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04010085 CITY OF CUPERTINO '"°�'3""' 7,u`�^x'kxe r BUILDING DIVISION PFRMI'_ C"0NaT32ACT01ZJNF0RMA, BUILDING ADDRESS: PERMIT NOO4 04 0 O 8 S 890 CRICKET HILL RD S NAME: 7 PERMITISSUEDATE WILLA CAMPBELL 04/14/2004 PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH _ o o LICENSED CONTRACTOR'S DECLARATION mjcr . C P I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job D Ci�»qa"s� //J�\\ to with Scnion7")of Division 3 ofthe Business and Professions Code.and my license is rJ {`�\��® infnnforceaddeffect. REPLACE WINDOWS F7 �lU ply j ill i License Class -Lic.a a Dau Contractor EE ARCHITECT'S DECLARATION JU!f a4 2004 C a 1 understand my plansahall he used as public reen,JS �yU O Licensed Professional ��``qq p n ppp 1p OWNER-BUILDER DECLARATION 1' kl����l„` flt�/'''`�� Y 1 naso affirm that I am sumps from Inc Contraomh Licence Law for the tlp�'(1Nn, !{!{!{B1f1y1+f��Vlt11 f(Q—J/ p p following reason.(Suwon 7031.5.Business and Professions Codc:Any coy It aunty Lm which¢quires a permit In construct.Slur,improve,demnliah,or repair any structure 7 C,0 0 _z< pfiomn I.issmnec, brie mriimuWapplicant fofsuch permit m file a signed sulentcnt ee mat he is licensed PUradantm the provisions of Commerce's License,Law(Chapter 9 Sq. Ft. Floor Area - Valuation ri- (commencing with Seetion7")of Division 3 or the Business and Professions Code)or ;?3 that W is magi Nedefrom and the basis for the alleged eaemptioa.Any violation of Section]031.5 by any applicant for a Permit subjeeu He applicant to a civil Penally of dT er00 Occupancy Type not more than five hundred dollars(5500). ❑I,u owner of the Property,or my employees with wages m Hch sole compensation, will tlo the work.end the swnurt is notinundetl or offered arsalc(Sec.]1744,eusincss and Professions Code:The,Cim mctor5 License Law dors not apply to an owner of Required Inspections property whobuilds or improves Hereon,end whodoes such work hin or through his own cmployeru.provided that such imprwemenu are not intended or offered forule.ll, however,the building or improvement is sold within one year of completion,the owner- builder will ban the burden of proving Hat he did not Wild or improve for purpose or sale.). ❑I,as owner of He property,am exclusively contracting with licensed contractors to conswer the project(Scc.7004.Business and Profusions Code:)The Coduapm'a Li ecru law does not apply to an owner of proper who Wilds or improver Hcmon.and who contracts for such pmjccu with a conmctor(s)licensed pursuant to the Contractor's Liaise Law. 1 am exempt under Sec. .B&P C for this rtamn WO O DECLA ADTION 1 hereby affirm under penalty of perjury..of the following declarations: ❑1 ham and will maintain a Ccninmte or Consent to self-insure rte worker's Camped- Sudan.as provided fw by Seca,n 37M or He laid,Code err the perfmmadec of doe work for which this permit is issued. 1 have and will maintain Worker's Compensauon Iruunnce,u required by Section 37W of the labor Code,for He perform moan of He work for which His permit is issued. My Workers Campuasa min Insurance carrier and Policy number art: Carrier. Policy No, _ CERTIFICATE OF EXEMPTION FROM WORKERS* COMPENSATION INSURANCE (,Tis section recd not W completed if tk Ma mit is fmone hundmd dollars($IWI of less.) I certify that in the performance of the work for which His permit is issued,l shall net employ any person in any manners,Sa to become subject to the Workers Compcmation Laws of 6lifo..id.Dau Applicant NOTICE TO APPLICANT:If,after making Nis Ccnifcau of Escmplmd,you Should become subject to the Workers Compensation PfovidOdS of the Labor Code,you must .JO forthwith comply with such pfnvisinru of this Permit shall he deemed rooked. z CONSTRUCTION LENDING AGENCY f~2 I hereby affirm that there is a constroctinn lending agency for the performance of Ci 7 the work for which this Permit is issued(Sec.3007,Civ.C.) LL.1 Q Lcddcis Nam. n,z Isndcr's Address U O I mnify Hat l have fund this application and sure that the above information is L,, F: correct.1 agree to comply with all city and county ordinances and state laws relating to 0U building coundri,n,and hereby auth,rimrepmscnutives of this city to enter upon the i G shove-mernimcd proper Tor inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cudef iso against T/] Iiabil itics,judgmenw,costs and capcades which may in any way Scenic against said City U z in co morardeu of the granting of this permit, '-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS CZAZ dt J t�C�Ate- N��L��/ Re-roofs Signature of AppluanVC,mmmm ✓ r Dau HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF Will He applicant dr brute building occupant sme or handle havarduus material cFord by the Cupenion Municipal Code,Chapter 9.12,and the Health and Safety e,Seeccti ns 25532(.)? All roofs shall be inspected prior to any roofing material being installed. Will the aPPlicantoffuture building acud,.n,0.equipment ordevireswhich If a roof is installed without first obtaining an inspection,I agree to remove mit ha,.ohms air conuminanu as defied by the Bay Ams Air Quality Management all new materials for inspection. District? ,l.w ❑Yen port I have read the huvardous materials requirements under Chapter 6.95 of the Cali foo- Sia Health&Safety Cede,Sections 25505,25533 and 25534.1 undersand but if the building docs not currently have a tenant,that iI is my respunsiM1illty m nnJly the ucnipanl or He regard la rich mdst erpdertUisauan«n,t "CcitlfcalcofD2.Up r' Signature of Applicant Date �� l�. �� C 2 � y�4- 2S tee, Um,ri>.ed agent Dnle '1 All roof coverings to be Class "B" or better • e� • CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp : Rng : Sub: Blk: Lot : APN . . . . . . . . : 34235016 . 00 DATE ISSUED. . . . . . . : 04/14/2004 RECEIPT # . . . . . . . . . 25184 REFERENCE ID # • . . : 04040085 SITE ADDRESS . . . . . : 22890 CRICKET HILL RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : WILLA CAMPBELL ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2635 RECEIVED FROM . . . . : WILLA CAMPBELL CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : • CITY/STATE/ZIP . . . , TELEPHONE . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---- - - ---- ------------- - --- ----- - ---- -- - - - ------- - - - BENERGY PERMIT FEE 137 . 00 41 . 10 0 . 00 41 . 10 0 . 00 BPERMFEE VALUATION 7, 500 . 00 137 . 00 0 . 00 137 . 00 0 . 00 BSEISMICRE VALUATION 7, 500 . 00 0 . 80 0 . 00 0 . 80 0 . 00 BPLANCHK PERMIT FEE 137 . 00 116 .45 0 . 00 116 . 45 0 . 00 - - -------- - - - --- -- ---- - - TOTAL PERMIT 295 . 35 0 . 00 295 . 35 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER -- - ----- - ---- - --- ---- --- -- ------ CHECK 295 . 35 4136 TOTAL RECEIPT 295 . 3S • 7:1 � 1 k a m � N \z o z Q �7 in,: m c '�' = � w Z m � Z vi O o C. 5 • � < � � T y n O ( ` WITY OF CUPERTINOf CITY OF PERMIT APPLICATION FORM CUPEkTINO APN -4/19 `O4 Building Address: Mailing Address (if different from building address): aaggo opuu1 -E -wL-L R!) Owner's Name: �2L�11 11 Phone#: I �G—L— —I Contractor: License #: V1s1wJ V As k)Imoou)s —7 -7 , 9 Contact: Phone: q3 G. C�f7d' Cupertino Business License#: Fax: Building Permit Info: Bldg E� Elect ❑ Plumb ❑ Mech ❑ Job Description: Qvplkce Residential Q Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: 7500DD Occupancy Group: R - 3 Type of Construction: Please check this box if the project is a second-story addition: ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 1 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 <= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA 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 Np 3S� (pm,IIWITY OF CUPERTINO*� CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee 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 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 BRENfNRAPP 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL 2 of 3 ,( -*CITY OF CUPERTIN(* CITY OF PkkMIT APPLICATION FORM CUPEkTINO 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 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 • I ' 3 of 3 CI•IN OP CUPERTINo k" tiv. �, r 'T. "' q� t.s nuu,nlnc nrvlsu)n PERMIT �dCON1RACTQRINFORMATION '' �' "an➢ +'cx r. �Ys �k ,rgks a --4!xa0pu;'?a� BUILDING ADDRESS: PERMIT N'O.0 4 0 4 0 0 8 CJ 22890 CRICKET HILL RD IiR'S NAME: PERMIT ISSUE DATE WILLA CAMPBELL 04Z14/2004 NE, SANITARY NO. CONTROL NO. CIIIIECI'/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MPCII 0 0 °00 LICLNSEDCONnsedorder DECLARATION cin E® U F I hereby affirm mat 1 am licensedB.under provisions ors CAdc, 9 tm mmensi is lob DCSCr ptlbnf tl Zw with Section 7lNtlq of Division 3O Be,NC Businca and Pmfcssinm CMc,end my license is Y� 3Nin foRforceandeffect. REPLACE WINDOWS ,�> Liccn.0 Class Lie N JUN 9 — 2004 tip Dhte Contractor nlt!] ARCHITECTS DECLARATION ?W U I undersmnd my plans shall W wad as public records =o� Licensed Professional BUILDING g OW NCH-0UILUER DECLARATION .� p I hereby affirm that I am cxcmpt from the Contractor's License Law for the 00 follawing reason.section 7031.5,Business and Prnfe.sAims Code:Any city or county K m which minims a permit to construct,After,impmve,demolish,or repair any,arunurc $7500 prior to its iisnonCe.21SO rtqures the applicant for such permit to file a signed statement k that he is lice need pursuant nthe pmvisinn offor Continuous Lice As,Law(Chapter 9 Sq. FL Floor Area Valuation (com mencing wi in Scali on 7000)of Division 3 of the B usinesa unit Professions Code)tar that he is exempt therefrom and the basis for IM alleged exemption.Any violation of Section 9031.5 by any applicamfora,mrailsubjecuthc applicant to acivil pknaliyof 3 SK 6Pr00 Occupancy Type not more than five hundred dollars(S500). P Y YP ❑ I,as owner of the property,or my employees with wages az their rule compensation, will do the work,and Ne structure is not intended morfered tarsals(Sec.7W.Business and Professions Coal The Con eacloa Ltaae,Law docs net apply to an owner or Required Inspections property who builds or improve thereon.and who ducssuch work I im.aelf or through his own employees,provided that such improvements are not intended or offered for sale.If. however,the building or improvement is said within one year of completion.she owner. builder will have the burden of proving mal he did not Wild or improve for purpose of salcJ. ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(SCE.7044,Business and Professions Code.)Tic Contractor's Li wrase law docs not apply to an owner of property who Wilds or improve thereon.and ho contracts for Such projects,with a comranor(s)licensed pursuant to the Contracmrs' License law. I am eaempl under Sec. ,84PCfm his reason re litie Date WORKER'S COM LN DF ECLARRATION j 1 hereby affirm under penalty of perjury ane of the following declarations: I have and will maintain a Certificate of Consent to self-insert for Worker's Compere - sation,as provided for by Section 3700 of the labor Code,for the performance of the work for which this Permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section 37M of the labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Cartier: Policy No, _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This•anima raced not tecompleted if the Permit is far one hundred dollars(510X) or Ice.) 1 certify Nat in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to Wcome subject to the Wmkcrs'Compensation Laws of California.Dale Applicant NOTICE TO APPLICANT:If,atter making this Certificate of Eamption,ynu rho d become subject to the Worker's Compensation provisions of the Ulan(!ade,you mum .J z fonhwith comply with such provisions nr this permit Shall W deemed¢yoked. Z N CONSTRUCTION LENDING AGENCY I hereby argent that there is a conametion lending agency for the performance of C4 the work for which this permit is issued(Sec.300.Civ.C.) U] Lender's Name Lender's Address ' oz U Q I certify that 1 have red this application and state Nat the above information Is - D, F^ correct.I agree to comply with all Lily and county ordinances and stoic laws relating to 0 building construction.and hereby authorim uprescroadws of Nis city to enter upon the ahove-cs,judgra property for cs renes purposes F 1 (We)agree to save,indemnify and kap K.R.the City of Cupeninn against V3 incoitia,judgmcnhecoatsing expensesmit. may in any way accrue against said City U inconsequence of DERSTingof this permit �-^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale SOURCE REGULATIONS s L N � - `/�u�y Re-roofs Sign urcof Applm.MfCon w, Ar Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle haearJom material defined by the Cupenino Municipal Code,Chapter 9.I;and the HCeIth and Safely . Section 25532(x)? ❑von pF All roofs shall be inspected prior to any roofing material being installed. Will mea applicant or future building Occupant use a If a roof is installed without first obtaining an inspection,I agree to remove PP seequipment Qu or which g Tit District? us air contnminanu az JcfincJ by the Bay Arca Air Quality Management all new materials for inspection. Disoia? ❑Yes §� I have read Ne haundous materials mquimmenu under Chapter 6115 of the Cali for nix Health d Safety Code,Sections 35515,35533 and 15534,1 Mosersund Or.ifthe Wilding Nres not currently have a tenant Nut it is my responeibil ity tu nnu 1,the occupant of the requrmmnnu which must n pno�w.i(ss.,n�ncco Ge A,of Ou UP y. Signature of Applicant Date q-`q`Z14, 6` y y/� All roof coverings to be Class "B" or better of authorised agent Date