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03050134 CITY OF CUPERTINOY `f' �- ' ' `°°' BUILDING DIVISION PERMIT CONTRACTOR TNF'ORMATIQ �a s�*vY'. ;Id.AsaS#TAS BUILDING ADDRESS: BILL GORMAN PERMIT NO{O�3050134 20203 CAMARnA CT OWNER'S NAME: PBRMIT�(/.78�2003 ILL GORMAN ONE: SANITARY NO. CONTROL NO. ARCHITECTIENOINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 1� 0 Sop LICENSED CONTRACTOR'S DECLARATION JbDescrition 1 lereby affirm d!Most 1 am Immu under nr provisions of Chamo Chapter 9(ea perclag p withsoction7 (Division 3 ofte Bud.wool Profession,Code.and my It.is full �maa RETILE SHOWER & BATHTUB in fum Cl Le.N S Dem Contractor As"It W uw DECLARATION Q � I understand my plans shell be used ss public rtceds `LLtttttt777777 Lacnsed Prof cseleast •I C OWNER-BUILDER DECLARATION o 1 hereby affirm that 1 sus exempt from the Contractors License Law,for Moo O o fallowing reason.(Section 703 1.5.Business and Professions Cade:Any City or County y ;ME $ which requires a permit P construct slier,improve,demolish.or repair any swctum ., prior to I%issuance,also requires the applicant for such permit to file a signed statement C that he is licensed pursuant P the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floe res $2��ClOn $ (commencing with Section 7000)of Division 3 of lM Business and Professions Code)or Nu he I.exempt therefrom and the but.An the alleged exemption.My violadon of Section 7031.5 by any applicant for a permit objects the applicant to a civil penalty or 0 0 Occupancy Type Out more tun five hundred doll.(5500). ❑I,uowmerof Nepropeny,armywploymwiNwagesutu4mlecampenudon, will do the work,and the,4ucwret.mtmundedarufferedfmasie(Sec.70u,Busivaa - d Inspections and Profns,iav Code:The Contactor,License Law doss not apply a an owner of 10 2 - PIERS p property,who build,or improves thereon,end who doss such wark himself or through his awn employers,provided that such improvements are not intended orofiernifssue.lf, 103 — UFER however.the building or improvement is sold within ate your of completion.the owne- Wilder ME bare w burden of moving wt he did nut Wild a impmw<for purpose oof 104 - REBAR sale.). 105 - ANCHOR BOLTS 1,ss Owner of the pmpeny,sum exclusively contracting with licensed comuaoa 0 106 - SEWER & WATER construct the pmject(Sec.7044,Business and Pafrstlons Code:)The Conmctm's U. cove law dm not apply he an mater of property who builds or Improves ft...and, 202 — UNDERFLOOR PLUMBING who contracts for such projects with a convulor(O licensed pursuant a the Conummra 203 - UNDERFLOOR MECHANICAL License Law. am eaemp�tpoder Ser. BI P C`forr this Mason 204 - UNDERFLOOR FRAME woe �T7.lily! Data—SkT/V? 205 - UNDERFLOOR INSULATION WORKERS COMPENSATIo TION 301 - ROUGH PLUMBING 1 hereby M.under penalty of perjury oro of following dcelvWons: I have and will maintain a Corti team ofCOnsem la,elf-Ivum for Worhar's Compen. 302 — TUB & OR SHOWER Mian,u provided for by Section 3700 of the labv Code,for the perfomaxe of the 303 - ROUGH MECHANICAL wark for which this permit la issued. 304 - ROUGH ELECTRICAL ❑I have and will maintain Workers Compensation Insuran¢,ss required by Section 305 — FRAME 3700 of the Labor Cade,for the performance of the work,for which this permit is Issued. My Worker,Compensation lnwmce carie and Policy number am: 306 — HOLDOWNS carder: Policy N.: 307 - INSULATION CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 308 - SHEETROCK (This section need not he completed ifthe permit l,foronchundaddallan(SI00) 309 - EXTERIOR LATH '"lean') 310 - INTERIOR LATH 1 op that fx afmmave of ra wah for which this permit i,sumo,I,hall not 311 - SCRATCH COAT employ mype any mannerm YmbeamambJCclathe Worke,'CommeNaBon Iowa of Cd' ¢ / .e/ ••� - 313 - ROOF NAIL Applicant N�Ic�TO APPLICANT:ItaMrmakingthl, enineaPaf mption.youshould 501 - FINAL ELECTRICAL ENERGY bec9r�isubject m Ne Worker',Compensation provisions of Nm Labor Code,you must 502 - FINAL PLUMBING ENERGY Z ZO to uh rnmply with such pmvisinns or this permit shall be dcemcd revoked. 503 — FINAL MECHANICAL ENERGY CONSTRUCTION LENDING AGENCY E.� Ihereby alnrnMet them isaconstruction lending agency for ftperfmmmttof 504 - FINAL BUILDING ENERGY D fwurkfor which thupermitUissued(Sce.3097.Or.C.) 505 - FINAL ELECTRICAL 4 O Lander,Norm 5Z Lemice.Address 506 - GAS TEST Uo ittAeMomIhewread ThutyandCouapplication and altaMorondabove InformWonis 507 - FINAL PLUMBING W building I once P comply with all city and coumy ordinances Of and auta Iowa Platin{to C) building eoniwction,and herebysuthorirertprcsenutiveamfthisCity mcnluUpon uP FINAL MECHAN CAL .?.W ADva•mentioned property for Inspection purpose,. C O 9 F I N F (We)agree bcost,Indemnifyeand hich bumpiest;the City of CupertinoAgainstCiti eT CL in consequence o tiuunc mengeusuing expenses which may in anywyamue agsinsusid City 5 I G \\l 11—b V 7 A APPLICANT. of the Ranting of thispermit. t1— APPLICANT UNDERSTANDS AND WILL COMPLY WITH A L NON-POINT Issued by:51 WORKS Date SO RCE ULA770N5. (f Re-roofs ins Ampll HAZARDOUSMA7ERIALSDISCLOSURE Oa Type of Roof Will the appiloo,or future building nesupmluom orhendle hazardous material u defined by the Cupertino Municipal Cade.Chapter 9.13.and the Health and Safely aC.Section 25533(x)7 All roofs shall be inspected prior to any roofing material being installed. ❑YeaO Will the applicant or future building =open,use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove It hnu,dous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. trout? �,�r!�� ❑ye 4•V I have read the hes Noun mend,mquireremr under Chameti.95of the Cattle,. nt.tlgaLN_g:Safctycode.Satim25Ru.25533 and 25534.1 understand taw Ethe Wilding dao�r/no�py�rrenty he.a nnant ten it u my mspomibllity m ufy asupmI of the 0 sal emu mnmmr a ymmnanaeniscedTtean q SignatureofApplicant Date Owner authorized agent �Z�e Date All roof coverings to be Class"B"or better OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: A. All the work authorized by this permit B. _ A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be erformed • 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer(see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be erformed ..................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information(reverse side). / Property Owner's Signature:�A�, G///1y1�s!� 4e: � — Job Addresses "LQ; Z ( +Am av�i+ ��� Permit# o3D�1_4 Anychangeso the information provided on this form shall be submitted to the City of Cupert Department. ac� CITY OF CUPERTINOU 3 0&-0 (,3 CITY OF PERMIT APPLICATION FORM CUPERTINO N# 6� Date: 5 IA9 3 Building Address: �a CAW,ard c, Covr4- Owner's Name: Phone#: © II Crormctn (L/O8) 3 �y-S2Sa Contractor: License #: Contact: Cupertino Business License#: "Build' Permit Info: Bld Elect ❑ Plmb, 44ech ❑ scription: Residential Z LCA omm a Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: `1 Occupancy Gr Type of Construction:1 7 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 BBOILERS 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 W 2, 1 1 of 3 OwlCITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM 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 BNUCONU M New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTUVIE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING MIXTURE 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BRENLkUMAN 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 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 2 of 3 010FCITY OF CUPERTINO PERMIT APPLICATION FORM CUPEfI;TINO Quantity Fee ID 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 BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special hispection 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 Mechanical sq. 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