni go,6Srx ;bzo uW Object C Wwrkeri ens Compation Laws of Cab r an am APPIi I ✓s NOTI E 0 APPLICANT:If,after m��aIkr is Ccnirieam of Exemption,you should babourn bject to the worker's Comlx6uaIt provisions of the Labor Cade,you must ,J O fmtwi h mhmply With such oov(simo Or this permit shall be deemed rtvnked. z CONSTRUCTION LENDING AGENCY 'p Iheahy a(nrm that there is a eonmrvdion lending agency forte performance of [� r' We work fur which Nis pcmhit is issued isle.3097,Civ.CJ Itl Q Linda's Name z Lcndcr's Address U O 1 ecnify that 1 have read this application and sate that the above information is correct.1 agree to Comply with all city and county ordinances and sum laws relating to oUbuilding construction.and botchy avhoria representatives Or MIS city to enter upon Nr abovementioned pmpcny for inspection Purposes. (Wit)agme to save,indemnify and keep havwlcss the City of Cupcnina against / r Fp) liabilities.judgments,costs and exproses which may in any way wane agamstxaid City U ,Z In consequence of the granting of this permit. ' '—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR fi EGULiTONS. s sq _016 60 Re-roofs l h 91gmooM Of A,plub.tUCAlrouldrI., Daattw HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant Or future building Occupant stoic or handle hararduus material s defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety Cale.Seldom 255321.)+ All roofs shall be inspected prior to any roofing material being installed. Yea V1. Will the applicant or future building occupant use equipment on drvi,es which If a roof IS installed without first obtaining an inspection,I agree l0 remove emit haeardous air coulnminants as delined by the Day Area Air Quality Management all new materials for inspection. District? ❑Yes I have real Nit hu.nduurro annals nquircments under Chapter 6.95 of Ne Califor- nia Hca11h.u,Safety Code,Sections 25505.25533 and 25334.1 understand Woe 1Ithe huilding Jos we co nenlly haw:a mn.m,War it Is my responsibility to nutiry the wcupam of the rcyui c v w h�^sl be mel poor to issuance of a Certified of ro paney. L ( r}`y\� Signature of Applicant Date All roof coverings to be Class "B" or better Owner Wloohmired agent Dam ® CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp : Rng : Sub: Blk: Lot : APN . . . . . . . . : 37509043 . 00 DATE ISSUED. . . . . . . : 10/12/2004 RECEIPT # . . . . . . . . . : 27408 REFERENCE ID # . . . : 04100077 SITE ADDRESS . . . . . : 19121 BARNHART AVE SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . : IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : HOME LIFE TRUST ADDRESS . . . . . . . . . . : 19121 BARNHART AVE CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : STANFORD PROPERTY CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . , TELEPHONE . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL -- - - - - ---- --- --- - - ----- ----- ----- ---- --- - - - ------- - BENERGY PERMIT FEE 126 . 36 60 . 65 0 . 00 60 . 65 0 . 00 BPERMFEE VALUATION 5 , 370 . 00 126 . 36 0 . 00 126 . 36 0 . 00 BPFIXTURE UNITS 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00 BPLANCHK PERMIT FEE 126 . 36 168 . 63 0 . 00 168 . 63 0 . 00 BPREPIPE NO OF FIXTURE 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00 BPSTORM PER DRAIN 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BPTRAP NO OF TRAPS 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BELFC200 METERS 1 . 00 29 .43 0 . 00 29 . 43 0 . 00 BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BREMFIXT NO. FIXTURES 3 . 00 3 . 60 0 . 00 3 . 60 0 . 00 BREMPOWER POWER UNITS 3 . 00 83 . 94 0 . 00 83 . 94 0 . 00 BREMRECEPT NO. OUTLETS 6 . 00 7 . 20 0 . 00 7 . 20 0 . 00 BR-EMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00 BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00 BSEISMICRE VALUATION 5 , 370 . 00 0 . 60 0 . 00 0 . 60 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 TOTAL PERMIT 764 . 54 0 . 00 764 . 54 0 . 00 l0kOD OF PAYMENT AMOUNT NUMBER ---------- - - - - - - - ------------ ------- ----- CHECK 764 . 54 09981 TOTAL RECEIPT 764 . 54 *CITY OF CUPERTINO* OCirY OF PERMIT APPLICATION FORM CUPEkTINO APN # 3�J O C v u 3 Date: /t (6 q Buil i g Address: I l ailin AddressL(if dif nt fr "buil n address): I a ( rn 4 c 1 C c>( C (X F �rfa O 9 Y 'J6 Owner's Name • Phone#: Nv ..e (� �e IS ' 336_ 533 Co tractor Lic se#: ,qUwY, �'wr�os as t uez Co-4 Nc u c C� o vk � 6 Contact: Phone: " Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: 5)'Ji )a"` uP44, .Residential ® �1 uae. . °"` Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost ofproject: �3� O Occupancy Group: i ype of Cnstnftion: Please check this box if the project is a U c4,C �,K4uUS d K N VS e(e��s c�1 FQIt�" second-storyaddition: El Project Size: Standard ❑ Large ❑ 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 B1 VESTIGA Investigation fee BUILDING 1 of OCITY OF CUPERTIN(* CITY OF PERMIT APPLICATION FORM CUPEkTINO 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 j BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINfERCEP Ind Waste Interceptor PLUMBING j 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 BREMAHUiAN 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 BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heatin MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 (a .1 WITY OF CUPERTINO* CUP TOF YO PERMIT APPLICATION FORM 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 Insection 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 Change BUILDING 3 of 3 v iHEf51�1 .- � �o-in 94 D9f C E ES Slee of P � a job at a8 times and it is nn' 040 �oo lawful eny changes or afteratiorre � ,e without vaitten permission (ding Dept.; City of C + tie b In of this plan and specifications the s mP g or to be ar. ` FHA NOTbe held toperm rovrsron9 �nPPr ral of the violation of eYLaw. an r City Or or WPM CDPV u« (a� tn.Tl41"( eu inoI . n Iii I r�.l � . ► � Lk leu: LAM v i q F ' Mire (, � Q � Doti-5 Cavrt �Il 1 1