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04080035 CITY OF CUPERTINO BUILDING DIVISIONPL+'RMIT TORINk'ORMATION:' BU ILDING ADDRESS: PERMITNO. NOBLE CONST 04080035 OW NER'S NAME: PERMIT LSUB DATE ONE: SANITARY KCrROU NO. ARCHITECVENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 upQ LICENSED CONTRACTOR'S DECLARATION Job Descriptio ;-P 1 hereby affirm Na,1 am licemed under provision of Chapter 9(commencing p site with Secsion 1pgl) !Di inion Sof dtc Business and Pr ssion GOdC.ittd myliccmeis HNALED ;per L;«9�7. ✓^ uc.a 1 7 m REBUILD CHIMNEY FROM ROOF R. Date Conuazw�r II AUG Ip 2004 ARCH CTS DEZ'GfK4xJ N LIOW5 I. u y bans ahail M used a puhl' rnNs ' o'U LL1 LKCniCd Pn,fCSSlnnl ®I ®®® `0s OWNER-BUILDER DECLARATION iP 1 hereby affirm that I am exempt from the Cnnhaao's License Law for the —00 following....(Section 7031.5.Business and Professions Cc&:Any city or County x m 0�. which requires a Permit to contest,alter.improve,demolish,or repair any•uuetum .iy poorwits mource.al.r requites tWapplieanl forsueh permilm file.signed summer a that he islimrtmdpursmmtothe provisirnofthe Commear'sLiamLaw Sq. Ft.Floor Area Valuator i:a (commencing with SectionTOM)of Division J of the B usincss and Professions Chei or i ik— Na he is exempt therefrom and the basis for Ne alleged ascription.Any violation of Securer 103 L5 by any applicanlfur a permit subjects the 2pplican10 a Civil penalty of 3 0 Occupancy Type not Mort than five hundred dollars($500). I,u Owner Or the property.or my employees with wages as their sole compensation. will do the work,and Ne slnatun is not intended or offered for sale(Sec.7044,Business and Professions Code:The conlaacmra License Law don not apply to in owner of Required Inspections propany who builds Or improves thereon,and who doessuch work himself or through his Own emplryccs,provided Out Such impmvemenu are not intended or offend for salt.It, however.be building or improvement is sold within one year Of completion,Ne owner- builder will have the burden of proving that he did not Wild or impmve for purpose of sal..). 1,as Owner Of the property,am exclusively contracting with licensed contractors 10 constrict the proje (Sec.1fW 'Business,and Professions Cade:)The Coouacwr's Li. caner wed l applym an owner of property who Wilds or improves Neuron.and wham t for such projects; n with aconuaOr(a licensed nseJ pursuamNO Conuaaors At aw. as Opt under Sec. .B 6 P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of NC fallowing occlusions: . 1 have and will maintain a Canireate Of Consent to sel6insure for WOker's Compere 737M ion,as provided for by Section 3700 Of Ne Uboformce r Code.for the peranof the rk for which is permit is issued. I have and will maintain Worker's Comperuation Insurance,as required by Section of the Later Code.for Ne performanceor Ne work for which this permit is issued. y Worker's Compensation Insurance carrier and Policy number am: rtier. Policy NO.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need nut he completed if the permit is fortune hundred dollars(SIM) Mss) 1 unify Nal imance of the work for which is per it is issued.I shall not employ any. manner umbecom iso ar rf Compensation UteVV ApNOf, res ca of houlJis ompc n provisions o Ne UWr CMe.you must OfoMprnvisio orNipermitihall bedumcdrtvpkcd.Z ONSPRU ION DING AGENCY IWmat therein. on tion lcndinyagcr¢ylmNc perfumtar euf Ne work for ermit is iss d(S .Jo9's,Civ.C.)Candles Nam Z 1<ndcr's adders. V O I coldly that 1 have read this application and sure that the above information is building 1 agree to comply with all city and county.thinner.and some laws relining to fit) 31mvi-ammuwction.and thereby authorimmoses. asrf this any to enter upon Nc above-mentioned property forinspectionImcf,ea. F a (We)agm�save,indemnify and trap harmless the City of Cupertino again. N lmu'liueajud enu,COsu and expenses which may in anyway ammo against said city Uzincmvequc oaf Ntgfanll of this permit. ^' t!�2 flileo APPLICA UNDERSTAND ND WILL COMPLY WITH ALL NO -POINT Issued by: Date SOURC EGULATION Re-roofs / I P r V atm Date H s MA ER ALS DISCLOS Type of Roof Will Nc appli m rfuwrc builfng cupanuwrc or handle has esus malarial u defined by Nc Cu Wino Municipa Chapter 9.IT.and NC Health and Safcry Codc.Sccuon2553 a1 All roofs shall be inspected prior to any roofing material being installed. ❑Yc. o Will the applicant or Twort building recti�pl-day'.. ay y ipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit haafdous air contaminants as define c Bay Arca Air Quality Management all new materials for inspection. Or...inl ❑Ye. I hav read lic haasrN .materials reyuimmenu under Ch.Mc,6.95of,mCaIdm- riaHcalN Safny Cole, ccuu 255(15,25513 anJ 255Jd.l undcrsund NOt if the Willing docs not urcntly have tete NM it is my respunsihilhy w nmtily Ne Occupamaf thc requir dntewhichor Ipo,to"Ip CtepraCenlficateoIXcppaocy' Signature of Applicant Date e rr anthers,.°. ret „e All roof coverings to be Class"B" or better Community Development e 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 �UPEI�TINO BHilding Department JOB ADDRESS:,JV e¢I//5o IT # C 3 ,3 OWNER'S NAMe::;:P r PHO GENERAL CONTRACTOR: FAX # I am not using any subcontractors- / D Signature Date Please check applicable subcontractors and om lete the fo owin 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 "Til Aj ! r ontract r S gna ate ( - CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO IIIKPN # Buildin��ss: o Mailing Address (if ifferen from buil ing address): 0W A4, Owner's N Phone #: c ?)• �J ,�Sa Cont oq: License �J � Con act 2 Phone: �o Cupertino Business Licen e#: 2 1✓ 2 A Fax: Building Perm Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: of Residential 1.i ommercial Sq.Ft. Floor Are : ' 1 $/Sq.Ft.: Cost ofPr 'ect: /gig Occu cy Gro d c 16 Type ofonstructionk. Pie a check ox if thiKproject is a ff second-story addition: ❑ Project Size: Standard ❑ L e ajor ❑ 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 3 Z2� . a ` CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCON2 M New Comm Mechanical MECHANICAL BNUCOMMP. New Comm Plumb PLUMBING BOVERTWE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING 11 BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE PbIg 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 rinklerBackflo 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> 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/Platfonn 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 2of3 CITY OF CUPERTINO ' CITY Of PERMIT APPLICATION FORM CUPERTINO 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 MEC14ANICAL BSCBLVD Scb Specific Plan BUILDING j BSEISMICOM Seismic Commercial BUILDING 17 BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUS IC 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 Fees foot PLUMBING ZADDCHG Address Chane BUILDING 3of3