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04010128CITY OF CUPERTINO ^ '� '� ° - "�' ' �"' "" "'' so `� a', BUILDING DIVISION PERCONTR AA60,M 2INT®RM N . BUILDING ADDRESS: cid-) PnRT MARTHA MOWRER PERMIT "04010128 OWNER'S NAME: PERMITISS11UEDATE NE: SANITARY NO. CONTROL NO. ARCHITECrIENGINEER: BUILDING PERMITINPO BLDG ELECT PLUMB MECH C LICENSED CON RAC OR'S DECLARATION Job Description I hereby affirm that 1 am under provisions of Chapter 9 (mmmcnse is Nc Ousincssand Professions Codc,endmyliccnscis with Section of the a i ndeffecDivisionJof m ren roma effect. BATHROOM REMODEL s License Class Conp Is Datc Contractor ARCHITECTS DECLARATION I understand my plans shall he used as public records . U Licensed Professional g OWNER -BUILDER DECLARATION y 1 hereby affirm that I am exempt Been the Contractor's License Law for the O following reason. (Section 71131.5, Business and Professions Coda: Any city or county �+ which requires a Permit to construct, alma improve, demolish, or repair any structure y poor o its issuance, also requires the applicant Branch permit to flea signed statement Comma., Llconse Law(chm., 9 Sq. Ft. Floor Area Valuation that he is licensed inrsuaot hs thepmvisinnurrtnc s n (commencing with Section 7") of Division 3 or the Business and Professions Code)or 2 BOB he is exempt therefrum and the basis for the alleged exemption. Any violation of 354GNJAH QrO0 Occupancy Type Section lW 1.5 by any applicant for a permit subjects site applicant to a civil penalty of not more than five hundred dollars (S500). ❑ I, as owner of the property, or my employees with wages U Neir sole compensation, Required Inspections will do One work. and the structure is not intended or ofrered for sale (Sec. 7W, Bunn and Pmfccesmu Code: The Continence, Lice. Law dao not apply to an awns,, of p;openy who builds or improm thercou.so d who does uch work himselfor through his own employees, provided that such improvements mc not intendW orortered for sale. It. I—G� B lt�111 ik A LE 0) however, the building or improvement is sold within one year of comPIC6011. Ne owner- IJJ�� �J v builder will have the burden of proving that he did not Wild or improve for purpose of sale.). JUN 2 /. 2004 J 1. as Owner of the Property, am eaeluaively contracting with licensed centimeters to construct Bepmjee (Sec. lOaa, Business and pmfossions Code) The Conn acwr's Li. ' scnx Law docs not apply to an owner of property who builds or improves themon, and who ch Pru sea, ph acomncIm(Q licensed pursuant to Nc Contractor. n A Lic Law. �. BUILDING �YY��®it�� B&P forQ Niyrt amm ❑ rept r Date O Date WORKER'SCOn PENSATIOND N I hereby atria under Penalty of perjury one of BOTOI declarations: 1 have and will maintain a CCrtlficate of Consent to self-insem for Worko'sCompen- ion. as provided for by Section 37M of the Iar Code, for e icof .... of Ne salWN workfor which Nispermit isissucQ I have and will maintain Workers Compensation Insurance, as required by Section 3]00 of Ne labor Codc, for the performance of the work for which this permit is issued. My Warkcts Comp rection Insurance carrier and Policy number are: Cartier, Policy No, CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE rrbn section need not W complewd if the Permit is roronc hundmd dollars or leas) 1 certify that in the pmf rrma es, r Ne work r which this lc,mil is issued. ) shall nm employ mceubjcn to the Wahcrs'Compcnvtion e1.mployma oUY C2_1ry Celi(ornia.6' APPlicanL ice � an. you old Eacptish u • "OTIC PPLICANT: IL after making this Cenifcam of m I Ice m the Worker's Compcuc ion Provisions of the Lathe, Code, you mus Z forthwith comply with such pmviume, or this permit shall be deemed revoked. Q y CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of 7s Ne work for which Nis permit is issued (Sec. 3091, Civ. C.) lenders Name •. Lender's Address Q 1 certify Nat I have read this application and suite that the above Mrormati ul is F" correct 1 agree to comply with all city and county ordinances and stand laws relating to uarive representatives or this city to Inter upon the U building construction, and herebyaN U ahave-mentioned properly for inspection puHwaes 1 (We) a save, indemnify and keep harmless the City of Cupcnino against N liabilities,' gmcnta, s n pen"my ecmc against said Cityin /zAPP eon uenec of Ne 6 an f Nis CANT UN STA NH ALL ONP INT Issued by: Da[r!W2�4' OU TIORe-roofsppin to,Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Neapplicanton future building occupantsore or handle harandMiSmaterial defined by the Cupeninn Municipal Code. Chapter 9.11, and the Health and Safely We, &,Mot25532(.)? All roofs shall be inspected prior to any roofing material being. installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant orm�ubuilding Occupant use cyuipmcntordevice.which it haeardous air contaminants as dclincd by the Bay Arca Air Quality Management all new materials for inspection. - isvia? ❑Y.0 Ihavc road" N sem rials¢yuiremcnts under Chap¢r 6.'JS oftM Califon- uHIaINkSaf Wc, oat 25 5.2553JZn1Uu understand Naif Nc building Jas c.11 have a i e resprnsibillty m notify the occupant of Nchave e i e res Wnsibility m nntily the occuipao of Ne rt „ m cements n¢n0 he et ouromanceeracemfcmbrOmap ey. Signature of Applicant Date Ay All roof coverings to be Class "B" or better owns,, r aaNan,.ea ¢sem Da a M/,i=TF1/-\ MOWER, ��o�, 255-lylo -0 \r r --c-> T 4e a Dtz- CI.LP e IZ-T-Irry o CA Z � D RI UR " 5CA LE %Z'= I' / CXI sT� NC, r6/1,7r -k ROOM lfi%00".� = 7ALLs -FO rye I��VED YPl A 09D HEw bf3�IG To i3E Ian LA-raP k pt11 th ob at fu dFvA zEMiL withou'' i the building Dept.! Ci The stamping of t IR' SHALL NOT be bi it approval of the viols' of any City ordinonc L-p2DPOSCjD rJ I o� 6' ro �Zo 000�o NEW 2X14'- � n'0, • O n, �T P �y F _ STp . & D " -'r a T3 117' LINeN CLDSET WA LL To Toi�ET 26L.00P"`ED o- 3y - n of dv uravmioT' 01 or Stet Law. �1 LE7� F=L�Xj NEW t=,q tJ _ F0 IZ=' O fF `/S" vaivrs�c i EXiSTINC� wA(y To �EMAiN lo4"- 7-0 r3j:r ACCM T-tNEL r�T A r rJ T=ine Mode" Y i Z t Z-4- 1 N � m i- r SZ r --c-> T 4e a Dtz- CI.LP e IZ-T-Irry o CA Z � D RI UR " 5CA LE %Z'= I' / CXI sT� NC, r6/1,7r -k ROOM lfi%00".� = 7ALLs -FO rye I��VED YPl A 09D HEw bf3�IG To i3E Ian LA-raP k pt11 th ob at fu dFvA zEMiL withou'' i the building Dept.! Ci The stamping of t IR' SHALL NOT be bi it approval of the viols' of any City ordinonc L-p2DPOSCjD rJ I o� 6' ro �Zo 000�o NEW 2X14'- � n'0, • O n, �T P �y F _ STp . & D " -'r a T3 117' LINeN CLDSET WA LL To Toi�ET 26L.00P"`ED o- 3y - n of dv uravmioT' 01 or Stet Law. �1 LE7� F=L�Xj NEW t=,q tJ _ F0 IZ=' O fF `/S" vaivrs�c i EXiSTINC� wA(y To �EMAiN lo4"- 7-0 r3j:r ACCM T-tNEL r�T A r rJ T=ine Mode" Y i Z t Z-4- '+ clh-I- 1 N � m i- SZ � m '+ clh-I- OPER -BUILDER VERIFICAT*N 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A. All the work authorized by this permit B. • = A portion of the work C. None of the work If B or C is checked, complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or ® portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. • Type of work to be I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner -Builder Informations' / Property Owners Signatu 6 Date; I 2 `� Job Address: �Z �o�T 9AA::�F 2 Permit # I AM changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. • CITY OF CUPEkTINO Dear Property Owner: City of Cupertino Building Department 10300 Torre Avenue Phone: (408) 777-327 An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner -builder you are the responsible party of record on such a permit Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may Drotect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding, federal social security taxes, workers' compensation insurance, disability insurance costs, and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are 40 especially serious with respect to workers' compensation insurance. For more specific information about your obligations under federal law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your obligations under state law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner -builder building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in -your community or at 1020 N Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification forst so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino • • Printed an Recycled Paper (c� CITY OF CUPERTINO OCITY OF CUPERTINCID PERMIT APPLICATION FORM �(,D�o�zS QPKPN # / In r7 4v Date: Building Ad ress:� Z )eT o�AK�2 �+2 �, u-��E J Al 9S61 Owner's Name: MAI? -THA Mow 1✓r2 Phone o ZSS-1 N Contractor: owt,JE r, •, License #: E I Contact: K I>6 e IARA Co ertino Business License#: Building Permit Info: Bldg 4 Elect Plumb Mech Job Description: Residential p =L Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: 'Cost of Project: Occupancy Group: Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M 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 Flee 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 LJ b'- z�33/ 1 of 3 C S OF CUPERTINO IRCITY OF CUPERTINCO PERMIT APPLICATION FORM 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 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 BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER WaterHeater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit-> 10,000 cfm MECHANICAL BREILUUiAN 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 2of3 2EE, CITY OF CUPF&JINO WITY OF CUPERTIN(* PERMIT APPLICATION FORM u i Fee ID Fee Description Fee Group 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 Sips, 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 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BMISCELL Building Misc Fees BUILDING 3 of 3 1 J 7 J • • CITY OF CUPEaTwo BUILDING DIVISION PERMIT X0NTRAG I R i FQRMATIO,N ,4 BUILDING ADDRESS: MARTHA MOWRER PERMIT '%4010128 ' ER'SNAME: MARTHA MQWRFR PERMIT 13S.EDATE 04 PRUNE: SANITARY N0. ONTROL NO, C ARCH ECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTORS DECLARATION Job Description under Provisions of Chapter 9 (commencing I I I a dunder affirm thn I am - P of Division3of the Businaa and Professions Code. and mylicenx is ionhereby70 Bi With Section or the and iamBmmas erreet BATHROOM REMODEL {{Ppee f1�� Lica xClaz.s g} a aaIalU�AL{L�© Dale Contractor Conte aYs refill '�tlX7 [[CCS ARCHITECTS DECLARATION 1 understand my plans shall W card as public records �� 2004 Licensed Professional OWNER-BUILDER DECLARATION theLaw for the 1 hereby affirm I am cacmpt from me Contractor's tens, L (Sian to ]1131.5. Business and o :Any err county following momma on Code: easo ����®�� which reltims a Permit to Consumer, alter. improve, demolkch, orrepair any strucmm Prior rt its issuance. also amu ms the applicant for such permit m Glc a.signed statement for he islictowd puesuaatto the provisions of the Contractor's Licensor Law (Chapter 9 Sq. FL Floor Area Valuation (commencing with Section ]000) of Division 3 or to Business and Profcasions Codc) or that he fa coni sorelaom and the basis for the alleged caemptlon. Any violation of 3 5 UI'�18f8JC10 0 Occupancy P Y Type Section 9031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of not more than five hundred dollar, n50Q. ❑ I, as owner of the pmpeny, or my employees with wages as their sale compensation, Required Inspections will do Ne work, and the awnum is not intended or offered for sale (Sec. )Odd, Business and Professions Cade: The Contractor's License Law dors not apply to an ownerof property who builds at improves thereon, and who does such work himself or through his own cmplo,is. provided that such imponnementa arc not intended or orhared for sale. IL however. the building or improvement is said within ono year of completion, the owner. builder will have the burden of proving that he did not Wild or improve for purpose of sale.). ❑ I, as owner of the p.,ny, am eulusively contracting with licensed convenors ro construct the project (Sec. 7t , Business and Professions Code) Tho Contractor's Li - comefawdoesnotapplytoen r of property who Wilds or improves Merton.and. 'sh wore co h pm' s contranor(s) lircnced puranant to the Contractor's C eco. ❑ am esemDt r . B & P far shi rcmon Dae WORKER'S CO ENSATIOND N I hereby affirm underpenalty of Pejury orc.fine nll.wiog declartimun ❑ [haw and will maintain a CcrtiGcam of Consent to aelf-imme for WartrrhComPcn- xlian, az provided for by Section 37W of to LaWr Code. for the Far..... of the work for which this permit is issucd. ' ❑ 1 have and will maintain Wert Compensation Imuran¢, az testifid by Section 3900 of Ne labor Code. for the perfarmance of the .,it for which this permit is ial My Worker's Compensation Insurance Cartier and Policy number arc: Carrier: Policy No.: ' CERTIFICATE OF EXEMMON FROM WORKERS' COMPENSATION INSURANCE rimuxetion need not M1ecamPlaled fifth permit is raronehundretl dollaa(gIW) of less.) I certify that in the performance r the work fa which Inis pefmit is barred, 1 shall not ampleyany pc yma c au c lime a jeer to the Workers' Compensation taws 1 Cali ori UU ApPlicanfa�. NQiIC PPLICANT: If, after making this Ceni0cate of Esc peon, you should .Coro a jcct m the Worker's C.mpcmation provisions of Ne Labor Codc, you must forthwith comply with such provision or this Permit shall o deemed rooked. CONSTRUCTION LENDING AGENCY I hcmby affirm that more is a construction lending agency for the Performance of the work for which this permit is issucd (Sec. 3097, Civ. C.) Undoes Name • Lender's Address I certify that I have read this application and state that the above information is - conecf I agree to comply with all city and county ordinances and state laws relating to Wilding construction, and hereby authoma mpmsentatives of this City to carte upon da ahovnmentioned proPcrty for inspcnion purposes. (Wc) a save, indemnify and keep harmless the City of Cupertino against liabilities,' gments. s n may inany way, come against said City in con =nee of areg an' RmitAPP1 RK,Whl=h CANT UN STA ILL COMPLY WITH ALL ON-P INT Issued by: Datf U 0 Re-roofs Type of Roof aturc ApPlicanUC.nlnator Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future Wilding occupant some or handle hazardous material az defined by me Cupenim Municipal Cock, Chapter 9.12, and the Health and Safety ' de, Section 25532(a)? ❑Yes XV. All roofs shall be inspected prior to any roofing material being. installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or furore building occupant use cyuipment or devices which emhaaardous air contaminants az detinN by the Bay Area Air Quality Management all new materials for inspection. Diatit ricl? ❑Yes. 'u hel'k, 11 area tpralloopiacmcnH under Chapter6.15.f the Califon Calthdc.Spl. um 25915.255]] anJ25534.1 a dcrsundthmiftM building t a tit .0 's�mspomihilay m notify tM b:c loan of d , tHI mmestln et narttiax....r.CC_Bc¢orthan =r Signature of Applicant Date - All roof coverings to be Class "B" or better ee rarmaripedasent Da