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04020096 LBUILDINGADDRESS: Y OF CUPERTINO i%+ "- �" wtat T�a'��aa,,�a•r BUILDING DIVISION PER °CONT�2ACT�OR IL\�Ol�lvltl . N apafif« 'u;::;'-3$ ^Y..k..!: aY4Aar, Zia d4 'z:. ( SM CONSTRUCTION PERMITN%4020096 VER'S NAME: PERMIT ISSUE DATE PHONE: SANITARY CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 LOo LICENSEDCONfRACTOR'SDECLARATION Job De �[�� w 1 hereby affirm that.I am CONTRACTOR'S under provisions of Chapter 9(commencing <ZYY FF ith Sceuon Of Mid of DivisionJoL`tt�s�ncss and Profcuions Codc.and yliccnse is W w ^ / _gym in fulll��}n (tett ,pz License¢ Gam_ Lie.. Q FIRE DAMAGE REPAIR �{ =$w Dau: Ca st. r E: ,, MAR 2.8 2004 �yyts J pIanRCHI he us bARAccords a �ymeer J =oG Lica�dP ,re arkb1I BUIL®INCA S U VOWNER-BUILDERD, RATION <P I hereby alfirm that 1 am cxcmpE from Contractor's License Law far the —C OD rollnwing Mason.(Section 7031.5.Business and Profrssivas Code:Any city Or county %m K which orim J a permit to Mourned,0im,.Improve,derodi h,or Rpalr my structure •uin prior in its issuance.aria requires the applicant for such permiuo file a signed statement yFZC that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq. FL Floor Area Valuatl0❑ yam$ (commencing with Section)rR10)of Division J of the Business and Professions Code)or an y Eliot he is exempt themfrom and the basis for the alleged exemption.Any violaJon of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 36VAI6V1be00 Occupancy Type Apt marc than fare hundred dollars(5500). ❑L o the wed of Enc pmpeny, remy cmptoye¢or wages u (SM. compensation. will dotheand thestructureiteesanereseLwd far.1 apply so an war or Required Inspections ss and property wh obu Code:The Committees nd who Law dors not apply a an owner of q P property who builds or improves that thereon,and who are i n work Mmol!edthrough his pian vA,.thcuiprovided pr suchimprovements amnotintendedomoQerA formic.It. ' however.Ne building r improvement is Bald within one year of completion,the purpose of builder will M1am de burden of proving that the did not build or improve for Puryaz of sale.). I,as owner of the property,am exclusively contracting with licensed convectors to E constma de,project(Sec.7014.Business and Professions Code:)The Conractor's Li- rsse taw does not apply to an ownv of progeny who builds or improves themon.and who contracts for such projects with s canractor(s)licensed pursuant w Elie Conracmh License Law. I am exempt under Sec. ,B&P C for this reason Date WORKER'S COMPENSATION DECLARATION 1 hereby alarm under Penalty of perjury one of the following dealaratiurc: I haveand will maintsin.Ce rl..afC.ttosdf-insumforWarkescompcn- sauon,as provided for by Senian 3100 of the labor Code,for the lai foam...of the work for which Nis permit is issued. I ❑I have and will maintain Workers Compnsxxdon Insurance,as required by Section 3700 of the labor,Code,for Ne Pendwmanoc of the work for which his permit is issued. My Wodefs Comperrasion lnsurmMa , dP icy number ate: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thissecdor need m ithe completed if the permit is faroac hundreddollars($100) in,less.) I unify that in the performance of the work for which this permit is Oman.l Shia]not employ any person in any manner so as in become subject to the Warlans'Compeasation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making Nis Cemiliem,of Exemption,yon should become subject at the Worker's Compcwtian provisions of the labor Cade,you most .J O fordwith comply with such pmvisiora or this Permit shall an deemed invoked. zo CONSTRUCTION LENDING AGENCY E"' I hereby aft that Here is a Construction lending agency for the Xtrurmatum of !Y 7 work for which this permec it Is issued(S .3091,Co,C.) j. W A Under's Name I3. Lender's AddMss V C) I mmiry bar I have read this.,Plication and state that the above information Ls (y rMMML 1 agree to comply with all city and county ordinances and sure law!Mlating to building construction,and hereby authorise Mprrreenutives of this city to enter upon the ,r W shove-mentioned property for inspection purpo iL a (We)agree to save,indemnify and keep harmless dM City of C.Nnod against a UZ incoirequeo of the and expenses;which may in anyway accrue against said City 6 Uz A APPLICANT of Elie gtanun of this pclmll. I ti APPLICANT NDERST DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Daze SOURC R UL ON . I � &`t. o Re-roofs adt tgmE r _pPl'caHACZARDCO MATERIALS DISCLOSURE Date Type of Roof . Will the applicant or return building occupant store or handle hazardous material AA def nod by Ehe Canadian Municipal Code.Chapter 9.11.and the Health and Safety AM mke.Semions532(ar rerun All roofs shall be inspected prior to any roofing material being installed. ❑yes Will the applicant or future buildim t use a ui ment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove g occupant y p emit hazardous air conuminamts az defined by the Bay Ama Air Quality Management all new materials for inspection. , D'nrics1 ❑Yes NN. I have mad Ne hazardous materials requirements under Chapter 6.95 of the Califor ria Health&SaLlyCa)e.Smuou 15X15.25533 and]5534.1 mumumnd that if than building docs not curtcnit have a tenantMas it u my resnnuihility to notify the axupanr of the cyu antsw hm mc! `artaixsu.m.r.CcnlgcmeafOccuparcy Signature afApplicant Dale 411 o own h md agent Date All roof coverings to be Class"B" or better O File #: ASSESSOR COPY FIRE DAMAGE REPORT [PZECEIVJE�� DATE: v'L F 12 4 Received by: Reporting party: LOCATION: G>S ar/ . MrnwvrmdK¢flttT( Extent of Damag� W)wr �° VC2;.I��R1a �r•aChanaaaa 0r lalterabOnS ally ,,.,;�cinn tMM ©fl same without WC'ty erbno. Dep of Cop the bullding r h,,olan and specifications the smnIN•'�- erma U1, L yeatano SHALL NDT be held to p Assigned to Inspect: ,onroyal of the violation of any P. r ally City Drd. -- or WIL Comments: o s G9 e y ST eel �/'/fid �o x .•,.01 U� qir� PP %e��e 2 //�� �ee�J�e -7a� Date Insrected: Signature of Inspector: v� s PROVED On IN pCCOROANCE VM THE CITY G f) Wppt11N0 CODE ND 0 ANC S OAT RECEIVE Ft1e L SIGNED and specdicaiio� MOST FEB 12 This set of p', De kept on .,e job at atl limes and it is un lawful to make any changes or aiteraGons �_ on same without written EI ` ��mDAMAGE EPO the building Dept., City of I of this plan and specifications The stamp errc't or to be ar. aHAll NOT be held to P rowsrons OFFICE OR v I he violati o` Y rPiLjrd. e t. Received by: Reporting party: / LOCATION: w Gr/72� Extent of Damag �//fIL� Assigned to Inspect: Comments: 70 �/✓ /z/ 7e zL,ps�n SPY 2 � �/I', e //4,9/ ,cue el?'111'oe1-7 Date Inspected: ;-- Signature of Inspector: s�// o�l— *ITY OF CUPERTINO c CITYof PERMIT APPLICATION FORM l a U U Y CUPEI�TINO JA APN # Date: 661o06 a � lalo Building Address: Mailing Address'(if different from building address): W2�, Owner's Name: Phone #: e ct (,$B - HO-7 Contractor License #: J . M. rsfi, -1 736oS6 Contactj,e 1 -Pho e:37q _I$Sa Cupertino Business License#: e. q,le Fax: Building Permit Info: Bld lect/❑� Plumb MechA!fr Job Description: yJ Residential ❑ /Lem Co mere Sq.Ft. Floor Area: $/Sq.Ft.:l Cost of Project: Occupancy Group: �O�Q-o4 Type of Construction: r� Please check this box if ine 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> 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 BFLEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 / C %TY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO rQuantity 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 Re eat 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 > 1 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 44 BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heatin MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 tTY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Ouantitv Fee ID Fee Description Fee Grou • BREMTHEATR Theatrical Li tin 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 lnsection 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 EPERNHTFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPEPMITFEE PlumbingPermit Issue PLUMBING PPLBG -PlumbingFee sq foot PLUMBING ZADDCHG Address Chane BUILDING • • 3 of 3 CITY OF CUPERTINO BUILDING DIVISION PERMITFORMATION' BUILDING ADDRESS: JM CONSTRUCTION PERMIT Nc64020096 OWNER'S NAME: PERMIT ISSUE DATE E: SANITARY CONTROL NO. ARCHITEC 7ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 C= 0 LOp LICENSED CONTRACTOR'S DECLARATION WU 01 hereby affirm that I am licensed under pmvisions of Chapter 9(commencing Job Description withsci"i )ef Division3 ft �n.g and Profcasi.m Code.and my license is �� �L � ,�_ clmdagdn r� a Lic.0 (�-1 76056 FIRE DAMAGE REPAIR z Date ¢r Co sur sy ARCH CLARATION MAR 2 8 2004 �1 ut�c J plan public rttnNs J,U 3 G Liccnutl Pnsfc o 1 . BUILDING 'i IS ARATI I herchy a(Br that I eacmpt from Conuurons License Law for the _O D following mama Permit in IIU I.S.1. Business and sae,de oro Code:Any city or county which jU jims a permit m Uim the alcor,improve,demolish,or repair ed suunum �Zi prior to i.uoncc.also requires the applicant for such Coroaritmce asLaw(ummem FSC WtWisliccmcdpursuanttoINprovisiovoftheComncmr'sLicensclaw(Chepmr9 Sq.FL Floor Area Valuation as (commencing with Section 7")of Division 3 of the Business and Professions Code)or i $ that be u exempt thereffom and the basis for Ne alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subject,the applicant o a civil penalty of 3 6VAIS9rlbep 0 Occupancy Type not marc pun five hundred dollars($500). 1,as owner of Ne property,or my employees with wages.their role compensation, will do the work,and the structure Is not inundcd or offered finale(Sec.7044,Busineas and Professions Code:The Contractors License taw does not apply to an owner of Required Inspections propeny who buildsor improves thereon,and who docs such work himself or through his own employees,provided that such improvements uc not intended oroRere l formic.If. however,Ne building or improvement is sold within ON year of completion.Ne owner. builder will have Um burden of proving that he did not build or improve fm purpose of sale.). ❑h as owner of the property,am exclusively contracting with licensed contractors to construct she project(Sec.7814.Business and Profossiona Code:)The Contractors U. moss,law docs am apply to an owner of property who Wilds or improve daemon.and who contracts for such pmjcm with a contrecou(s)licensed pursuant in the Contracting Lice.law. U 1 am exempt under Sec. .B k P C for this resson Owner Dau WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of IN following declamations, 1 have and will maintain aCertificam of Consent to self-insure fur Worker's Comp,m .tion,as provided for by Secti.n 37W of the tabor Code,for the find.no.nee of the work for which this permit is issued. a 1 have and will maintain Worker's Compensation Insurance,as myuired by Section 37W of the IaWr Code,far the performance of the work for which Nis permit is issued. My Workena Comparmhon Inman=camir4Ypd Pglicy,number am: —] 'cr. V�aSSer+-va�ls�Ma.<..c BaR1cYANa.:'"ik WiS33� / CERTIFICATE OF EXEMPTION FROM WORKERS' . COMPENSATION INSURANCE (Thissection reed not W completed if the permit is faro.,hundred dollars(SIM) or less.) I certify tint in the performance of Ric.,it for which this permit is issued,1 shall not employ,any person in any manner m as to Wcome subject to the Workers Compensation Laws of California.Dau Applicant NOTICE TO APPLICANT:IL after making this CeniRcam of Exemption,you should become subject to the Workers Compensation provisions of the labor Code,you mu t z fonhwith comply with such provisions or this permitshall W deemed¢raked. z o CONSTRUCTION LENDING AGENCY F" `Z' I hereby olfirm that Norm is a construction lending agency for ON performance of rL> the work An which this permit is W.cd(Sec.ID .Co,C.) 0 Under's Namc z Lenders Address U 0 1 certify that I have mad this application and sou Nat the.1N.information is D.F' cora I agree to comply with all city and county ordinances and shale laws minting to DUbuilding construction,and hereby ambodm mpresenutives of Nis city to tour upon dm } [led above-memioned pmNr y for inspection purposes. (We)agree to.ve,indemnify and hep harmless the City of Cupertino against F" N liabilities.judgments,costs anexpmay any way amnic against d expenses which in mid City U in consequence of the grant in of Nis permit. 6 ^t APPLICANT NDERST DS AND WILL COMPLY WITH ALL NOWPOINT Issued by: D e SOil�RULON . Re-roofs(gn ✓Canuxto DemAZARD MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupanutore or handle harndous mawrial u defined by the Cupertino Municipal Coda.Chapter 9.12,and the Health and Safety Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. 0Yc4 t9 No Will the spplicem or Twort building acupam esu equipment or Ucvices which If a roof is installed without first obtaining an inspection,I agree to remove hazardous air contrminanu as defined by the Bay Arca Air Quality Management all new materials for inspection. District] ❑Yes NO 1Wv,madthehaaardousrmi rialsreyuimmenmunder Chipmr6.95oftheCalifor- nixH.)th&Safcty Cade.Srtions25505.25573and25574.1umkr Uutifthe Wilding does nil curseml hoc•unapt Nat it u my responsibility to noury IN occupant or the mya rents nm sues ortoissuanceofaCcrtmcamofOccupan Signature of Applicant Date d IoDa¢ Owner or hdagcm All roof coverings to be Class"B"or better