04050136 CITY OF CUPEB.TINO a+ g x;;:i ' _ ,. t "'
assn tnnc Drvls:oN PERMITCONTRACTORINFORMATIo
RUILDING ADDRFsS: PARKER PLUMBING PERMITND04050136
104�NAME:
ARA DR
OWNER' PERMIT L6UEDATE
CHNIEDER 24 CHELTENHAM ONE: SANITARY NO. CONTROL NO.
(408) 374-1832
ARCHITECf/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION O O O
Yw 1 Mrtis from that I,on licensed Mulcr provisions of Chapter 9(mriumming Job Description
-Z� wiMsecliou](�) f Divisior 3 of Me Business an fcssimn Codc.ind my license is
in mu mrt=aa6(d see e GAS LINE
Liccnsc Class Lic.N
ZFn Dam —LL6--Comrecsor
ARCNITECI'S DE CL N MAY 2/
�-i `✓�n sjBMtr dAs Ore rhea 2004
'.0
y Liccnsc mfcssio sin f� .�/
vs 3 O NER-BUILDERDECLARATION
9y9y I hereby alTirtn Nat I em exempt from the Comracmts License Law for the Swim.`Oo following reasoo.(Secdon 7011.5,Business and Pmfessiom Cane:Anycilymosimy t�J.l
0 m� which requires a Permit to c'mrs-rot alter,improve,demobh,or repair any amucmre Pnnn
°iO porous its issmorra.aBo requirts Me applicant rorsuch permitm Rleasignedsousemen
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft.Floor Area valuation
ytt--0 (commencing wish Section 70 Xy)of Division 3 of Me Business and Professions Code)or
.s. that he is exempt therefrom and Ne basis for 1M alleged exemption.Any violation of
Section 7031.5 by any applic:ntfor apannotsubjects the applicant o a civil Penalty of &QJa&t8er00 Occupancy Type
not mom Nan tons hundred dcllars(5500).
❑1,uownerof Nepmpny,ormyempioy wiffi gEmasthcirsolecamMnutlon,
will da the work.and Ne stmc ort is not intended uroffered for sale(Sa.7014,Rusin•.a
and Poufassiov Code:The wrs(monacrl License Law donut apply m an owner of Required Inspections
property who Wilda orimproves thereon.and whodaesmsh work himselfor through his
Own employers.provided Nati such improvements art not immndrd or ofresed for sale.IL
however,the building or improvement is sold within one you of completion,Ne cwrer-
Wilder will have the burden r f proving that M did not build or improve for purpose of
sale.).
❑1,as owner of 1M pro crt,4 am exdusivclY contracting with licensed consumers to
constmet Ne project(Sec.70 W,Business and Profusions Code:)The Contractor's Li-
cense Law does not apply to m owner of property who Wilde=r improves thereon,and
who contracts for such pmjcaa wish a cotnramm(a)licensed pursuanuo Ne Contractor's
License Law.
lameaemptunder Sec _ .B&PCfmthismamn
1307WW
er Data
WORKER-3 COMPENSATION DECLARATION
1 hereby affirm i nderixnalry of perjury oro of the following declua0oM:
have and will mainuin aCesti0cate of Covent mself-insure for Worker's Compen-
o,as provided for by Sm son 37W of Ne labor Code.for the performance of the
for which this permit is usohed.
have and will maintain Worker's Compensation 1�s urance,as required by Section
of the labor Code,for sec performance of the ouNk ,which this peonit is issued.
Workeri ComPensasonLosunnce mer end Policy numier Ste_ T'L Policy Np.///"Z2�
CERTIFICAIEOFEKEMFITO WORKERS'
CCMPENSATION INSURANCE
('Thu scetioh need not ceompicted if the permit a rmorchundmd Millan(5100)
in kss)
1 certify that in the pcdorma¢e of Ne work for which this Permit is issued.I spall not -
employ any person in any mar per an as in become subjecuo the Workeri Compensation
Laws of California.Date_
Applicata
NOTICE TO APPLICANT:Ir.after making this Certificate or Exemption.You should
become subject m We WohclS Compensation provisions Or the labor Code,you must
.,O fonnwi th comply with such P rnviomis or this Permit shall M deemed mvaked.
z'� CONSTRUCTION LENDING AGENCY
I-+ Ihereby All Wt lM to is a construction lending agency for the perfurmance of
C' 7 the work for which this permit is onto(Sec.3097.Civ.C.)
W Q Lcndcr's Harm
0. LcndcrSAmmus
7Z
J Q I ttnee that)have rt hd this application and sute that the above ws missing is
W U correct 1 agree m comply with all city and county madwtces his sum laws r upon
e
Q V abovengcovlmctiogand herebyins suthon pr recces. tires of this city to enter upon the
W anovc(We)agree
to saw for inspection keep ha.
D. (We)agree to tare,in lcmmfy and keep hasmlcss the City or Cupertino egoist
F(n liabilities.judgmenl5.costs and captious which may in any way accrue Against said City
U on consequence of the gratin,of this Permit.
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE LATIONS.
So of Applia-utUC Dow
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will the applicant fufutureort m Wilding occupant shhandle h ardous material
az dc0nc0 by the Cupertino
MMunicipal Code.Chapter 9.12,and she Health and Safety
.dc.SccYtion25532(a)7 All roofs shall be inspected prior to any roofing material bei g installed.
❑ es o
Wits me a Ilcam or furore building occupant use equipment nr aemcn wmen If a roof is installed without first obtaining an inspection,I agree to remove
pp s p
mit hatardous air contaminants u dc0ncd by the Bay Arca Air Quality Management all new materials for inspection.
Distrin7
p Yes NO
(have mad Ne hoard aterol3requirementsutkrCMpmr6.95oftheCalifor-
niaHealN&Safety Gox.Section 25505.25537 and 255ls.I undersmM that iflM Wilding
does notcunind,here.tenant that it u mY.,miton,to ratify eupam ofthe
rtgairem hie vbcroes te raneenraeonseateOfo«p- Signature of Applicant Date
rte prizes,gent „e All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
s' Cupertino CA 95014
Telephone(408) 777-3228
" CITY OF Fax(408) 777-3333
CUPEkTINO
Buildi ng Department
JOB ADD ESS: PERMTlt W D O J
OWNER'S NAME" J PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following 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
Tile
QL�
/ e ontractor Signature ate
10/28/03
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM Off{-
CUPEkTINO
APN # 3 O O Ll 8 Date:
Building Address: Mailing Address (if different from building address):
to t� GO C)aP/L/+ v Z
Owner's Name: Phone#:
Contractor: License #: /
iee-n Cviz�,c3.� o4'.S"Oo 3
Contact: Phone:4io(? I-1 3 Cupertino Business License#:
�i~u e, Fax: Z + - X4.9 ZO
Bg Permit Info:.
i
Bld Elect ❑ umb Mech ❑
Jo escription: Iy
Residential �] �J ��`e
7 Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: / Occupancy Gro e—
Type Construction: Please check Oshox if the cct is a
Ilk2 2 second-story addition:
Proqt Size: Standard ❑ Lar e ❑�/Ma'or ❑
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
131301 R5 Boiler> 1.75MBtu 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
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-amm, CITY OF CUPERTINO
CUPEY OF PERMIT APPLICATION FORM
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 rinkler/Backflo PLUMBING
BPSTORM Stonn/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 cfrn MECHANICAL
BREMAIl2HAN 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
BREN=AT 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
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,taa, CITY OF CUPERTINO
CUPEI�F PERMIT APPLICATION FORM '
Quantity Fee ID Fee Description Fee Grou •
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING •
ZADDCHG Address Change BUILDING
•
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