04030044 CITY OF CUPERTINO "`
BUILDING DIVISION PER
CONTRACT , INFORMA�N ;
FEB-02-2004 10:06AM FROM-KVE DEPOT 6635 406-006-0000 T-566 P.001 P-300
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.he building. epCjit� Cupertino.
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12PER 6fkTY �I O .
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
N 0 , Date: L
Building A • Mailing Address (if Clferent om b lding address):
- /1032 8(Le c
Owner's Name: Phone #:
To ..�L •6a6
•Contractor: License #:
osSt1L-t';y K_ 1 -uK�S �/ 383�'
3
Contact: j Phone: Cupertino Business License#:
aU2Tn (---I ax:
Building Permit Info:
Bldg Ec rtn PI mb ech
Job Description:
Residential EC4AV6(a. ECtSr KtTCW',tJ Commercial ❑
.Sq.Ft. Floor Area: �^ $/Sq.Ft.:
Cl
Cost of Project: /# / Occupancy Group:
Type of Construction::/ Please check this box i e project is a
second-story addition: ❑
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 1 M 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
�e n1 FvJ 6002
1 of 3
H(C, ATY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Wguantity Fee ID Fee Description Fee Group
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
BPIN'TERCEP 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 " Stom]/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
t 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 Heating MECHANICAL
BREMRESADID Remodel Res A liance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS (� Remodel Signs, M r uee ELECTRICAL
p���of3
q-ITY OF CUPERTINO*
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Grou
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
13SEISMICRE Seismic Fee Res BUILDING
BSPECDZ 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
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
J
3 of 3
CITY OF CUPERTINO 4 a'"''
BUILDING DIVISION PERMIT CONTRACTOR �INFORMATI0- �.
N:.�
Ps asllb 8-.. .rw .
I BUILDING ADDRESS: POSSIBILITY KITCHENS """"04030044F.R'S NAME: PERMIT ISSUE DATE
TON
ONE: SANITARYNO. CONTROL NO.
(408) 924-0204
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
Lazo LICENSED CONTRACTORS DECLARATION
m�C I herm lice
hereby affirm met I son under pmvimms of Chapter 9(commencing lob Descriptio
�Zm with Section 7asain of Division 3 of the Brains and Professiom Cade.and my license is
�,h infull force and effect. KITCHEN REMODEL
�nK License Class LIC.0 ✓t"N�/
ZFp Dam Contra.,
2� ARCHITECT'S DECLARATION pO4
5y e< 1 undersand my plan shell tv uwtl as Public menrds A
D aU ,ALN®�
;0 t; Licensed Professional
-XI
OWNER-BUILDER DECLARATION •'gVV/�
20 1 hereby.(Stc Nat 11. exempt Item the Cream Cod License Law for the
a O following ressaa(Section 8131.5.Business and improve,
de ms h.or:Any tiny or county
di:m ff which msl issuance,
a permit to enres the ober,improve,demolish,Fi repair ed atracmrc
v�'^ prior m its issuance,sive requires the applicant for veers Permit fie a signed statement
OIL heislicensed pusiw
ursuanothePmviOftheContractorsu
Licenlaw(Chapter9 Sq.Ft. Floor Area Valuation
�'a (commencing with Section 7000)of Division 3 of the Business and Professions Codi or
i $ that be is exempt Jcafrom and the hues for the alleged exemption.Any violation of
Section 7031.5 by ary,applica t for a permit wbjcets the applicant to a civil penalty of 3 et0 0 Occupancy Type
not marc Nan five hundred dollars(5500).
0 I,as owner of Its property,or my employes with wages as their vele compensation,
will do the work,end Ne swcmre is nos intended or offered for sale(Sec.7040.Business
and Pmfcssions Code:The Contractor's License Law dors not apply to an owner of Required Inspections
pm,eny who builds or improves Berms,and who docs such workhimself or through his
own employees,provided Nat such improvements ase not intanded oroRemd for sale.If,
however•the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did nm Wild or improve for purpose of
le.).
�(L as owner of Be property em exclusively convening with liccraed em uxtara to
convect she pmjm(Sec.7009,Business and Profen ios Code:)The Commusem u Li
cwt taw does not apply us an owner of property who Wilds or improves Merton,and
who contracts for such pmjecu with a conustor(s)licensed pursuant to the Contractors
License law.
01shi Lander a. ,B&PCforth awn
el Dae
•R'S COMPENSATION DECLARATION
I hereby sin oder penalty of Perjury one of Ne followingdec arnions:
1 have and will mainaln a Cenifiane of Consent toself-iwum for Worker's Compen-
smion,u provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Work se's Compemation Insuvnce•an required by secfion
3700 of de Labor Code•for the performance of the work for which this Permit is issued.
My Wmkers Compemvtion I...artier and Polity number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed if the permit is for one hundred dollars(SIM)
or lea'.)
1 ccni fy that in Be performance of the work for which this permit is issued,I shall not
employ any person in any mann.,an as m become subject to LW Workers'Compermilm.
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificee of Exemption.you should
become subject to the Weams Compensation previsions of the Labor Coda you must
7, r."wim comply with each pi nvisions m Nis Permit loll be deemed mvokcd.
Z O CONSTRUCTION LENDING AGENCY
�-+ IWr lly which um Nemmeisaed ISeConstruction 097.lending agencyfor the Performance of
'Ya the work far which Nu permit u issued(Ser.3097,Civ,C.)
D]0 lenders Name
G tender's Adtlrcss
U 0 1 certify Nan 1 have mad this application and stem that the above information is
F corm.1 agree to comply with all city and county ordinances and mute laws reading no
DU building convection,and hereby authorim eprescnmtives of this city to enter upon the
r W above-mentioned Property for inpeetiom purposes
(~ 4.
(We)agree m save.indemnify end kith harmless lbe City of Gehenna against
N liebilili(We)amcto ems indenityand kers may in anyway eCity f alines mid City
U Z APPLICANT UNDEor the RSTANDS of AND WILL COMPLY WITH ALL N N-POINT Issued by: Date
SOURCE RE LATI S. 6L
Re-roofs
attireppliant/ v ter Dam Type of Roof
N 1101 MATERIALS DISCLOSU
Will the applicant or future building accupwn store or handle haradous mueriai
defined by the CupeMunicipal unicipal Code,Chime,9.12,end Be Health and Safe,,
Ie.Sa0aa2ss3z(')" All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes ON. P P Y g $
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
mit harmdous air conaminars as JCOncd by the Bay Area Air Quality Management all new materials for inspection.
Disvin7
C]Yes Nu
I have medl de hsaardous materials rcquiremens under Chapter 695 of the Califor.
nia Hwt"SafnyCodc.Satire 25505,25533 ands U534.1 understand Nal if One Wilding
Jos trot cormody hose a eoan4 that h is my rtsponibility to nod7ylhc occupant of the
mquircmcnawh2 Raabe eLM.01 to iesaence oft CwOaeof capancy. Signature of Applicant Date
Owner morimd agent Dal. All roof coverings to be Class "B"or better