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04020157 CITY OF CUPERTINO BUILDING DIVISION PERMIT VCONTRACTORANFORMATION BUILDING ADDRESS: PERMIT NO. 04020157 OW NEWS NAME: PERMIT ISSUE DATE BOB LAYMAN ONE: SANITARY OL NO. ARCHITE MNGINEER: BUILDING PERMIT INFO BLDG Et.ECT PLUMB MECH Loo LICENSED CONTRACTOWSDECLARATION Job Description w I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing � with Section 9300)of Division 3 of do Business and Professions Code,end my lice i „ inrmuameand ercec�_Z9 Lk.g PAIR FIREPLACE y�{? License Class zDate camxwr TRACTOR: JACK N BATINICH MASONRY ARCHITECTS DEC �i 1 understand my plans shall be used u pas is cords �yU 3 0 Liccnud Pmfcsxinnel S OWNER-BUILDER DECL RATION in + 1 hereby affirm that I em exempt from don Comnetors License Law for the i 0 o following memo.(Section 7031.5,Business and ProRsslav Cade:Any city or county k$E� which mquiry a pcmtit ,,construct.alter,improve demo)§R ar rtpai,any structure i1-r^ prioro its issuance.also requires the applicant for such permiuu file a signed statement that he is licensed punuantto the provisions of the Cimactmi License law Chapter Sq.Ft.Floor Area the Valuat' 9 y+�F$ (commencing with Section 9030)of Division 3 of Business and Professions CM02 Chile) 500 .. that he is exempt temfrom and the basis for Ne alleged exemption.Any violation of Section 1031.5 by any applicant for a permit subjects tc applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollen(5500). ❑I,asawncrofdre property,army empluYcm with wagesu thebmle compensation, 36921015 . 00 will do the won:and Ne swctum a not intended m offered foraale(Sec.1044,Businev and ProreVIOK Code,The ConaacmYs LIRRSe Law does not apply o an OWMr of Required Inspections Property who uOicisi rimprovv thereon,and whodoessuch work himxlfor through his own employces,provided that such improvements arc nut intended proffered torsos.If. however.on,building or improvement is old within one year of completion,the owner. builder will have the burden of proving that he did not hoild or impmve for purpose of sale.). 1.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.1014.Business and Profeniou Code:)The Comma ors Li- cove law docs not apply to an owner of progeny who builds or improve demon,and aQ who contracts for such projects wit a contractor(s)licensed pursuant to the Contractor's Licame Law. t/t1tV1/� ///fff I am exempt undo,Sec. B A P C for this recon // Owner Date MAPa y Q WORKER'S COMPENSATION DECLARATION A `-U(/J00 1 hereby alarm under penalty of perjury ane of dm following decluatimu: 4 1 haat and will maintain a Ccnifico¢of Contin to self-insure for WetFers Comfort, union.az provided for by Section 3700 of the tabor Code.for the performance of the V 4 ped work for which this permit is issued. 1 ban and will maintain Worker's Compensation Insurance,as required by Section 3900of dx labor Cods,for dte pcRormancc of the work for which this Permit is issued. My WorkeYs Cs1MMgpntiAon / ;/�/q `"cm`xO vbbPol, pu�m 6TY27� Cartier: ✓ 1 /�/ 'Li Policy No.S-/ a� 7 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Mosuction need not becompleoJ if the Permit is for one hundred dollen(51110) or leas.) I celllry thm In the peffximmtee Of the waft far which this pemtil is lyued.I shall nal employ any Peron in any manner so as to become subject o the Workeri Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If.am,making this CeniGci m of Exemption,you should Income subject to the Worker's Compensation provisions or de tabor Cade,you must .,z Amlwith comply with such provisions or this permit shall he doomed revoked. yO CONMUCf10N LENDING AGENCY [-+ 1herebyv0irm that there is a construction lending agency for the perfomtauc or LY > use,work for which this permit Is issued(Sec.3097.On,C.) ILP Q Lender's azNvnc a Lan Address U O I nnifr that I have mad thit y and nn and share that the[bawl information testinn o U bunco.1 coram comply with all city and county mdinanas and sum laws relating to Qw almn-goonswction,od hembyaudatlrzmpmsenutissof this city manor upon the t: shove-mentioned to ertysaw for demnify an Untoxa a (WC)agree m Sawa,in t I.Pey Na tech astir I. she City of GUpc oit ld City F'p) liabilidu.judgmcnts.casts arta expenses which may in any way attrue against said City U z in cmaxq% ncc o he Booting of t it. APP (CANT DERSTA Y WITH ALL NON-POINT slued by: Date rSecfiw25532(a: E Ot�g. _ - e-roofs APE[ tics r Da ( L_ , 6 �, HAZARDOUS MATERIALS DISCLOSURE Type of Roof �Q the applicant or forum Wilding occup.......handle h,rudmer meterii i y the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety on x5532(!)? j�/ All roofs shall be ins ected rlor to an roofin material beinas No P P Y g g installed. the applicant or future toilet,occupant tau equipment or devicas whicIf a roof is installed without first obtaining an inspection,I agree to remove ons air comnminan¢aydcrined by de Bay Arca Air Quality Management all new materials for inspection. ❑'Nu 1 have read the ha suchousmmerielsmquiremcnts under Chapmr G95 of the Cslifm. nix HcaldhSafctyCodc,SaWor 35505,255 and1S534.lundc dthatifthebuilding does of cum oul an a mnant t it is y.IM oceopenwf the u req mos, oar aeon marOch an 2 Signature of Applicant Date orircJ af Date All roof coverings to be Class"B"or better Community Development l 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408) 777-3333 �UPEI�TINO Buildin De artment JOB ADDRESS: PERMIT U� r b roOKule- I ( OWNER'S NAME: Lc. PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: '2'tat�� gnature Date Please check applicable subcontra ors and complete the followin 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 Septic Tank Sheet Metal Sheet Rock Tile Owner ctor Signature Date 10/28/03 Sm CITY OF CUPERTINO o y (-.o, C, (S 7CITYOF PERMIT APPLICATION FORM CUPEkTINO JP-PN # / l 2 / O / Date: 0, _OC! Building Address: Mailing Address (if different from building address): /D Owner's Name: , Phone#: 4�6 L Contractor: License #: ani 'c unci f, 338 3 Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: Bld Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential ® q c Commercial ❑ Sq.Ft. Floor Area: S/Sq.Ft.: Cost of Project: Z p rt--) Occupancy Group: Type of Construction: Please check this box if the project is a ® t O i r /q C second-story addition: ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other A liances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILE0Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> IM 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 BELEC 1001 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 Iof3 � 7. J � CITY OF CUPERTINO FGGZ- CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity 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 Pb1g Fixture PLUMBING BPGAS Gas Piping S stem 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 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 BREMFIXT Ligbting LightingFixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > I 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 BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM ' CUPEkTINO Quantity Fee ID Fee Description Fee Group 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 Swimmin 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 Chane BUILDING • 3 of 3