04090270 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INF0RMATI0N .
BUILDING ADDRESS: CEVAN FORRISTT DESIGN 1E11ITN004090270
OWNER'S NAME: PERMIT ISSUE DATE
E: T SANITARY 5o. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�WU LICENSED CONTRACTOR'S DECLARATION
wC 1 hereby 0).f that 1 am licensed reals and
Preons mChapter 9(commencing Job Deserip[i D
_iW withll to=]OeffecDiviaion]of tlm Businev and Prafesiou Cade.and mYlicense u
red infullc Claand effect.
,,��� Licen¢Clau Lk.M TRELLIS
Dam Couleacts,
ARCHITECTS DECLARATION OCT 2/ 1004
aI understood my plans shall the used as public records
Licensed Professional frA a
OWNER-BUILDER DECLARATION Lj
��`NV■
.�<P 1 hereby of ion that 1 em exempt from Ne Commeou's License law for me
a o following moon.(Scetun]TILS,Business and Professions Code:Any city or county
m which require a permit to cnmwct,alter,improve,demolish,or repair any structure
priorm its issuance.aam requiretheapplicant forauch Formula fIeasigned,mo mern
that he is licensed pursuant m the provisions Of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
x
(commencingwishSection70M)and the
basis
afr the
theegeinexemMon.AnProfessions CMe)of
_ Nat he is exempt therefrom and dte bests for Ne alleged exemption.Any violation of
Section]031.5 by any applicant for a Permit subjects the applicanuo Advil penalty of 3 5V14mankno 0 Occupancy Type
not mom Nan foe hundred dollars(ML -
❑I.uownerofthepmpmy,mmyemployeawiNwageautM1ehsolecampcnsatiDn,
will do Oe work.end me swmurt is not imendcd ar oRead rmgd,(Sm.7Wa,Business
and Professions Cade:The Contractor's Liceme law does not apply to an Owner of Required Inspections
pmpeny who builds orimproves thereon,and who doessucb work himxlrm through his
Own employees,provided that such improvements arc not intended oraRe ed for sale.If.
however.the building Or improvement is sold within one year of completion,One owner-
huiI,W will have me t unden of proving that he did not build or improve for purpose of
salc.l.
I,as owner of Nny,e progea exclusively contracting with licensed contractors m
co bun the project(Sec.704,1.Business and Protections Code:)The Contnemr's Li-
ecve law does not apply to an owns of pmyeny who builds or improves Merton,and
who commutes for such projects with a contractor(s)licensed pursuant to But Contractors
License law.
01 l son exempt�an(dF,r�See lJJ .B&PC for this
04nyf I J y 4\ i Date
TION�w , WORKER'S OMPENSATION DECLARATIO
1 emby M.under penalty of peejury one of Ne fallowing declaminns:
have and will maintain aCenifrate of CmtsCnlla self-insure for WorkceSCompen-
sation,as provided for hY Section 37M of me Labor Code,for the moromm ue of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the pmfowancc of the work for which this permit is issued.
My Workers Co.Proxmion houng¢extent,and Policy number one
Carrier. Policy Ner: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This.0mr need muWcmrPlacd if the Form..:;future handled dollars(SIM)
or lei)
1 ccnify Nat in me performance of me work for which this Permit is issued,l shall not
employ any person in any manner an as to become roban to the Worl 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 the Labor Cock,you mug
.JO foMwith comply with such provisions or this permit shall bo deemed mmkcd.,
Z" CONSTRUCTION LENDING AGENCY
'r.^ Ihereby af0,m mat mere is a construction lending agency lbr the Performance of
C(i me work for which mu permit is issued(Sec.3087,Civ.C.)
W� Q Lenders Name
=z lender's Address
V C) I ccnify Nn I ham mad this application and sum that the above infotmadun is
L, comm.l agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby auhome repmsemadve of this city In enter upon the
C above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless Be City of Cupertino against
FNliabilities judgments,costs and expenses which may in anyway accmc ageing said Ctry 1, lfi
U in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON'-POINT Issued by: Date
,)
SOURCE REGUL9TIQN5.y� #1 I L� gIr
fApp/Riticmu/Drt =m, —dare Re-roofs
c HAA Dous�iSCLOSUaRP d Type of Roof -
Will meappiicant urfmure building necuparo store orh dle out material
as defined by the Cupeoind Municipal Code,Chapter 9.12,and de Health and Safety
Cade.Season 25532(,1)? All roofs shall be inspected prior to any roofing material being installed.XNa
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
t hmamm.air contaminants Is cerium!by me Bay Area Air Quality Managcmcm all new materials for inspection.
is0ia?
❑Yrsu
1 have mad the hvaNues materials requirements under Chapter 6.95 tithe Califon
nia Health&Safety Code.Sallons 25505.25533 and 25534.1 understood thatiUbc building
does not curtendy have a tenant,that it is my responsibility m rodl'y the occupant of the
require nuwhi= mots be to w,miavane a fa cadre�f apancy ,e1/ Si re of Applicant Date
0 famhmind agent as^ D All roof coverings to be Class"B"or better
CITY OF CUPERTINO ' t
..�CBmLDINCDIVIs1oN PE S.a;N`;�.k .1N'TRA0-TbR`
RII
`
BUILDING ADDRESS: LEVAN FORRISTT DESIG PE " ND04090270
OWNER'S NAME: PERMIT ISSUE DATE
E. SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION �[1�_f 1pyj CCpTTf�`y�{�]I1'lD(yC�S��CjP
0o II U N Vd UL` ED
C . 1 hereby affirm that 1 am licensed under pmvi9ons of Chapter 9(commencing
i with Seclim7")afDwision 3.fft Busioean and Profesdom Code.ml my licensee
in fall rata and eneev TRELLIS
l2 Z
=�
Dmc Clens Lic.tl Dau Con DELI.
AR Cori he ums DECLARATION OCT �' 200q
w� I uMcnsund my Peru shell k urA a Pahlic reenNs
LLo Licensed Pmfchereby one( a •s I ®I■ L
OWNER-BUILDER DECLARATION `■■lsfl■a
1 hereby&Rrm Nat I am exempt from Nc Canuutur's License Law for the
a o following mason.(Swum](n15.Business and Rofcsuom Cods:Any city or county
m which requires a permit to chomm,a@r,improve.demolish,Or mPail any structure
iy prior in its issuance.also requires the applicant for such permit to file a signed statement
< thatla,euatmainherent tothepaviaimtaordoCers aemrauameLaw(Chapmr9 Sq.Ft. Floor Area Valuation
�$ (mourns ang with Seeuon]Oho)of Division 3nf,h.Bum.and Profeuim¢Coca)or .
9 Nat he is Bump,Nenefram and the base for the alleged caempmn.Any violation of
Section 7031.5 by airy applicant for a Permit mbjeeu the air licarso to a'I'll penalty of 3 50131MI14I)e170 0 Occupancy Type
am moa than f,c hundred dollars(5500).
❑1,a owner of the pmpmy,or my employees with wages w their sole compmatim.
:will do Rework and Neawcmala roti Licent,Law ddfwtapply.]Oan dwetws Required Inspections
and Property,
W ons Code:The was she contractor's Liam.Law docs not apply lf an oww of q P
pmpmy whm o,prom impmt sack improM a who awauc weak tended ims.lf ed through he
Own e .to.buiping Or i Netsuch impmrsmmtsaR net intendedoPlathad for axle If.
bull&,.Re building m impmwment is old within one yama mmple,for Ne owner
builder will have the herds,of proving that he aid not Wild m improve for purpose of
sale.).
S1,as owns,of she property am ueluaiwly contracting wish licemsed contractors in
co mesa the pmject(Sec.]Ws,Business and Professions Code:)The Contractor's LL
ecrmm law does not apply or an owner of property who builds or impmws hereon,ad
who contracts for sal,pmjcc,with a couvmmr(s)licensed pursuant to the Cmuramofa
License Law.
E3 lame un r5¢. .B&PCfor Nis
Data L
WORKER'S OMPENSATON DECLARATIO
1 Baby affma under Pertalty of perjury can of the following declarations:
0 I Nm and will mainmm.Cs,Nfoaof C...l tu seir-imus,for Worker's Compere 1
sation,as Provided for by Section 3700 of the Labor Code,for the perfomame of the
work for which Nis permit is issued.
0 1 Itaw and will maintain wmker's Campeouation Inarana.as required by Section
3]00 of the L mor Code,for am pmtmmance of the work for which this Permit is issued.
My Worker's Compensation Insurance carter and Polity number me:
Castrom Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE e
('1113 scctime need not mcomplcm!if sec permitiefm am:hundred dollars($)001
or less.)
1 artily that in the performance of hs,work for which this permit is issued,L shall not
employany sore inany monster so as tu become subjects,sec Workers'Compensation
Laws of Calif..,..Date
Applicant
NOTICE TO APPUCANr:If,after making this corifiae or Exemption,you should
became mbjeet to Ne Worker's Compensation provisions or ase Lahnr Code,you must
O fothw th comply with such 1.11 imu or Nis permit shall M deemed ranked..CONSTRUCTION LENDING LENDING AGENCY
1 herehy.lrum that Nem is a construction lending agency for the perfo mmm of
d> Ne work for which this permit is issued(Sec.309],Ci,C.)
ALsndcr's N.
Z Lender's Address
O 1 anify that I have mad our application sad sum Nat the snow irdmonim is
P cmRCL 1 agree N comply with all city and county ondo anm and mus laws mlaung tu
�U Wilding crosumcuon,and hereby authorize repnvcmauws of this city to enter upon One
r 4T7 aMvn-mentioned Pmpeny rot inspection purpem&
y G (Wu).,me m am indemnify and keep harmless the City of Cupertino&gains(
h liabilities.judgmcnu,emu and expenses which may in my way attme Mainufaid City
Z in APPLLICeeNTeof da,iflatinj Of UN UNDERSTANDS ANDWILLWWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU TIQNS.
n aA� w. � 1 ' LQ Re-roofs
��gy+c� c fApplmmUCon
V- -- -
HAZARDOUS MATERIALS DISCLOSURE' &re Type of Roof
Will lheapplicm(ser future Wilding Occupant store or h dle nus mmen.1
as Mined by the Cupertino Municipal Code.Chapar 9.12.and the Heshh and Safety
Coat,Seemn 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
0Yes -�'No
Will the applicant or tutus building occupant use equipment or deviw which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit hararmus air contaminants as defined by the Bay Area Air Quality Muugcm.nt all new materials for inspection.
DimricR
O Yesyu
1 More reau he hvaNnusmmedalsrequiremenu under ChaPur6.95 or she Caliror-
at.Huntth&SafmyCodc,Sccu.. 5505.25533 and 25534.lmdermad Oheirthe Wilding
duct not currently haw a ho ant.that it is my respons hility at notify the Occupant of one
again nuwhi. maybet 'I taissaanaararsrtifareyr span Si re of Applicant Date
o .athodmdsgem '/l1( D All roof coverings to be Class"B"or better
��� FENCE APPROVAL
� , .C�� AIS
CITY OF
CUPEkINO
Community Development Department 10300 Torre Avenue, Cupertino, CA 95014 (408) 777-330
RECEIVE
SEP 2 004
(DATE)
I am an adjoining property owner of Ii( N
(NAME)
whose property is located at C-- 'Ori
(ADDRESS)
I approve (as per Ordinance No. 686, Section 16.28.040 of the Cupertino
® t
Municipal Code) the allowance of a Ip _ foot high fence facing
(8 FT. MAXIMUM)
my property.
1
SIGNED: N 1 1� ��
ADDRESS:
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KIRWIN
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+ - eCITY OF CUPERTINOP
CUPEYOF PERMIT APPLICATION FORM ° 4 07c> 2 70
APN # O ` Date:
Building Address:/1 Mailing Address (i d fferen from b ilding address):
�064�-� �>,ror� �✓�7 c��efTlrJ0
Owner's Nam Phone#:
51t�PH6tj UrJ�
Contractor: ' License #:
(,t Vhj f::0 ''15(T'
Contact: GJ Phone: M X3.337 Cupertino Business License#:
J�c(vl AH►) Fax: I
Building Permit Info:
-Bldg ❑ ,� Elect ❑ Plumb ❑ Mech ❑
Job Descri tion: .
�
p . /JIk, ,
Residential El ❑5
Sq.Ft. Floor Area: / $/Sq.Ft.:
Cost of Project: / 27a-- / Occupancy Group
Type of Construction Please check this roject is a
second-story addition: ❑
fProject 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 IM Btu MECHANICAL
BBOILER4 Boiler> IM 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investi ation fee BUILDING
Z, Zv 2-
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Gu
ISCITY OF CUPERTIN(*
CITY Or PERMIT APPLICATION FORM
CUPERTINO
IV 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 Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
j BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstaWAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
i 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 Fumace> 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
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IWITY OF CUPERTINO*
CUPERTO PERMIT APPLICATION FORM
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
BSPECIAL Special Inspection BUILDING
BS WIM 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 Chane BUILDING
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