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03070095 CITYOFCUPERTINO �' -_� , '* " BUILDING DIVISION . PERMIT CONTRACTOR INFQRMATIQN BUILDING ADDRESS: SUNNY VIEW LUTHERAN HOME PERMITNO.03070095 OWNER'S NAME: PERMIT ISSUE DATE SUNNY VIEW T.1TTT4P.RAN T40MR, ONE: SANITARY NO. CONTROL NO. ARCHI7SR/ENOINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 moo LICENSED CONTRACTOR'S DECLARATION lb Description C 1 hcrchy afRrm that 1 am licensed under Provision.or Chapter 9( mop com encing b with Section 7011 )of Division 3 ofd.Business and Professions Code,and my license is in full force and effect. ipz License Chat Lie.0 UPGRADE ELECT. PANEL t„ Date Coronaclm ARCHITECT'S DECLARATION < 1 understand my plans shall be used u public tecmda 3 Licensed Pmrwi...I JUT. T 5 2003 OW N".11UILDER DECLARATION I hereby affirm that I am exempt,roan the Contractor's License Law for the p0 following reuOn.(Suetion 7131.5,Business and Professions Code:Any city or county BUILDING $ which requires a Permit to cnnsoun,elmt,improve,demolish.of torn(any structure 2oo pdonn its issuance.also requires the applicant for such permit rile a signed aahment ��< that he is licensed pursuant to the provisions of The Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation ^� (commencing with Section/110))Or Division 3 of the Business and Professions Code)or .. than he is exempt therefrom and the beau for the alleged exemption.Any violas! of Section 7031.5 by my applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type not more than Ow hundred dollars($50)). ❑1,u Owner of the property,or my employees with wages as their sole compensad.n, will do the work,and the structure is not intended or offered far.1.(Sec.7W,Business _ euuull s L,R I'`TD Tr'jyT.nS and Profwions Code:The Connotation,license law does not apply to an owner of seeztmrC91F19f1wL10 property who Wildso,improves thermn.and who dauauch work himself.,through his 501 - FINAL ELECTRICAL ENERGY own employees that such improvements are not intended oro0cred for sale.If. 505 — FINAL ELECTRICAL however,the building at improvement is sold within arc year.(completion,the Owner. Wilder will have the Wrdcn of proving that W did not build at improve for purpose of sale.). ❑I,as ownv of the property,am exclusively contracting with licensed contractors to co=tthe real" m tit(Sec.70th,Business and Prorudons Code:)The Canncoori U. ' cense I�w da I apply tom owner of property who Wilda or improve Neeson,and whoconoacu r uchpmJer with a conancomns)licensed pursuant to our Contractor's LlceyCLw 'f oma lade,Sec .B&Pcf llhtts eon Ow Data 7 6 W RK 'S COMPENSATION DECLARATION 1 hereby&Man under Penally of perjury ane Of the following declarations: 1 he-and will mainuln a Ceniricste of consent to ser-alum for Wartme,Compen- noun,u provided for by Section 3100 of the Leber Code,for the performance of the wick for which this permit i[issued. ❑1 have and will maintain Workees Compensation Insurance,u required by Section 37W of the Ta bo Code.for the performance of the work for which this permit is lined. My Worker.Compensation I.e....aria and Polity number art: Cartier: Policy No.: _ CERTIFICATE OF EKEM PnON FROM WORKERS' COMPENSATION INSURANCE (This secllat need not W completed IrIM Tconit b rnrmn:hundred dollars(SIM) Or less.) I certify Nu In the performance of the work ran which this permit Is issued,l shall not employ any person In any nu nnerm u In become subject to the Worker.COmpcdatlon Law,of C.lif,ria.Data Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject to the Worker's Compensation previsions of the Lthnr,Cod.,you most .JO forthwith comply with such provisions w Ni.Permitsmvo hall W deemed reked. 'z"' CONSTRUCTION LENDING AGENCY -(..t y. I hereby M.that there is a mwrunimt lending agency ror the performance of Cthe work fur which this permit is issued(See.3097,Civ.C.) Q Lender'.Name =,z Lender',Addrom le t,)Q I certify Na I nave read this application and state that the above information is Pcorrect.I agree to comply with all city and county ordinances and shot laws misting to U building consnnion,and hereby aulhorim representatives of this city to enter upon the above-menoioncA property for inspection purposes. c)agreeA emnifyand keep harmlev the City of Cupertino against liabili udgmeeapenseed keepmayinany way ssthocty orcapertinainst.ig CityAon PP I A netUNor bis poranit. DSranting of IAND WILL COMPLY WITH ALL NON-POINT Issued by: SO R GU Re-roofs fig I App rant/ ramor Da HA ARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future Wilding Occupant store of hartdh haudous material u defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety Calc,Section 25531(.)? All roofs shall be inspected prior to any roofing material being installed. ❑Yea No Will the applicant 1u.building occupant use wuipmndOr device,which If a roof is installed without first obtaining an inspection,I agree to remove ittheIl he'a'd s air cmnumina r<ud DIN by the Bry Arte Air Qwliry Managemcnl all new materials for inspection. Ih cuad Ne aur nussmquimmentsundcr Chapmr6.95ofthc Califn hie ties' Sof YC c,Sccouns 25505 25533 and 25534.1 unokratatl Nairthe Wilding does nm rem ho mnenL Thal it is my reapnuihiliry m nndly the rccupal of the ,..IDI ntswn n es aan.ceNn.am .er Signature of Applicant Date I .arced. m a1 All roof coverings to be Class"B" or better OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: A. c� the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed • 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed ..............................................................................:...................................................................................................... I declare under penalty of perjury tha h ab a is true and correct. I have read and understand the Owner-Builder Information / (revers d ). Property Owner's \w,nei s Signatu�6: v Y Dat Job AddreCX� 2 Permit# Any changes to the information provided on this form shall be submitted to the City of Ciipertino wild Department. San CITY OF CUPERTINO gS� � � � 7� CUP CITY OF O PERMIT APPLICATION FORM v APN # („_ Date: -7 V .� Building Address: Mailing Address (if different from building address): 2 ce0 9f ,k—7 i.- -) e.4 Owner's Name: Phone#: Contractor: License#: 6 Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ le Plurpb ❑-- ech ❑ Job Description: Residential ❑ 6A7Comme c Sq.Ft. Floor Area: $/Sq.F .: P Cost of Project: OccuVancy Group: 3 Db Type of Construct' Please check this box it thonroject is a Adak second-sto 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> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1 M 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 I of XG s 1 CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res 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 Repipe Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER WaterHeater/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 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 2 of 3 r.� CITY OF CUPERTINO cl 0 PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group 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 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING i 3 of 3