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05080209 CITY OF CUPERTINO ' �T r"`t%''"�E BUILDING DIVISION PERMIT CONTRACTOR*INFORMATIQN - BUILDINGADDRESS: PERMIT NO-OSOS 0209 1157 OWNER'S NAME: PERMIT ISSUE DATE GORDON PERRY' 08/23 /2005 NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 ipp LICENSED CONTRACIOR'SDECLARATION Job Description I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of dm Business and Profimio"Code,and my license is n�din full force end enc -�„ REPLACE SIDING p✓�Z Lianu class Lic,x Dam coma r CONTRA. : HOME IMPROVEMENT BUILDING MAINT ARCHITECTS DECLARATIONround s i 1 undcrsash nJ my plans all W used u public mcmm JyU soG LiccmcO Professional a 5 OWNER-BUILDER DECLARATION 1'em" affirm on I am eaempl from the Cssions o :Any c Law for the p o following mason.(Section](131.5.Business and Professions Code:Any city or county <m which oyuires issuance,permit re eOnawcl,alcor,impose,demolish, fi repair any swcmre < tpoor hat he its ensed also..attoido thatapplicantfor such Carrot to Blam Law(Chapter Nal mencingitpurmanlmNeofDiviomoftheCamrumr'andProflaon$Codmr9 Sq.FL Floor Area ValuaCf¢t7000 Lam$ Cut he is exempt with hereon and Winds 3 of al Buseged essexemption. and Professions Code?of Nat W u exempt thertfom and Um baso far the alleged cxempuon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penally of APN Number Occupancy Type not morn Nan five hundred dollars(i5003. 36651021 , 00 I.as owner of the property,or my employees with wag"as their sole compensation, will do Ne work and the structure is not intended or offered for sale(Sec.1066,Busims11 and Professions Cone:The Conureces Limoe taw do"an,apply a an owner of Required Inspections property who builds or improves dtemon,end who does such work himself or though his Own employes,provided that men improvements art not intended or onered for We.If. however,the building or improvement is sold within ane year of completion.the owner. builder will have the burden of proving that he did not build or improve far purpose of We.). [� 1,ru owner of the n � Prape Y•am exclusively conuamin8 with Emmettlittfued contractors m construct Nees not (Sec.?014,owner of and property who Code:)The Conhemom whotaw do"not je an owner m ,rcom(y who Wilda or iropmvss Nemon,and, who ase Loco for such pojecu wiNaconuactof(s)liceved pursuamw Ne Convxtoh sa0ss YYY Lice ase taw, fnrT ' � 1 am exempt under Sec. ,B&P C(or this Owner DI {'!1J q ` WORKER'S COMPENSATION DECLARATION N IOU,{ / 1 hereby of cto under penalty of perjury ane of the following decorations: ,,//�� I hsmand will maintain a Certificate of Coruem to self-insum for Waders Compen- IV(VVVIII tion,m provided for by Section 3700 of the labor Code,for Out performance of Ne work for which Nis permit is issued. ❑1 have and will maintain Wurkcr's Compensation Insurance,az required by Section 3]00 of Ne tabor Code,far the performance of the work for which this permit is issued. My Worker CompemaIion Insun a canis and Policy number Carrier� CERT Policy No.: 131..0 3L CERTIFlCAIE F EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Trissection need not hecompkim!if IW Permit is for one hundred dollars($IIXp I"e.) I cenify that in the porfameanee of the work for which this Permit u issued,1 shall net employ any person in my..a,u as to become subject o the Workeri Compensation Laws of California.Doc Applicant NOTICE TO APPLICANT:If.after making this Cerriflome of Exemption,you shouW became Subject to the Worker's Compensation previsions of on,tabor Code,you must .,O fonhwith comply with such provisions or this Permit shall be deemed revoked. 'Z^' CONSTRUCTION LENDING AGENCY [—s�.. I hereby alarm Nal them is a mou.1minn lending a,.,for da performance of 1:5 the work fur which Nis permit u issued(S".3(X1,Civ,C.) - t[7 Q Leaders Namc 6. Lender's Address ' J C) I certify that 1 have read this application and sole that the above information is cmren.I egom to comply with all city and county aNinmces and sum laws miming to �(J building consuunion,and hereby mnorne myresenutiws or this city to enter upon the W show-mentioned property for i"pecuon purposes indemnifyCL (We)agree to sam, Fw , Liabilitiess judgments,costs andexpenses which may in any way am=against said City V z APPLICAeNTeof ffic UNDERSTANDSthis AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGULATI S. Re-roofs SiBnmu o plicanVConlfactor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the apPli"cat or forum Wilding occupant dote or handle ha�ous material u defined by the Cupertino Muniripal Cod.Chapter 9.13,and Ila Health and Safety Cade scet;an'1553z(.? /I All roofs shall be inspected prior to any roofing material being installed. �Ycx .ST91W will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it 1111.1.111 air contsminants as defined by the Bay Area Air Quality Management all new materials for inspection. isuin? ❑Yes I have read theh=u wsmaterialsmquimmenuunder Chapter6.95of Ne Califon nia Hcahh&Ssfmy Codc,Smumu25505.25533 ard1=4.1undcrstand thmifNc Wilding does net currently haw a¢nano Nat it is my respanibility to notify the occupant of Nc requirements which rood be Met Certificate certificate of occupancy. /g. S ignature of Applicant Date owneror.am nmagenl 6/" D,te u All roof coverings to be Class"B"or better a Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY 0, Fax(408)777-3333 �UPERTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: IPHONE # GENERAL CONTRACTOR: FAX #fid I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 65 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 Roc Tile Owner/Contractor Signature Date (C CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM P IZ � CUPERTINO APN # Date: Building Address: Mailing Address (if different from building address): Ow er's N e: -Ph&e#: -3 1S- 6 C tractor: / License#: Contact: vPho 3i57—y6(�3 Cupertino Business icense#: Fax: Building Permit Info: B I d Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential c®\ Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this box if the project is a v, r second-storyaddition: L1 Project Size: Standard Large ❑ 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 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 BELECl001 Elec 600V> 1000A ELECTRICAL BELEC200 Flee Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 3 1> 1 of 3 3 OJ', 7 c7 CITY OF CUPERTINO CITY Of PERMIT APPLICATION FORM CUPEI�TINO 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 Repilpe 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIltHAN 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 BREAUNHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BRENC RAP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rept], Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 . CITY OF CUPERTINO 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 Seb 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 Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE 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