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05100010 CITY OF CUPERTINO .+sem .-fir` z � az- r�`," BUILDING DIVISION PERMIT CONTRACTOR INFORMATION �''. BUILDING ADDRESS: MIS S PLUMBING PERMIT NO.05100010 10865 W ESTATES DR OWNER'S NAME: PERMIT ISSUE DATE PETER POLUZZI 12246 S NE: SANITARY NO. CONTROL NO. (408) 867-6010 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 o o LICENSED CONTRACTOR DECLARATION Job Dscri [ion U C w 1 heree by affirm that I am licensed under provisions of Chapter 9(commencing b ithStals.7")of Division 3af NC Businev and Professions Codi.and my license is 4)p �fj 9y intvllfoacanae( at REPLACE WATER MAIN `Y3N [g' ✓�Z Liccna Claza Lic.N {� Ts ,�p ED Date Cuntracmr�� asWj - AsshalI use DECblicreT1ON OCT �-- 1005 I undersunJ my plans shall be used az public records tau s u. Licensed Professional OWNER-BUILDER DECLARATION f I hereby offi,m Nm 1 nm exempt from the Contractors License Law fur the 1 \. ,,�R t' �•a•q� 00 following mound,(Secutor7031.5,Business and Prorczdons Cade:Any city or county i 3 which m,mics a permit to construct,aIle,,improve,demobh,or repair any structure $1475 y¢i prior to its issuance.also requiresPermit the applicant for such Peit to rile a signed statement < Nat he is licensed pursuantNNeprovisions ofthe ContactersLicense Law(Chapter9 Sq. Ft. Floor Area Valuation YF0 (commencing with Section 7")of Division J of the B ushum and Professions Code)or y Out he is ezempt tbertfrdm and the buts for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects Ni applicant to a civil penalty of c 0 J Occupancy Type not more Nan 0ve hundred dollars($500). 0 I,as owner little property,army employca with wagesser Neir.sole mmpena lion, will do On work.and the structure is not intended aroffered for fele(See.7044,Business add Professions Code:The Commander License Law does not apply to in owner or Required Inspections radiantly who Wildsorimpmvea thereon.end whodois mchwork himself or through his Own employees.provided that such improvements art not intended or offered for ale.IL how cit the building or improvement is sold within one year or completion,the owner- . builder will have the burden of proving that be did not build or improve for purpose of sale.). ❑1,as owner of the Properly,am exclusively contracting with licensed contractors to construct the pmjca(Sec.7144,Business and Profusions Cod,:)The Contractor's U sets Law does not apply to an owner of propery who builds or improves Thereon,and who contracts for such projects with a contactor(s)licensed pursuant to the Cnmhael0rs License Taw. I am exempt under Sec. a rk P C for this season whir Date WORKER'S COMPENSATION DECLARATION I thereby affirm under penalty of perjury one of the following declarations: I have and will maintain a CaNrieam of Consent to self-insum for Wmker'a ComPcn- atimn,u provided for by Section 3700 of the Labe,Code,for the performance of the work far which this Permit is issued. ❑1 have and will maintain Workers Compensation Insurance,az required by Section 3700 of the Lamm Code,for One performance of the work for which this permit is issued. My Wnrkeea Compensation Imar;c/a'rie,and Polity number a Cartier. 'T4 C � JeL—j Policy No.: C I r �7� CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (Ibis section need not W complemd if the Permit is for one hundred dollars(SIM) in In".) 1 serif,Out in the mFormance of thc work for which this Permit is issued.I shall not employ any puritan in any manner so az ur become subject to the Workers Compensation Laws of entire .Data Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers Compensation provisions of ft Lamm CMO,you must aZ forthwith comply with Such provisions or Nis permit shall be deemed rooked. Z O CONSTRUCTION LENDING AGENCY I hereby affirm Nat there is a construction lending agency for the Performance of a Ne walk(or which this Permit is issued(Sec.3097,Civ.C.) Lumme:Name = z Lendcrress Add U C I certify Nat 1 haat read this application and state that the above infmmadiun is comm.I agree to comply with all city and county ordinances and male laws minting to 0U building construction.and hereby auhorim representatives of this city to enter upon the r W a1mve-mentiond tonicity for inspcctien popnn. (We)agree to ave.indemnify and keep hornless On City Or Cupertidm against F' h liabilities,judgments,costs and expemcs which may in any way accrue against aid Ciry U z APPLICANTOUNDERSTANDSof the granting a(tANDhis ,WILL COMPLY WITH ALL NON-POINT Issued by: Dale �—T-p <:t_ SO RCE REGULATIONS. Pal C1 io/YXS� Re-roofs Si wrc�ot pplican/Conlmeror Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will On applicant or future building occupant moa or handle harndous mai as defined by rise Cupertino Municipal Code.Chapter 9.13.and the Health and Safety We.Section 255J2(a)7 ❑Yea 14", All roofs shall be inspected prior to any roofing material being installed. Will the applicant o,future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it b,odnus air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection. isuict7 ❑YOs �RjNu I have read the hexandows materials requirements under Chapter 6.95 of the Califor- niaHealN&Sam yCoat,Sections 25505.25573 aM 35534.l understand thaz if the building dos mol eurcndy have a mnanc tha it is my responsibility to noufy No acupmt of the reyuirements which be me(�psi�qJArm�h�j'amu nn eed;Biate or / a7name ) Signature of Applicant Date U� G . o eroramhonadagent Dam All roof coverings to be Class "B" or better .,�. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPERTINO Building Department JOB ADDRESS: PERMIT # / OX 6S 1.✓, zd" ee, j -VG av/O OWNER'S NAME: e4t,,�- Qo(/v z z , PHONE # K&Y- - IT3 0 GENERAL CONTRACTOR' 1— 1 -),,-, 4A FAX # I am not using any subcontractors: � U 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 Owner/Contractor Signature Date L CITY OF CUPERTINO o CITY OF PERMIT APPLICATION FORM CUPEkTINO is %IAPN# Date: 3(,::,1 - 23 - o'7.r /0 - y— � � BuilingAddress: lrs Mailing Address (if different from building address): Owner's Nam Phone#: c t -AL vzZ Contractor: License #: Contact: SSb7-6oio Phone: 86�-6 a r o Cupertino Business License#: ��_ Fax: 4i d ti Building Permit Info: Bldg ❑ Elect ❑ Plumb ER Mech ❑ Job Description: Residential Commercial ❑ Sq.Ft. Floor Area: q.Ft.: Cost of Project: �y_ Occupancy Group: !y 7S Type of Construction: Please check this box if the project is a second-story addition: ❑ roject 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 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 <= 1O00A 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 SACITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO 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 I 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 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 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 > 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 BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of �,t CITY OF CUPERTINO 'l CITY OF 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 BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECLAL 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 EPERAHTFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERAHTFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING • 3of3