04110106 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTQR INFORMATION n -BUILDING ADDRESS: GENERAL LIGHTING SERVICE PERMIT N`64110106
10591 N DE
OWNER'S NAME: PERMIT E SITE DATE
FRED 13ARNHART 975 CHESTNUT ST 11 /17/2004
ONE: SANITARY NO. CONTROL NO.
(408) 298-6670
ARCHITEC(ENGINEER: BUIIDING PERMIT INFO
- BLDG ELECT PLUMB MECH
a�aOp LICENSED CONTRACTOR'S DECLARATION Job Descri to "
C I rcb affirm at 1 am licensed under Bions of chapter 9(commcncing -.-
b wilts Smu )af Divis+on3of NCB sin Prufcssiu+u Code,end myliccnw is
_may inlbBr MdeffbrL !!o yb d b /` RECONNECT METER
zOil g n Dart, Class G U'.
O=p Lien lunars,sur7�—Cool clor(euTPY6 vUIT 5 ✓pt r �` --- " ' "
ae�war nd nd my plaoss�CTSD h rte/
3 0 Liccnxd Pmfcssionel
OWNER-BUILDER DECLARATION
<2 I hereby,(sec that l am exempt from Nr ContmasCo License Law for the
p o following rensmn.(Section](GIS,Business and wn,de tins Code:Any city or manly
,1 m 0 which its issuance.
ss a a Permit m cnnswct,aafter,pplicant
Impmse,h Norio t fi math any swcmre - --
Fiya poor mits�ensed c,owrit1.thsthe urfAsoicans forsucun,Cahncrmiuo 0lc asignad summcm — —__
that Amending wit pScccon In the of Divisions tMConuacmr'and Pro Law(Chap¢r9 _ Sq. FI. Floor Area Va Ion
(commencing with Sec0on 7")of OivisionJof the Business and Professions CMe)mrin $ that he u exempt lhertfrom and the basic for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects me applieanl m a civil penalty of
not mom than ryebuMreddollars(55W), ¢ 0 Occupancy Type
0 1,in owner of me pmpeny,or my employees with wages ss their sole compensation,
will do the work,and the swctuv:is not intended or offered for sale(Sec.1W,Business
and Per evtima Code:The Confiscates License law does rut apply man owner of - - Required Inspections
property who builds or improves thereon,and who dean such work himself or through his
ownemplowers,provided that such improvements she not intended oroffemd forsale IL
however,me Wilding or improvement is sold within one noutdcompkuon,demwer-
buildv will lave me forces of praying that he did not build or improve for purm se,of
sale.).
0 1,as owner of the prepcny,am exclusively contracting with licensed mnuactors to -
construct the pmjen(Sec.700x,Business and Professions Code:)The Conuactor's Li-
cense law docs not apply to an owner of pmpcny who Wilds or imprem themon,and -
whocontnctsforsuchprojecsswithaconuactmr(s)licensed pursuant to the Conuacm6 -• -__ , - _ .
License law.
0 1 am evempt under Site .B&P C for this muon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm once,penalty of perjury ane of the following declarations:
I ban and will maintain a Cenifica¢of Consent to self-insum for Worker's Compen-
7�cm
imn,u provided for by Section 7]00 of the Labor Code,for the pcRormance of 1W
W
for which this permit is issued.
1 have and will maintain Wirker's Compensation Insurance,as required by Section
00 of the labor Cods,for the performance of the work for which this permit is issued.
Warl s orag�nsauon lnwnna 'erm�Iiey_♦7/raw: 066 Yog
YC FG a Pqn qty/'/��
CERTIFlCATE OF FJCEMPnON OMWORKERS' ' s
COMPE,ISATIONHNSURANCE
(Thisseclion need not W complemd If the permit is formic hundred dollars(SI00)
for less.)
I cenify font notion peO(oamnnec of the work for which this permit a issued,l shall nut
employ any pe.a.In My mMner w a5 la become subject 10 fine Worked Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenir+cam of Esemplion,you should
become subject in the Worker's Compensation provisions of the Iathr CMB you most
.JZ forthwith comply with such provisions or this permit shall W deemed mvokM.
Z O CONSTRUCTION LENDING AGENCY
Ihereby a im that then is a eomwction lending agency for me Performance of
(Y tW work for which this permit is issued(Sec.3Pa9],Civ,C.)
Is7 0Lenties Name
ddress
0' Lender'sAgrees
U Q 1 cenify that I have read this application and suite the te that aWn information is
(•-'
correct.
1 I agree 10 comply with all city and county Ordinances and sum laws missing to
,
C) V aovWilding construction.edet,and hereby im,e tion purposes.rescnutives of this city to toms upon the
W aluvc(weMent)are to saveterty for inspersiontic,ho
(We)agree to save,indemnify and kap harmless me City of
me againino id City 1
F-' N lie consequence ftheeosuand es pensu which may in any way attmc againstsaid City 1111 v
U z APPLICACNTc of DEgranANDSlhis N it. COMPLY WITH ALL NON-POINT Issued by: Date
RpT
SOUR t.G)JL 0 t t /1���
Re-roofs
Si tum mf ApplicanVCr Data
HAZARDOARDOUS MATERIALS DISCLOSURE Type of Roof
Will y t applicant or forum building Occupant.Chpsafore m handle Health
sd Safer l
as refined by the Cupertino Municipal Cade.Chapter 9.11,and the Health and Safely
AMJFWr.or:25532(a)' Nu All roofs shall be inspected prior to any roofing material being installed. .._
Will the apprrsofor future Wilding Occupant use equipment for devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit he ardour air contaminants in defined by the Bay Area Air Quality Management all new materials for inspection.
Distort?
0y.
1 have mad me havarmms materials mquimencnks under Chapter 695 of me Caldor-
.isHeslth&Safety Cial Sections 25505.15533 aM 255M.l undentaM that if tM Wilding
Of not cusm ly hast can n'umyr 'roibility nufytheoccupantofde
.7 hieh s br to issuance ofe Ceni0c c
X �j Signature of Applicant Date
Owner or summit d a ant - All roof coverings to be Class "B"or better
Community Development
F 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
Jos AD0DS�` , n �� &-'zxD PERMIT #
OWNER'S NAME: Z3 S/fir/ PHONE # S,-eP Z-q F 6?. 7 a
GENERAL CONTRACTOR: epeijeis Y/ I W# 4,tO r- 6 37 9
I am not using any subcontractors: 7
Signature Date /
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing "
✓ Electrical /1011 t�C l Ct
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
Ah ile
'Q .
bw#er Contractor ignature Date
l
acCITY OF CUPERTINOCUPYOFFINO PERMIT APPLICATION FORM
APN # 6 l- U 6 Date:
Building Address:/O$ g �-�
/V 1joe , a�li�g/�Addr� (� re fr building address):
Owner's Name: // IPhone
Contractor: Q / /� License #:
Contact: P/ ne:(p1{6 3tV Cupertino Business License#:
Fax: -VF679
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: / Please check this box if the project is a
.I-./ CGU /J/ii�`f/� _ second-story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to I 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 Elee 600V> IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
Ei:plBENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
z� 70
lof3 s- 3v, / 7
t
Its ' CITY OF CUPERTINO
CirYOF' 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
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 Pblg 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 HeaterNent 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 > 10K 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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5CITY OF CUPERTINO
CITY°F 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
BREN'IVENSYS 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
BUS IC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elee Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Change BUILDING
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