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06120100 CITY OF CUPERTINO77717771;7.7-7-77,777 BUILDING DIV ISION PERMIT CONNTTRACTORIATkORMATION, p BUILDING ADDRESS: PERMIT NO. OWNER'S NAME: ATE WAGNER KARL 12/19/2006 NE: SANITARY N0. CONTROL NO. ARD111=0ENGINEER: BUILDING PERMIT INFO BLDGEIFCf PLUMB MECH 0 0 0 0 lop LICENSED CONIRACrOR'S DECLARATION Job Descrl tion w FF I hereby affirm that I am licensed under provisions of Chapter 9(commencing {3 i`w$ with Section]O(g))of Division 3Ofthe Business and ProfcssionsColk,andmylicense is 200ANP PANEL UPGRADE in fall farm.m.rect- X7915 Lieeny{IurS Com / -1 Date `L{. CSDECr ARCNI(ECTS DECLARATION �a< I understand my plain shall be used u public merits idO °0 Licensed Profcssionel OWNER-BUILDER DECLARATION ,c 1 hrcxo slims thin 11. exempt from the fimems ars License Law for dte :o o following mazoa(section 103 LA Business had Pmfcsxions CWc:Any city os county m which requires issuance,permit to construed alcor,impmsu demolish,or repair any simmer 1—r^ this to Wisl ensed alwmquithe the provia applicant for Co mrmt'sLieea Lawjed sutemem iSC (cmmimingwi p&ctim7o )dDivi ion3of CBuacmr'andcf iamC pter9 Sq. Ft. Floor Area Valuation that he is exe with Section]000)of D osis f 3 of alleged exempt Professions Calc)ar $1700 Not he u exempt shuofrom and this basis it be alleged exemption Any violation of an,..]than by icy reddollaIns apermit wbjc<m dte appl¢antmativil penalty a( Number Occupancy Type not term than Bae Wnemt aanara(sham. 36909035 . p y YP ❑I.as owner of the property.or my empioyem with wager as their axle compensation, ' will do the work,and Ne structure is our intended oroRered far rah:(Sec.7614.Basi. and Professions Code:The Contractor's License Law deet rot apply to an awner of Required Inspections Own enylo,�a.pmvirimpawthimrowmeho doesouchwink hwmelfmtfor We hu awn employrra,provided that such impmvemmu are not intended oroRemd far salt.If. however.Ne buildingb r improvement u halt within arc year of cwophe for the owned ask,) will base 0te burden of proving that h did not Wild or improve fax Purpose of wteJ. ❑1,as Owner of the property.am exclusively contracting with licensed contractors to ceramics the pmjen(Sec.7614.Business and Professions Cade:)The Cantract er's Li- me Law dos mat apply to an owner of property who Wilds or imposter tutus.and. who contracts for such projects with a conuxtmr(s)Eanxd pasoani w the Conmmanes License Law. ❑ l am exempt undo Sec ,B&P C for this reawn Owner' Date WORKERS COMPENSATION DECLARATION I hereby,aRrm under Fatally of perjury ane of thin following doelaations: 41[him and will mainuin a CutiBnte al Consent as self-insure for Worker's Crmpcn. cation,as provided for by Section 3700 of the labor Cade,for the Performance of the 7ar for which this permit u issued. w 1 have and will maintain Workers Compensation Insursnce,as required by Section 3700 of NC Labor Cods.for she performmce of dte work for which this pemrir u issued My Wor'ker's Compensation In....carrier had Policy number art: Cartier. Policy No.: CERTIFICATE OF EXEMMON FROM WORKERS' COMPENSATION INSURANCE rlTu section need not be cunpleted if Ne permit is far one humb et,aBars(SIM) or less) I certify Net in the performance of the work for which this Permit is issued.1 shall not employ any person in any manna ha u,h�bcepgtesuhicnro the Workers'Compensation Laws of California Date �� aKC 1I A((,, Applicant NOTICE TO APPLICANT:If,after making this Ceninate of Exemption,you should Warne subject to the Worker's Compensation provisions of the Labor Code,you must .,O foMwiN comply with wch pvvisians or Nu permit dull W dmmctl mwkcd. E y CONSIAUCTION LENDING AGENCY 'i—� Ibemhy affirm that then is a cmnswcurat lending agency loot the performan¢of athe wank for which this permit u issued(Sec.309],Civ.C.) W Q Lender's Name 7 z Lenders Addros ' U O 1 certify Nat I have read this application and state that she aWve information is Ly cornet.l agree to comply with all city had county ordinances and sac e laws rtlating to 0U building conswesion,and herby authorir rpracntruwS of this city to enter upon roc ,hove-mmudgmJ pwpc set for map van which es may H W (we)agree r save,indemnify and keep barriers the City or Cupcnum against t,lZ liaansix,inudgmcnhe'ramand of thisexpenses which may in anyway ammo against said City V 2 inearoCAN're of Negn ANDS this permit. '—' APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATION ^ ISI,,� ^ 121 nit) Re-roofs Signature of ApphcanUContractor Dain HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupant stare or handle mem ors material as defined by the Cupertino IM pal Code.Chapter 9.11,and the Health and Safety Code,Section 15531(x)? All roofs shall be inspected nor to an roofing material bei. ❑Yon Na p p y g g installed. Will the applicant Or future Wildingaccupant use cquipmcmt or devices which If a roof is installed without first obtaining an inspection,I agree to remove it hu,mous air mnmminanu n rkBned by the Bay Am.Air Quality Management all new materials for inspection. District? ❑secs erfiu I have real the hamardmus materials mquin mem,uncer Chapier6.95 of th Califon no Health&Safcry Cade,Sxuam 15505.25533 W 2553,.l understood thuifNc Wilding docs not curently have a asnam,that it is my rap sedihility to notify the occupant of th myuirt ^w^irhmusthmet pr{ormissuan"rfiCc(d(Kateo/Dtt,,,n1�lo Signature of Applicant Date Owner or awh.n,c grnt C rXt../f Date. All roof coverings to be Class "B"or better Community Development " 10300 Torre Avenue p Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 46UPEkTINO Building Department JOB ADDRESS: \p-y Y CO\6 4r r tiVe— PERMIT # ld d OWNER'S NAME: Caro,6kh eY- PHONE # /-108- h 3 - 10 3 8 GENERAL CONTRACTOR: FAX # n q I am not using any subcontractors: �. , 12-1 1 g Ic�6 Signature Date Please check applicable subcontractors and complete the following 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/Contractor Signature Date CITY OF CUPERTINO • 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: amyw COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36909035 .00 DATE ISSUED. . . . . . . : 12/19/2006 . RECEIPT #. . . . . . . . . : BS000000031 REFERENCE ID # . . . : 06120100 SITE ADDRESS . . . . . : 10248 COLD HARBOR AV SUBDIVISION . . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : WAGNER KARL ADDRESS . . . . . . . . . . : - CITY/STATE/ZIP . . . : CUPERTINO CA„ 95014-3327 RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY WAGNER KARL ADDRESS . . . . . . . . . . : ' CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3327 TELEPHONE . . . . . . . . : • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- BELEC200 METERS 1. 00 29 :43 0. 00 29 .43 0. 00 BSEISMICRE VALUATION - 1, 700. 00 0: 50 0. 00 0. 50 0. 00 EPERMITFEE FLAT RATE 1. 00 38 .37 0. 00 38 . 37 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 68. 30 0. 00 68 .30 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER --------=-------- --------------- -------------------- CHECK ------------------ CHECK 68 . 30 5353 --------------- TOTAL RECEIPT 68. 30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL CITY OF CUPERTINO 01 20K�0 C]TV6F PERMIT APPLICATION FORM CUPEkTINO N# 21 „��6Q ^� Date: Building Addresss�\Y�'I�y �Q1 Col 4C'�Of ,Mailing Address (if different from building address): Cv. `no C,K Ci6o\LA Owner's Name: cr ` ' QI\he—r Phone#: Contractor:n 1, s � �1�1 �'�; C- License #: �j_1 / 7� 1 Contact: '" Q Phone: Cupertino Business License#: MN\��e_ Fax: �O g $ 81 Building Permit Info: \,KQ16kId tOq YVv� Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: 1 Residential Commercial ❑ Sq.Ft. Floor Area: �QQ Sq.Ft.: Cost of Project: I V Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ roject Size: Standard 2(� Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK 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 BINVESTIGA Investigation fee BUILDING • 1 of 3 CITY OF CUPERTINO aTMOF 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 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 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 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 MBRE POLE Pole/Platform Fixture ELECTRICAL OWER Power Device/Apparatus ELECTRICAL ECEPT Rc tl, Switch & Outlets ELECTRICAL ELOCA Relocation of Hood MECHANICAL EPALT Re air/Alter Heating MECHANICAL ESAPP Remodel Res Appliance ELECTRICAL 2of3 Jam- CITY OF CUPERTINO CITYOF PERMIT APPLICATION FORM CUPERTINO 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 Inspection BUILDING 13SWIM 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 Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3