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04030034 CITY OF CUPERTINO ^" ^".�'t��F"x ` "� ' � +r BUILDINGDIVPIRMI� COIVTI2ACTOR,INFORMAI#V n� Wiw� •nM9 s. .S-Y'.F+lA'By 30.�2K)r:'e R.A..A.ku. 6�V.Y' ING ADDRESS: PERMIT N0. JON R CRASE CONSTRUCTION I C 04030034 EST 2PRTNC; QT OWNER'S NAME: PERMIT ISSUE DATE PHONE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 u00 LICENSED CONTRACTOR'S DECLARATION Job Description mF I heathy affirm that 1 am licensed under provisions of Chapter 9(commencing Zwith Section] )of Division J ofthe Business and Profession Code.and my license is to n<n. in full( dcfren. 5nq— License s 6 f�l� I �l�SY/ REPLACE WATER HEATER/FURNACE/DRYWALL & —o Dam a_yyy c: DECr WATER SOFTENER ARCHTfECosto. ION yyt < l a%mac uhJ any plata sha111e used as pub at records ;oG LiccnmO Professional S OWNER-BUILDER DECLARATION 6/ 9R I heathy affirm that 1 1. exempt from the Crsions o License Lew for the ❑o o which following renes A Permit IDSL;Business and Purrve,dei of Codc:Anyepair any s roomy K m whim ma Issu a permit to construct,altar.improve,deermitt or mash any suuaure 1- Rat beor initsiensedpalsure to do,Useapplicantfor such Comearmit Licensle ae ned Law(Chapter Rat licensed pumtion to the pro visions of the Conuuturs Licenseselaons Cor mr9 Sq.Ft. Floor Area Valu (1pp m� teat he is (commencing Section 1000)dieof Divisionasifor of the AllBuseged exempts and on.LimAny violation of 13 4'3 0 i�$ Nm he is exempt Ncmfmm and Ne breis for the alleged exemption.Any violation of Section]031.5 by any applicant for a permit subjects he applicant to a civil penalty of APN Number Occupancy Type not more than five hundred doll..($500). �]I.ssowner of the pmprny,ar my cmployvs with wages as their axle compensation, 36651055 . 00 And Professions r thcwons Coadc he Concis tar's License Law does not Apply in in Owner of Required Inspections and Property who bis Codc improver tremon, nwho law uch not apply m an owuh of q P mam cra who builds or d thatsuch thenar,antlwho donsuch work himself orthrouge his ownemployees,lding or such improvements tient intendedor mplercd for mx It. however,the building or den of poem is sold within one year of completion,the owner builder Will have Ne hurtle.of proving that he did nm Wild or impmvc for purpose of sale J. I,as owner of the pmpeng am exclusively contracting with licensed contactors to cansuucs the project(Sec.]OCC,Business and Professions Cade:)The Conuactoi s U. Law don not apply m an owner of property who Wilds or improve thereon,and eontnehe for such projects with a eonmmor(s)licensed pursuant w the Convectors rase Law. ❑I am exempt under Seo. ,B At P C for this reason Owner Dam WORKER'S COMPENSATION DECLARATION 1 hereby Mour antler Family of perjury one of Ne following declarations: O 1 have and will maintain a Certificate of Consent to self-insure for Workers Camped. sation,as provided for by Section 3700 of the labor Code,for she Performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurana,as required by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. My Workers oat en.than InAurutce artier and Policy numggqqqqbe,,k��rttttt��_Are: cam n Policy 7S: -,'OC� CERTIFIC TE OF EXEMPTION WORKERS' COMPENSATION INSURANCE (Thu section reed not be completed if the Permit Is for one hundred dollars($100) or leu.) I certify that in the perfammrme of the work for which this permit 0 issued,l shall nm employ any person in any manner so as w become subject m the Workcri Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If,after making this Ceniriena:of Exemption,you should became subject to the Workers Compemetion provisions of the labor Cotle,you must - .J,z ronpwiN comply with such Provisions or Nis permit shall be deemed revoked. ZO CONSTRUCTION LENDING AGENCY p4 1 bemby afrm Nat Nem is a construction lending agency for the Performance of C4 7 the work for which Nis permit is issued(Sec.3097,Civ.C.) W Q (.endcr's Name 0. teem t._Orders �\ V Q au 1 comfr to Nat Nsure that at I have mad application and sat the above information 13 correct !a.0 I ao comply with all city and county ardinanas and tam law.relating to V abovengmneuumian.and M1emby auNorneapmscnuti.es of this city mercer upon the W .hove (W tion agree to save, for inspectionnifApupmsea (We)agate to save,indemnify and keep harmless thew City of Cupertino id City (0.q liabilities.judgmentsOf e cash;and expenses which may in any way eccae against said City C)z APPLICANT UNDORranting S N of thts phourt. ND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURpm _CER ATI , _rf-"0 Re-roofs HAZARDOUS MATERIALS DISCLOSUaElor 'TzDem Type of Roof . Will the applicant or future building Occupant store or handle hazardOas mammal as defined by the Cupertino Municipal Cork,Chapter 9.11,and dtc Health and Safety Cade,section 15531(a' All roofs shall be inspected prior to an roofing material bei. ❑Yn QNa P P Y g g installed. Will the applicant of future building Occupant use equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants at defined by Nr Bay Area Air Cuality Managcmcat all new materials for inspection. DisarlctT ❑Yes I have mail the hazardous materials requlatmcnts under Chapter 6.95 of Out Caliror. ria Head"Safety Code,Semimu 25505.15533 and 15534.1 undersand that if the Wilding _ Jas act cra eady have a whom.that is is my rsponsiEility to notify the oauPaat Of the mquimments winch us� mTfphormissuance Ofa Cenielm- Ocrapmry. Signature of Applicant Dale - 1 � B/ ownvttiorized Agent Dam All roof coverings to be Class"B" or better Jon R. Crase Constr ion, Inc. JOB- 164 Gilman Avenue, quite A SHEET NO. OF CAMPBELL, CA 95008(408) 370-1485 CALCULATED BY DATE FAX (408) 370-0238 CHECKED BY DATE Lic. #611547 SCALE L? 6; 11613 meas spar coo — T.a A RECED El Pnotr i4 2004: I MAR Ap IN AcCORD4,Vc, i CUPER len- plipf., THE Ry OF C D -:UPERTINO BUILDING ............-...........QATj .......... '; D EPARTMIthir SfGNEj This set0�pgal )OS bs ket 10 n1a On .7i req 6 is In the en T, U, SHALL p ng°f is y. NDT o Ci PProv t; to ipit .......... oil Inat Oie n , ............ ........... ....... ........... ............. ............ ................... ............ ........ d F .. ............. ............ .......... ........... ............ ..... .......... ............ ................... ... .... ....... ... ........... ................ ............ ........... ....... .......... ............ j ........... .......... ........... .................. .................................... .... ............... .......... ...... ........... ........... .......... ........... ice ........... ............ .................... ... ........ ............. .......... ------- . ........ . I n "I•; t �I , AI ' e�a , Nil' IN 0 i .'n3. i i r:.:..a-+v..vy. a,r 41 -744 �, rt i YP Pat�� t t JJ11 �y L PIAS t. • _ afpQA�`5rj �S1 N63��MA + 1 � x PI _ ,y*F .. s CCS: • ATY OF CUPERTINO CITY OF PERMIT APPLICATION FORMZ/1 °-3 U (-3c� CUPERTINO APN # 6 � Date: Building Address: L Mailing Address (if different from building address): 111.13 26a� Uur I Owner's Name: Phone eg,r N -/V k✓O </06 370 -rcl$S� Contractor: License #: o� IL eA,45 ��s � ,�,�� 6// sy7 Contact:,c� Phone: tidy SW-ldiIV Cupertino Business License#: Fax: ya t 000�. S'0 uildipg Permit Info: Bldg Elect ❑ Plu b Cc4-,� ascription: T 3PsN/�na + G+wta.- Hanlu- ✓/ N Residential [j] hnllf a AI1a- Commercial ❑ -Sq.Ft. Floor Area: $/Sq.Ft.: 70 . 3 st of Proj ct: bP Occupancy Group: i3 - Y3 ' Type of Construction: Please check this box if the project is a second-story addition: ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of3 �6� Satz-- , cY OF CUPERTINO CUP TYOF o PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTRAE 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 PLUMEING BPSTORMStorm/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 Fumace MECHANICAL BREMFURNOV Relo Fumace> 1 OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREVE RAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL �j BREMRECEPT Rc tl, 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 2 of 3 (m� ",i.�.ITY OF CUPERTINO* CUP TyOF O PERMIT APPLICATION FORM uanti Fee IDFee Descri tion Fee Group BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation S stems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimmin Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary BldgPermit BUILDING BTEMPSVCS Tem Dist Svcs ELECTRICAL BUS LIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL MFEE Elec Permit Issuance ELECTRICAL EE Mechanicals . foot MECHANICAL FEE Mech Permit Issuance MECHANICAL FEE Plumbin Permit Issue PLUMBING G Plumbin Fee s foot PLUMBING HG Address Chane BUILDING • 3of3