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04060055 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACT,OR�INFOR�M,ATION ; BUILDING ADDRESS: JM CONSTRUCTION PERMIT NO 04060055 OWNER'S NAME: PERMIT ISSUE DATE ET 4prE; SANITARY NO. CONTROL NO. 408 379— ARCHITEC tEtIGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u00 LICENSED CONTRACTOR'S DECLARATION- C 1 ha ct, ,rel In I vn Bcnucd under revisions of Chepto 9(commencing Job Description b withsecdnn) ) !Division Sof NC Bassin dPmrrsslnm Cn ,`mu,myf enaca Nranmm ane m. 7 5(� REPAIR WALL IN GARAGE (CAR�AP�fA�]1)LE j i License Class LI ,f w 4 tl"�1 F,p Da¢ Camnc �'� ��J 7W ms mailARCHIW used U ION, —y5.< Iundcrm,nJ my plana ahallWuxJupu li<rtcnrUs JUN 2� 2004 'u,,u ;W� Licensed Pofeentmal 3 OWNER-BUILDER DECLARATION a i 4 1 hereby affirm Nal 1 am exempt fru.the Conuacmr's License Law for the BUIL�� a0 following mason.(Section 703 1.5,Business and Nofeasium SIJ Code:Any city or county x m V which requires a Permit to construct,alter.impose,demolish,or term any struclum qnnn Y20. poor to its LtsuanMes the.also requirapplicant for such Permit to ftle a signed statement < Oat W is licensed pursuant to the provisions of the Connector's License Law(Chapter 9 Sq. FL Floor Area Valuation zea (commencing with Section 7")of Division Sof the Business and Professions Code)or i that he is ommpn Nererrom and the basis for me alleged exemption.Any violation of pp Section 7031.5 by any applicant for a permit subjccu applicant the applicano a civil penalty of 3M MidTOer 00 Occupancy Type not more Nan ors hundred dollars($500). P Y YP I,asowncr of the propenYamY employees with wagnsutheir sole compensstlon, will do the work and the awcture is not intended mortared for sale(See.7044,Business and Pror¢aio es Code:The Correctors License law does not apply a an owner or Required Inspections property who buildsorimpraass themon,and whodocssuch work himself or through his own employees,provided Nan such improvements arc not intended oroff red formic.If, however,On building or improvement is sold within one year of completion,me owner builder will have the burden or proving Nat he did not Wild or improve for purpose of sale.). ❑I.as owner or the progeny,am exclusively contracting wide licensed mnlrulors to construct Ne projce,(Sec.7064,Business and Professions Code:)The Contractor's U. mase Taw docs not apply to an awns or properly,who Wilds or imposes Neuron,and. who contracts for such projects with a conwnor(s)licensed pursuant re the Conmcloes License Law. I arn exempt under Sec. BR P C for this..on Owner Dau WORKER'S COMPENSATION DECLARATION I hereby affirm under pensly of perjury one of Ne following declarations: hale and will mainuin a Cenificam of Consent to self-insure for Workers Compere station,as provided for by Section 37M of the Labor Code.for the performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,se mquired by Section 3700 of the Lmor Cade.for the pedmmance of the work for which this permil is issued. - My Workers Cnmpanaatfon brsmance caricr and Policy number M: Cartier: >C PJC3 Policy No.:l�F�ry y�,�� CERTIFICATE OF E%EMPf10N,FRDTIW RKO ERS'4 COMPENSATIONI SU NCE Ohissiction need not W completed irthe permit isfororm hundred dollar(SIM) or mer) 1 certify Nal in the perrormanec of the.,it for which this permit is issued.l shall nal employ any pomean in any manner are as to become subject to the Workers''Compensation Laws of California.Date Applicant NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation previsions of tbe labor Code,you mum .J Z foMwidt comply with such provisions or mu permit shall be dammed ranked. ZO CONSTRUCTION LENDING AGENCY 1 hereby affirm Nat there is a construction lending agency for the Performance of W On work for which this pe.i,is issued(See.3097,Civ.C.) U7 Lender's Name z Lender's Address U O 1 terrify Nat 1 have had this application and state Nat Nc mum information is [t,r career.1 agree to comply with all city and county malmorms and sum laws miming no 0U Wilding comwclion,and hereby aummim mphemnutiacs of this city to cater upon the Y'U2about-mentioned property to,inspection purposes. CL (We)agree to save,indemnify soil keep hmmmus Ne City of Cupcnino against r rn liabilities judgments,costs and expenses which may in any way ecce against said City U z in conmqucnec of Oc granting of this permit. '—' APPLICANT UhjDERSTA1jiK AND WILL COMPLY WITH ALL NON-POINT Issued by:S a SOURCE R ATIONS.r 1 / t`7_p, Signature Ocam/Cmn .r a 6� Re-roofs HAZARDOUS MATERIALS DISCLOSURE'/ Type of Roof Will the applicant or future building Occupant snore of handle hazardous material as defined by me Cupertino Municipal Code.Chapter 9.12,and The Health and Safety We.Smuon 23532(x)? All roofs shall be inspected nor to an roofing material beim pYns p p y g g installed. Will the applicant or 'tum Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove harardnus air contaminaas as defined by the Bay Area Air Quality Management all new materials for inspection. tier, ❑Yes Fir 1 have mad Ne hmallous materials requirements under Chapter 6.95 of the Califon nu Health A, ct Cade.ScctiO.M505.25533a.125536.1undcraundthaifthe Wilding does rote t has a Tense it u my hempansibility he nouly the oceupent of the trcm, a vbe. reismanceofaCmifcm,o(Occapm . Signature of Applicant Date Owners amorivedagenT Dam All roof coverings to be Class "B"or better crrY of curEaTwo C®NTRAC ORANF®RMATION , BUILDING DIVISION PE MI INC ADDRESS: JM CONSTRUCTION PERMIT NOD4060055 PERMIT ISSUE DATE , a R'S NAME: ETH L SANITARY NO. CONTROL NO. PRONE: 408) 379-9852 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 LICENSED CONTRACTOR'S DECLARATION Job Description mF 1 hamby arc that 1 am limmed under sim,s of Chapter 9(commencing with Section 1, ) fDiv,sion 3 of,he Busin a d Professions end,,and an,license is ao�+ in ton mmeana L �3 �D 5 Cy REPAIR WALL IN GARAGE (CAR DAMAGE) �Z Lccnm Class Li . nrp.Dam Cameo . uJ ARCHIILCTS DE LA ION -a 1 understand my plans shall M umd es pis lie mcnrds Jyu ;u.� Licensed Professional 10:5 OWNER-BUILDER DECLARATION I hcmby alarm that I am exempt from the,Contractor's License Law for,he p o following mama(Seeuun 71131.5,Business and professions Code:Any city nr county K which nexP res a Permit to Comonli almr,improve demolish,or repair any amdurt si< prior to its issuance.arm mquims,he applicant for such Permit o Blot a signed statement S Ft.Floor Area Valuation that he is licensed pursuant toNe Committal's of thCommittal's License Law(Chapter 9 q' yF� (commencing with Section 7000)or Division 3 of the Business and Professions Cade)or ad that he u exempt thcmfrom and the basis for the alleged exemption.Any violation of OGGH araC Type Section]031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of 3 AVIS 0Q&T®er 0 0 P y yP not tome Orion five hundred dolls..15500). 1,as owner oldie property,m my employees with wages as their.mle compensation. willdo Newerk.andd¢s aetue is not intended or offered fo,sah(Sec.IBM.Basirma uired Inspections and Professions Code:Thor ConnevWx License Law docs not apply to an owner of property who buildso,impm.thereon,and who dmasuch work himselfor through his JUN 2 1 2004 Own employees.provided that such improvements are not intended or offered for safe It, J however,We building or improvement is sold within am year of completion,One owner- builder will have the burden of proving that he did not build or improve for pro pore of sale,. BUILDING 1.as owner of the property.am exclusively connoting with licensed contractors to commoner the project(Sec.7614.Business and Professions Cade:)The Contractors U. _Jfigrise law docs no,apply,o as owner of property who builds or improves thereon,and canncts far such pmjccm with a connctor(s)licensed pursuant o the Contractors II'm Law' B&P C far Nu moon un exam In under see. Date 10 her WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of per are of the following declarations: I hese and will meinuin a Ccnifiam of Cosxunuo self-insure for Warkei sCompcn- 7371W on,as provided for by Section 37M of fie Labor Code,for the performance of the k for which this permit is issued. 1 have and will maintain Wedges Campiumon on Insurance,as required by Section of Ne Labor Code.for Ne performance of Ne work forwhich this permit is issued. My Workers CompensatiotnInsurance carrier and Policy number ate: Carrier.X51 K119 f'nIS 7k+y� Polity No.;./� J CERTIFICATE OF EMFf10NiRGM WORKERS' COMPENSATION IN`s NCE (Thu section noted not hComp eted if the famen iaformc hundred dollars(SIM) ,or Ico 1 certify Nat in the performance of the work for which this permit is issued,l shall not employ any person in any manner u as to become subject to IM Worke,i ComPewtion Laws of California.Date Applicant NOTICE TO APPLICANT:If,art,,making this Cenifico C of Exemption,you should become subject to the work.cmarenssomp Provisions of Ne Labor Code.you mus, Z forthwith comply with ouch provisions of this Permit shall W deemed revoked. Z N CONSTRUCTION LENDING AGENCY _ I hereby afErm that there is i construction lending agency for the Performance of 7 We work for which this pooh is issued(Sec.309E Civ.C.) tS7 Q Ixodes Name a' Lender'SAddmaa V 0 1 codify Net 1 have read this application and su,e Na,,he above information is l5. f"' correct.I agree to comply with all city and county ordinances and state laws relating in >. building construction.ane.Inde aifyand repruemniss of this city toenm+upon the above-mentioned property for inspection Purposes. �"C ie(we)agree m save,indemnify and kith harmless the City of Cupanst a against liabilities.judgmen¢.cosmand expenses which may in anyway accrvc against said City U Z in<onuquenee of the loaning or this permit. - g .. )l APPLICANT U DERSTAI�D$AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCER ATIONS. I �'7-K'7 Re-roofs asgra,am o pplicanVCon star T e of Roof HAZA DOUSMATERIALSDISCLOSURE Type Will the applicant or future building occupant Stam or handle havamous matorial defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant or rutore bui Wing Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants ss defined by de Bay Arca Air Quality Management all new materials for inspection. Distrito? 13 yes N'u 1 have mad Ne horrid.,_m amiluds.4uircmen¢under Chapter 6.95 of Ne Califor- maHea1N5Safra Code Scctions25W5,8533and25539,1understand Natif Nc building does no,Cu CnI have amoan. it h my responsibility la notify the occupant of the requi„me . to Win 4,wicanceOr.cerurcamorOccupon Signature of Applicant Date o A- [/�."-,7"'hf All roof coverings to be Class "B" or better SMA CITY OF CUPERTINO $ CITY OF PERMIT APPLICATION FORM CUPERTINO APN # / U ow Date: v- -7_ O (5 � Building Address: I Mailing Address (if different from building address): IO ci �2Cf�AY� Owner's Name: Phone#: I:Tt - asp a Contractor: License#: Contact: Phone: 3l`l-`l 6Sa Cupertino Business License#: . < Fax: Building Permit o: Bldg Elect 34- Plumb ❑ Mech ❑ Job Description: Residential GE 'Qe RJL tNnll (r- p;wff Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy oup e of Construction: -� Please check this ox if the project is a second-storyaddition: El Project Size: Standard ❑ Laze ❑ Major ❑ 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 Elee Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING # �s7 J 1 of �� 7 ` V7 CITY OF CUPERTINO CITYOF 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfrn 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> 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 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 2 CUP TYOF O PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL uj 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 Insection 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 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 Chane BUILDING 3 of 3 APPROVED Of. IN R(NpttDANE WITH E CffY D NANCES (� � U DAT SIGNThis set of vans an6 'Necificatio-l� rn ;vu at all times and it is un to kept changes or altet�on lawful to maks any on same without writteof Cupe'ino, f the building Dept.. City 1v;R i.; The Mmpinii of this plantdt or. 3HA11 NDT he held top t) apprrvaI of the violation 0`a ll.L ta*r` a v CiIY Drdmarxe Or 0 �•�.. r<.� war.'i,'9'":. IIIlIlU1111PR;;;1111111111111 :: s,,x; 111JI JlAIHIllllllllllAllllll a PPfli�iUUAllIiiIPIJUuUll9f" JUrd 0 a p C,P�V ul- CUPE,!TT No 3U1,'LC1'1,'%C, ®ERAP MEHT ,«_ • Community Development F 10300 Torre Avenue '-% Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408) 777-3333 �JPERTINO Building Department JOB ADDRESS: 1pyril D eod ,,0 r/> PE IT # "V OWNERS AME: ETNkEL PHONE4 37 � ^ 9 K5 GENERAL CONTRACT R: J M C o >s FAX # 5 I am not using any subcontractprs: " �- 7 �' 7 "�C J Si' afore Date Please check applicable subcontractors and complete the following information: 21 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 Roofipg Septic Tank Sheet Metal Sheet Rock Til -OZ �I JC QK71/,-- ntractor Signature Date