04070025 (2) CITY OF CUPERTINO
BUILDING DIVISION PERNO INFQRMgAN
BUILDING ADDRESS: PERMIT NO04070025
ERS NAME: PERMITLSSUEDATE
KENNETH &
PHONE;
MARY CREW SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Met, LICENSED licensed
unOR'SDECLARf Chap Job Description
C 1 ion 7( offrue that l am fa D under provisions of Chapter 9(commencing
tI
with Section](MN))of Div Sofa Bu'nus andP f Carl xoom license is
lo in em rd a-rm't. ` �=11Z REPLACE 2 WINDOWS/1 mG
n Z License C CTS X 7t"'�7'f\ II /�
_w Dam cans 5mr CONTRACTOR: PELLA WI llmlT rtllllllf]`\\V`/tyr/////-1\U OHOVf1
ARCHITECTS DECLARATION
Z u �{in p Mann au ne aeu,a public rernras
to C
U.r, LI¢nc l Pm ssindid OCT.og OWNER-BUILDER DECLARATION C �- 2004
<P I hereby affirm Nm I am exempt from the Contractor's License Law for the
—a o following mason.(Section]1131.5,Business and Professions Code:Any city nr county
which mgouria a permit to consumer,eller,improve,demolish.or mpa,r any struetude
rt"^ Prior o its issuance,alar rcgairu the applicant(orsuch permiuu file a signed statement
=Za that he is licensed puddentto the provisions of the Contractors Liccnr Law(Chapter 9 Sq. Ft. Floor Area D ti1011'�'�O
cam$ (commencing with Section]0(10)of Division 3 of the Business and Prokesinns Code)or
n m3_ Nat he ix exempt H e rfmm and the baso for the alleged exemption.Any violation of
Section]031.5 by any applicentfor a permit subjects the applitantto a civil penalty of APN Number Occupancy Type
not mom Nan fivm hundred dollars($50D.
❑1.as Owner of the pmpeny,or my employee with wages as their taleeompensation. 36217043 00
wnldo me work,and Ne he Com is not s Licend or Law
do for sale(Sec.]044.owner of
and Professions Cade:The Contractor's License Law dose not apply to an owner is Required Inspections
Property who t.provided
ro or improves thereon,and who rem notch work himself oor ffered
his
oarsemployers,ping or improvement such improvemcmer itartne year fced mOBered forthe owner.all,
however Ne building hrimprovementg midwithinoneyear of completion.theuseof
builder will have me burden of proving that he did not build or improve for purpose of
mlcJ.
❑h as owner of the property,am Coclusively contracting with licensed contractors to
2onmuct the proj.a(Sec.7044.Business and Profession Code:)The Contractors Li.
cense Law docs not apply to an owner of property who builds or improves thereon,and,
who contracts for such pMjens with a comnmorrs)licensed pursuant in dm Contractor's
License law.
❑ 1 am exempt under Sec. .B&P C for this moron
1371Wrte, Dole
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Cenlfcam of Consent w self-inure for Worker's Compen-
sation.as provided for by Sminn l]W of the lab Code,for the performance of the
k for which this permit isissucd. a
I have and will maimain Wuhers Compensai n Insurance,as required by Section
of thc labor Codc.for the pertormmcc oY work for which Nu permi,is issued.
Worlrler's 5empc iuio;Insurance carrier oil Policy,On r I_ i ,
` l�—
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This taction need not nc completed it the permit is ror one hundred dinars($lur)
or Icss)
1 certify that in the performance of the work for which this Permit is issued.I shall not s
employ any Person in any manner to m to become subject w the Workers Compensation
Laws of C.lirornia.Dam
Applicata
NOTICE TO APPLICANT:If,after making this Cenilicam of Exemption,you should
become subject 0 the Worker's Compensation provisions of me labor Code,you must
.J Q rormwith comply with such provisions or this Permit shall be deemed revoked.
Z2 CONSTRUCTION LENDING AGENCY
(-h4• I hereby affirm that Imre is a commoreinn lending agency for the per(urmance of
C > the work for which this permit is issued(Sec.3097,Ci,C.)
W QLcndcrs Name
a. Isnders Address
(� 1 Certify that 1 have mad this application and sure that the above information is -
Iy correct I agree to comply with all city and county ordinances and also,Iowa relating to
�U building<onomethin,and hereby authorise representatives of this city to enter upon the
rW above-mentioned property rot inspection purposes.
(We)agree to save.Indemsi fy and keep harmless the City of Cupertino against
E' N Iiebi lilies,judgments.costs and expenses which may in any way acerae against said City
U z in consequence f rte pnfng ar mit pem,a. J
'—' APPLIC E STANDS AND WILL COMPLY WITH A NON-POINT Issued by: ' D
URC enc T r
' � Re-roofs
Sigwwrc of Applic,nUContramar Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m future building«cupan(start oT handle harudc us material
se defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Sa&ly
Cwe, Out, 25332(x)? ��J All roofs shall be inspected prior to an roofing material being Installed.
❑Yrs WNa P P Y g g
will the epplicanror fowrc building Occupant use equipm col or revises which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air eonmmments as dafnen by the Bay Area Air Quality Management all new materials for inspection.
Mo ria?
❑Yes Fl 11
I It.mad the hir.moas\materials mqu redur m under Chapmr 6.95 of the Califor-
rim Healm&SafmyCoco,Sections 255115.25533 and 25534.1understand thm ifdm Wilding
does der m h a mount Our I,.mymspansinho,m nourythc occupantnrmc
require entswhi oil hcmel brtoissmme.,raccrtfca a Occup Signature Signature of Applicant Date
Owner raurhori'redagcns �1 Date All roof coverings to be Class "B"or better
Jul 0104 04: 31p Pella Los Rltos (650) 210-9906 p. 3
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JUL 07 2M
3 CITY of CUPERTINO? �
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rho stamping 07 ibb " OW
d J 'HALL NOT be ?tS!d tD PMO 07 t9 03 CA
M� approval of the violation Of WV PC
any City Ordinetxe or State L=
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*CITY OF CUPERTINO*
CST of PERMIT APPLICATION FORM r
CUPERTINO
7Buildin
PN# Date:
2 l7 J
3G 3 . ,
A�d�iress: /� Mailing Address (if diffe ent from building address):
tt.�C [� ... 2
Owner's Name: , \ Phone #:
Cont 7 VV A c �> jLicense#: �1��
Conta Phone: Cupertino Business License
#:LL
Fax: t
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Job Description _ _ _ ,: ml
Residential a-�
Sq.Ft. F or Area: ` �\ $/Sq.Ft.:
-Co of Project � Occupancy Group: r
I q,
Typ of Construction: Please check this box if a profeet is a
second-story addition: ❑
Project Size: ar Lar e ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 100K Btu MECHANICAL
BBOILER3 Boiler> 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<= IOOOA ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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WITY OF CUPERTIN(*
CUP TYOF O PERMIT APPLICATION FORM
QuantityFee 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 Pb1g 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 Stonn/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 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT _ Lighting Fixtures ELECTRICAL
BREMFURN Relocation ofFumace 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
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WITY OF CUPERTINOO
CATV OF PERMIT APPLICATION FORM
CUPEkTINO
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
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 Chane BUILDING
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