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05090137 CITY OF CUPERTINO .� — s .77717 " BUILDING DIVISION PERMIT CONTRACTOR INFORMATION fr7 BUILDING ADDRESS: PERMIT NOD 5 0 9 0 1.3 7 21470 COLUMBUS A OWNER'S NAME: PERMIT ISSUE DATE SCOTT PARCELL 09/21/2005 ONE: SANITARY NO, CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGELECT PLUMB MECH 0 0 0 0 u00 LICENSED CONTRACTOR'S DECLARATION 1 Wmby affirm that 1 am licensed under previsions of Chapter 9(commencing Job Description with Section 7")of Division 3 of the Business and professions Code,and my license is "oma man fame effect. RECES . LIT /CIRCUIT/EXTER. OUTLET, ,y? License Class Lie.N ant cmanictor REPAIR CIRCUIT BOX, REROUTE WIRING IN FAM. RM ARCHITECTS DECLARATION 9, 1 understand my plans shall be used as public meet& JyU s LL Licensed Professional `O OWNER-BUILDER DECLARATION �, nO I hereby.(Sere that 11. exempt from dr Contractor's o :Any Cense ty o for 1W V D O following mason.(Section)11]15,Business and profeadnns Code:Any city or county L E $ which requires a permit to censuuc,.almq improve.demolish,or repair any structure prior or its issuance.also regulons the applicant for such permit m Glc a signed statement < thatbculicensedpunuamtothepmvimmsofthcCrouatim"Lianmlaw(CMpter,9 Sq. Ft. Floor Area // _lua 205 x11-C (commencing with Section7W0)ofDivision]oftheBusinessandProfessionsCodc)or 7—an _ that he u exempt mereand from the basis for the alleged exemption.Any violation of Section 7031.5 by airy applicant far.permit subjects the applicant o a civil penalty of APN NumberflOccut,pancy Type not mere 6.five hundred dullam($500). 36205002 . 00 II��R N 'll� Ili ❑I,as owner of the pmm peny,or my employees with wages as their sole compcatien, Ir C7 will dote work.and theavunum is not intended orofferW for sale(Sec.7W,Business Required Ins eC(IOn$ w�� and Professions Code:The Cornerstones Lieu Law don not apply as an owner of q P pmperty,who buildsorimMnvu themon,and whodoessuch work himselfor through his , own employees,provided that such improvements are not intended proffered for sale.IL however,the building or improvement is wild within one yea of completion,the owner- builder wilt have the burden of proving that he did not Wild or improve for purpose of It.). E(L asr of the pmpeny.am exclusively contracting with licensed convectors m eomuuct Na project(Sec.705,1.Business and Professions Code:)The Contractor's Li- _ come Law dose not apply m an owner of pmpert�who Wilds m ushomvesthereon,and who convects for such pmjecm with a tomcat Gr(s licensed pursuant W We Conmorloes License Law. ❑1 am exempt under I B&P C for Nis mason Owner Dam W CER'S CD dP ENSATID f DECLARATION 1 hereby affirm under pemhy of perjury oro of the following declarations: 1 ham and will maintain a Certificate of Consent to self-insum for WorkcesCompcn- sation,as pmvided for by Section]700 of me Labor Code.for Ne performance of the work for which this permit is issued. ❑1 have and will maintain Wortcr's Compcmation Insurance,as requited by Section 1700 of the LaWr Code,for the perfmmance of the work for which this permit is issued. My Worker's Compensation Insurance artier and Policy number am: Gnier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Oho section meed not W composed!Bribe Permit is for one hundred dollars(SIM) or las.) I certify Wal in the performance of the war which Nis permit is issued,l shall nut cmployany person in miy'5 nterx as to c e subjcy tplM syork/prs'Compenaation Laws of California.D-11 i Y/T//n. Applicant ,t2 NOTICE TO_�LicAf ff iffa'Itcr Raking As Cenificam of Exemption,you should become Subject to the Worker's Compensation previsions of the Labor Code,you must .J Z forthwith comply with such provisions am this permit shall be demand revoked. zCONSTRUCTION LENDING AGENCY 'C.N Ihereby aRrm that Wore is a conevuctinn lending agency l'or the performance of a Ne work(ser which thin pewit is issued(Sec.3097,Civ.C.) W Q Isndcis Namc D Z Lender's Addrau U Q 1 certify that I hart mad this application and some that Bic above incrimination is V.F' covecL 1 agree to comply with all city and county ordinances and some laws relating to 0U building construction.and hereby auronre repmsemativcs of this city to enter upon the Gabove-mentioned property for inspection purposes. (We)agree W save,indemnify and keep harmless the City of Cupenino against F"(n liabilities.judgmcnu,cru and expenua c may in anyway sciatic ailmolL=it City of the V z APPLICANTeU1) NDERmn11ng of dims NDS AN mm LL GpMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULA S. ✓'/// Signawrc of ApplicanlCCCoomncbm Dam Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will We applicantor future building occupant store or handle harardous material az defined by 1W CupcNnn Municipal Cods,Chapmr,9.12,and the Health and Safety we.Steden255320)+ two All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant or future Wilding occupant use equipment m device which If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air contaminants az andefined by the Bay Area Air Quality Management all new materials for inspection. District? Ycs MIN. Iharc mad the Wrvd1ws materials¢quirt uunder Chapmr6.95oftheGlifor- niceHealth&SafctyCodc.Scctium25505.235 an 553a.Iundersmndthmifthe Wilding dna nom cunemly how a one the its nmht' us notify me occupant or the requirements which..in et prior to rceafa n,Gcmenroeeumbsty. Signature of Applicant Date '� All roof coverings to be Class "B" or better Owner or authorized agent Date Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY 0, Fax(408)777-3333 �UPEI�TINO Building De artment JOB ADDRESS: / PERMIT # Zl�7o Lo�um�IM /� �c U� /3 -7 OWNER'S NAME: 5,-,t1 izcc, PHONE # % A,0 /�zt GENERAL CONTRACTOR: Su h IF07 ac X,, FAX # I am not using any subcontractors: 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 L/ 161 Owner/Contractor Signature Date aw CITY OF CUPERTINO o� CUPERTO PERMIT APPLICATION FORM 13 � o N # Date: 31Q2a5o �z 9 ai os' Building Address: // /l Mailing Address (if different from building address): (�W ll 4xa/71( NO Owner's Name: Phone#: /76 G Contractor: F License #: T��rA� O r�C� Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: 1� s�s // -ee,-SS•ul /i,/,//,71w Fm 4 /:nhcv , aeW eiiru,r 7 -r 16't-ele� N[r✓ CXlui,-� ou/(rr Imo +', �re�a: �C�ic• i�e>c reIVWr w"-1%7 Bldg ❑ Elect Plumb ❑ Mech Job Description: IhNla4l r&-eJeJ1 A1*2, IYxk& NxwCireuif- rou//els re-ov�ib(/�9�/e i.r/ud rN.erc Residential 10, j e Commercial ❑ Sq.Ft. Floor Area: q.Ft.: Cost of Project: Occupancy Group: 22og- + re ✓ou Type of Construction: Please check this box if the project is a second-story addition: ❑ roject Size: Standard EI Lar e ❑ Ma or ❑ 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 BINVESTIGA Investigation fee BUILDING 1 of ��/Z� XCG , CITY OF CUPERTINO CITY01 PERMIT APPLICATION FORM CUPEkTINO uanti Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMNM 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 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 chn 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 Fumace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMUMOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREN N P Rem Non-Res Appliance ELECTRICAL BREN20LE 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 2 of 3 IL ` 'I CITY OF CUPERTINO CM OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, 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 BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING O o 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 PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3of3