03100120 (2) CITY OF CUPEVI'INO +^pn m+ -'= +�
nU1LDINC DIVISION PERNO COl\sL1�Cl-QR&I ON:g',
< °Ti�ar�Yr
BUILDING ADDRESS: JON R CRASE CONSTRUCTION I MITND.03100120
OWNER'S NAME: 164 GILMAN AVE PERMIT ISSUE DATE
49 NE (408) 370-1485 CO: SANITARY NO. NTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
t BLDG ELECT PLUMB MECH
.00 LICENSED CONTRACT'OR'S DECLARATION C] O O O
1 hereby of that 1 am licensed under provisions a(Chaptcn 9(cbmmcncing Job Description
iz5 with Section 70(ID)firmof Division 3ofdre Bmi000md Profession.,Cade,end my license is
License full Claanderren. ��l Jr�f'� REPLACE FIREPLACE TO BAY WINDOW
License Claus Lic.ro
a-p Date 1<G' Coattail.,7,, R (Harm Cin:ks,if's�a.4
w ARCHITRCPS DECL RA ION "�P�-_
redu I understand my plans shall be used as public records
°off Licensed Pmfcssional
3 OWNER-BUILDER DECLARATION
a} I hereby affirm that 1 am exempt from the Contractor's License Law for the
:p o following reason.(Section 703 1.5,Business and Professions Code:Any city or county
f m Idi which requires a permit ser construct,total improve,demolish,or repair any structure
prior In its issuance,also requires the applicant for such permit to file aligned statement
;zp mat he is litansed pursuant o the provisions elthe Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
g I-$ (camntctming with Seni.O70W)M Divi .0 of thn Businasmd Prafessinns Code)or
_ that he is exempt thca anon and the basis for the alleged exemption.Any violation of 35620054 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of APN Number Occupancy T
not more man five hundred dollar(SSW). P Y YPe
❑1,u owner of the properly,or my employca with wages as their able compensation,
will do dm work,and the s mentm is not intended or offered for sale(Sec.7044,Business
a^�
and Profasibrts Code:The COntrdoes aclora License law donot apply in an owner of Required Inspect gr�3i u
property who builds or impmws merman,and who does such work himulror Enough his /t
cwyc
nemploes,provided that such improvements are not intended oroffmcd fmvle.11, AUGLOoY
however,me building or improvement is sold within one year of completion.me owner- U 1
builder will have the burden of proving that he did not build or improve for purpose of
mlaJ.
❑I,as owner of the property,am exclusively contracting with licensed correlation,to BUILDINGconstruct me project(See.7044,Business and Profusions Code:)The Collusion's Li
menu law dors not apply to an owner of property who builds or improves thereon.and
who contracts for such projects with a contractor(a)licensed pursuant o the Contractors
License Law.
❑ I am exempt under Se B&P C fee this Treason
Owner s'^" '- Da¢/ /r/0
r
WORKER'Sf COMPENSATION DECLARATIO
1 hereby affinm under penalty of Perjury one of the following declarations:
have and will maintain a Certificate of Consent to ulf-insum for Worker'sCumpcn-
ion,az provided for by Section 37M of the labor Code,for Ne PenPormnnce of the
work rot which this permit is issued.
0 I ban and will maintain Worker's Compctlsadon Insurance,as(aloud by Section
3700 or the Labor Code.for the performance of the work for which this Permit is issued.
My Workers Compensatian Insurance carrier and Policy number am:
Can
Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thisuction need nm lucompleted ifthe permit lifetime hundred dollars(SIW)
or less.)
1 curry mai in the pmfomtanec of the work for which this permit is issued.I shall not
employ any Person in any manner sr,as to become subject o the WorkeK Compensation
Liws of California.Dau _
Applicant
NOTICE TO APPLICANT:IC after making this Cmerteatc of Etemption.you should .
become subject to the Workers Compensation Povisime Or the Labor Civic,you must
�,Z rbrrhwlth comply with men provisions m this permi a shat l W deemed acwked.
�O CONSMIUCION LENDING AGENCY
I hereby affirm that there is a construction lending agency or the Performance of
-e the work far which this permit is issued(Sec.3097,Civ.C)
+l Q Undnh Name
lr
7 'z
1 dIAddress .�
;J Q I unify that I have read this application and sole that the above information is
y
building construction,
o na ofcomply,and with all city m0 county epres nNtives Of and area laws mining Me
bhow-geonswction, lily nor ins mthonprpoeunuti representatives of this city to crime upon me /J
0. ahovcmc a)aged to save fin inspection an Purposes.
(We)agar to cove,indemnify and keep harmless the City accrue
Cupcninb against
~ Z incosequnce of thecostsang expenses which they in anyway testae againstsaid CityS k
/ `
,Jz APPLIquNTUNDERSTingorthis lkWI to (J/
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
SigSignatureof ApplicaDam
HAZARDOUS MATE RIALS DISCLOSURE Type of Roof
Will mo applicant or future Wilding occupant stare or handle h material
as defined pe
by the Cupertino Municipal Code.Chapter 9.12.and the HealthcalM anand Safety
Code.Scam.25532(u)l All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea IF No P P Y P, g
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 naeamous norrcaentro rts as deraed by the Bay Arca Ail Quality Management all new materials for inspection.
ntricl[
Yes No
('have land the haaamb as Materials requirements under Chapter 695 of the Cali for
nit Health&SadbtyCodc,S4cduo 25505,25533 and 25534.1 understand thd if that Wilding
dos not Carmody have a therm that it li my responsihility b nod fy the weapon Of the
rryuicmcmn mhmust et prior to issuance of aCcrdfcato foaepaney. Signature of Applicant Date
_ ,._�.. /O/�C7C 7
_Qwfrr Or authoneed a ge no Data All roof coverings to be Class "B" or better
APPROVED
WACCoF.,oAi,,cz ,vrrHTHE aW0F
CUPER 6 AfM
IDATE
_WNE
This so ot Wm snd ,dime MUTT be
kw on ft ob d 03 tow aw A is Urd;,twU to
hake vlY dwQw Cr alterations or,. same
ci#w rMftGn PTfi0V0 W6 do hilang
dopt,C41Y of ottpomraj
The G14mping
AVwfcatiorm
.-SHALL NOT-
b;isld tO P8,1i or to be an
approval of ft violatioll. of arvy WwWm of
Li any City 0r rwrxe State Lawl
A
ICE COPY
rRECE
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5164 CITY OF CUPERTINOOCITY OF v
CUPEkTINO
PERMIT APPLICATION FORM o 3 l
N# } o Date:
3-r — ?rO 1 `i lq 2 V-3
Building Address: )/
2! �7 Ccs��'�,.t-,�t� .:�. ert-u�, (-As`� Y
Owner's Name: Phone #:
Contractor: -16n P, C on u i Ln4 License#:
Contact: _ Cupertino Business License#:
Building Permit Info:
Bld Elect ❑ Plumb ❑ ech ❑
Job Description: b
Residential � replar"e �Gre�i e u2t[ Rsw Commercial
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: c Occupancy Group:
Type of Construction:
7!QuantityFee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS 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 > I OOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigationfee
it. Fee BUILDING
BMITIGATC Comm.m. Housing BUILDING
10 2,3�� P�
1 of 3
gS-4- 2-
S
*ITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEI�TINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Future 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 cfm MECHANICAL
BREMARU AN A/C Units <= 10,000 clip 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
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aCITY OF CUPERTINO* A'
CITY OF PERMIT APPLICATION FORM
CUPEIZTINO
Quantity Fee ID Fee Description Fee Group
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
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
BSWIM Swinirning 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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
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