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04040099 CITY OF CUPERTINO BUILDING DIVISION PERMIT aCONTRACTORINFORMATION:1 yx )K Sm3dA a9£�3, BUILDING ADDRESS: PERMIT N0. 04040099 ' • OWNER'S NAME: PERMIT ISSUE DATE KEN WOO )NE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Lop LICENSED CONTRACTOR'S DECLARATION - - - - m hereby of an that I Am limned under princess of Chapter 9(Commencing Job Description i� withSection?IXlo)a(Dlvision3 ofthe Business and Profession Code,and my license if ^ o in full force and effect. tI 5Eg= License Class Lic.N UPGRADE ELECT WIRING 8 �; k��U n I-es Dam Conunctor qq ARCHIJrP TECTS DECLARATION CCfI O O Lr)QO� 2 I understand my plans shall W used As public meet& 3 u G Lice ssed Professional �w re 0� OWNER-BUILDER DECLARATION B.GA 1��aB�pp n 1 hereby affirm that I am exempt fmm the Conuactoes License law for the SU I T�IaN 30 o following mason.(Scctiun 9131.5,Business and Profession Code:Any city or County K$ which requires A pmmit In Construct.tea improve,demolish,fir repair anY'(—in- w�'^ prior to its issuance.also requires the applicant for such permit to file a signed statement ts'< thatbeislicensedpunuanttotheprovisionsoftheContractor'sUcenseLaw(Chapter9 Sq.Ft.Floor Area Valuatio A,-$ (commencing with Section 7")of Division]aide Business and Prof.inns Cudc)or .9- Nu utherem at he empt froand the sesta for the alleged esamprim.Any violation of Section 7031.5 by arty applicant for a permit subjects lha Applicant to a civil penalty of 32' N7b19*er00 Occupancy Type not mom Nan five hundred dollars(SSDO). I,As owner of the pmpeny.Or my employ.with wage As their sole compensation, will do tte work and the swcmrt is not intended or offered for sale(Sec.7W.Business and Professions Code:The Contractor's License Law does not apply m An owner of Required Inspections pruPeny who builds or improves th ncon.and who docssuch work himself or through his Own employ.,provided that such imp owmenu art not intended or offered for sale.If, hawewr,the building or improvement is sold within one year of completion,the uamer- builder will have she IACOCCA of proving that he did not build or improw for purpose of As ). 1,As owner or the property.am esclusively contracting with licensed contractors;to o wet the project(Sec.?Os4,Business and Professions Codc:)The Conuacmfs U- se law d.not apply to an owner of propeny who builds or improves thereon,and who convects for such projects with a contractor(s)licensed pursuant to the Contractors Licensa law. 1 am exempt oder Sec. B&P C for s mason Ow Data WORKER'S COMPENSATION OEC RATION I hereby eRw under penalty of perjury one fthef lowing dwluntions: I have and will maintains Caralle m of Canscm to self-insum for WorkersCompen- sation,As provided for by Scctan 3900 of the labor Code,for the performance of the work for which this awl,is inucd. 1 haw and will maintain Workers Compensation Insinuates,As equirtd by Section 37M of me later Cade,for Ne pertowuuc of the work,far which this permit is issued. My Workers Compensation Insmaarco Cartier and Policy number art: Cartier: Policy No.: CERTIFICATE OF EKEM MON FROM WORK ERS' COMPENSATION INSURANCE (This scaiw need not W completed if tha pewit is roraoe hundred dollars(SI00) Or leas) 1 certify Net in the performance of the work for which this permit is issued.l shall not employ any person in any maramrso As to become subjecuo IM Workert Compewtion Laws of Califomi..Do¢ Applicant NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should become subject m the Worker's Compensation previsions of the I bor Cede,you must .JO foMwide Comply with such provision or this Mrohitshall W dcemed revoked. z CONSTRUCTION LENDING AGENCY [-+ 1 hereby alnw that mart is A contraction lending agency In,Ne Papuan.of C IM work(Lir which this permit is issued(Sec.3097,Civ.C.) W� A Lenders Name zLender's Add.. L)Q 1 certify that 1 have mad this application And sec that the above infonnatun is u, COMCL 1 agree as comply with ill city And county Ordinances and state laws relating In pU budding construction,and hareby authorise represenutives of this city to cater upon the r fy above mentioned property for inspection purposes. ,�CL (We) re,m save,indemnify and kxp harmless w City of .,osno id City Iq liebilit(We) m,asams,costs andmnify es And ket hams.may in Any wayty or Ctmenasaid City /// L)zin consequence of the granting of this permit. ^' 9j"(. APPLICANT UNDERSTANDS AND WILL COMPLY WITH 76-Z AL NON- OINT Issued by: Dat SOURCER IONS. ,/ O.t; T T Re-roofs mune of ApplicantConuacmr au HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will to applicant of(more Wilding occupant ream or handle hazallom material as defined by the Cuyenino Municipal Codc,Chapter 9.11,and the Health and Safety Calc,Section 15532(,)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes �No Will the applicant or future building menpant arc equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? `�,`,' ❑Yes N 1 have real the havardsms m`aunials requirements under Chapter 6.95 of the Caliar- niaH Ire&Safmy Codc,Scctiuns8505.25533aod25534.iundcrsundthaifthc Wilding dt m emr=nty haw a tenan4 Nat it is my responsibility In notify Lie=upam of the m mentswhhv9hm'narmmeIf.°°q((missaaneso/lCC.fiC.teor Signature of Applicant Date owner ar anmoriv" cJ agent -� � All roof coverings to be Class"B"or better AS - Community Development 1030 Torre Avenue 1t' ` � C pertino CA 95014 TTelephone(408)777-3228 CITY OF Fax(408)777-3333 9UPEkTINO Building Department JOB ADDRESS: C1:rc Gr � Cl-t> PERMIT # o1+0 Lt 00 q C'105--Twp CA 9s0 OWNER'S NAME, PHO 4c�q gZ-LB GENERAL CONTRACTOR: MDR $,)EI 60M RpmoFAX # 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 .4, r, /Contractor Signature Date ZHU-- CITY OF CUPERTINO 6 0 � � � T. CITY OF PERMIT APPLICATION FORM CUPEkTINO APN # Z h� / Date: 1 t/� Building Address: V !' Mailing Address (if different from building address): j<XF76 CMCGT11 Pam CJ(?az1f30 CA T5b Owner's Name:- Phone#: Ic�.1 woo _ (03) M-2,1%9 C ra o ) Li nse #s L-1 � � �fZ Contact: Phone: Kofs-128 ,;LIS Cupertino Business License#: lZ Ge i ctz I Fax: Building Permit Info: Bldg ❑ Ect Plumb ElMech El Job Description: Residential ❑ .v 31 =4 sta::� w ?r��Com�r erc�al Sq.Ft. Floor Area: Vsq.Ft.: Cost of Project: Occupancy Group: Type of Construction. Please check this bo if the project is a second-story addition: ❑ Quanti 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 IM 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of3 / ,� "C CITY OF CUPERTINO ' CUP TYOF O PERMIT APPLICATION FORM QuantityFee 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 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 cfin MECHANICAL BREMAHUiAN A/C Units <= 10,000 cfin 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 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 AML BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 F� «m CITY OF CUPERTINO ` CUP TYDF O PERMIT APPLICATION FORM 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 BSPECLU 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 Change BUILDING 3 of 3