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04030015 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTQRAINE0kMATIO.N, '"$ - BUILDINGADDRESS: _ A & H HEATING PERMITNo04030015 - 22386 HAAN DR OWNER'S NAME: PERMITLSUEDATE LARRY JADVAR 770 CHESTNUT NE: SANITARY NO. CONTROL NO. (408) 279-0722 ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 to® 0 0 u00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion FINAL 0 U 1 hereby affirm that 1 am licensed under provision OfChapmr 9(rommcneing p s�«^^ii n� with Section 701X5).1"0ivision Softhe Businevsad Profession Code.and my license is in full farce a ad eIf `2' REPLACE A/C & ADD 220 . CIRCUIT LleenmGl= — Llc." APR e^3 2004 Z;:p Da¢ Contractor ££7W ARCHITECI'SDECLARATIN I understand my plans shall W used as public reenrda Licensed Proficatimll 13UILDING OWNER-BUILDER DECLARATION pr I hereby affirm(SCOW 1 1. cxcmpl from Nc Canlraclarf e:Anyc Law for the O following won. PermitI7031.3, t,Business and Pru@ssion Cade:Any city or county $�a which requires a permit m Construct,IN,alter.W prove,h Permit t ri repair any o mete FZ< prions in lensed e.also pursuant to Vm islons of forOn sucContractor's filemLaw Comment mm (that he commesccenoJPurstion7 h)ofDislmuofofOcBuacwrinicenafassi Chapter Sq.Ft. Floor Area Valuation �F$ (commencing xempt Section and WasionrO alleged Business AnyonaCMe)or ��.. Nat he u exempt 0mrtfrom and the bun for Ne alleged eaemptian.Any violation of Schon 7031.5 by arty applicant for a permit subjects the applicant to a civil penally of 3 MWaAkiZerO0 Occupancy Type .at more Nan Bvs hundred dollars($500). L es owner ofthe pmpusy,army anploye s with wages az their sole mmpenuuan, will do On work,and dresmsnum a rmthmanded car offered fors 1,(SCe.7W,Business and Prefeasion Coals:The Contracmrs License law dens nor apply to an numar of Required Inspections property who WBdsor improvesthereon.and whodecseachworkhimselfor through his Own employers,provided duo ash improvements are not intended or offered for sale.if, however.the Wilding or improvement is sold within one year of completion,the owner- builder will have IN burden of proving Baltic did not Wild or improve for purpose of sale.). ❑1,Its;owner of the Property.am uCluiwly contracting with licensed comm cmn to Conuuct the project(Sec.70aa.Business and Profusion Code:)The Contractors Li. cone law does not apply to an owner of property who Wilda or improves thereon,and, who contracts for such projects with a cMVlewr(s)licensed purmlanl in dm Contractoes License law. 1 am umaps under Sec. .B&P C far this mazan wnu Dam WORKERS COMPENSATION DECLARATION 1 hereby affirm under peruRy,of perjury one of the fallowing declaradmac I have and will maintain a Cenifonu of Consent m self-inure fn WmIng'sCompen- ntion,u provided fm by Section 3700 of the labor Code.for the performance of the work for which this permit is issued. CTT$Avc and will maintain Wartmes Compensation Insurance,u required by Section 3100.(she law,Code.fm the performance of On work for which this permit is issued. My Workcri Cnon mmpeadInsure.Cartier end Policy number am: Carrier, 4 l07 V'D 7 Policy No.: IRU It �NS CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Qhu section reed not W completed if the permit is for one hundred dollars(SIM) or less.) I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner an az to bearers,subject to the Workers Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should become subject to the Worker's Compcnation provision of 1M kalxm Code.you most �7, rortanO comply with such provision or this permit shallW demand revoked. z O CONSTRUCTION LENDING AGENCY [.. 1 hereby.Mere that then its.oressused.n lending apeney far Ne penformaNn of IL'9 IN work fur which this permit is iuned(Sec.3097,Civ.C.) Tk1 ionones Namc D. Lender's Addasa V 1 certify that 1 have mad this application and sum thn IN shove information is D. c.nccL I agree I.comply with all city and county ordinances and sum laws misting w building convection,and hereby authodm mpreamatiws of Nis city to enter upon thc al,eve-mentioned property far inspection purposes LL (We)agree I.save,indemnify and imep harmless Bre City of Catania.against qj Iiabilines,judgments,cuts and expenses which may in any way accrue against mid City V Z in consegnence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date SOUIt�E REGULA�ONS. �M / 75— 2-04 Re-roofs Signuure of ApplicanVContracto, Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding occupant uom or handle hvardau material az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety c,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed. 0y. QrIr Will the. rant or future building t use equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove rep d^yup^^ Its t havardnus air contaminants az dc0nc0 by the Bay Area Air Quality Management all new materials for inspection. ria? (:1 Yes (� I have mad the bvardnus materials requirements under Chapmr 6.95 of the Caltfor. Hcolth&SafctyC.dc.Smv 25505.n533ud2553a.lundcrsaerrdNuifthcWilding immcnts which mug be mel w' tion fa Certificate of Occapancy. Signature of Applicant Date ner thorircdegcm D,� All roof coverings to be Class"B"or better Community Development ''' 10300 Torre Avenue wJ Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 UPEI�TINO Building De artment JOB ADDRESS ZZf E{bfl�t D Z ?RRMTT#OL' OWNER'S NAME: I. TOVAk-- P 1^9 73Z Z4' GENERAL CONTRACTOR: FAX # I am not using any subcontractorN 3— Z—eLfC � Date Please check applicable subcontractors and complete the followinginformation 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 Rock Tile Owner/Contractor Si ature Date (�� CITY OF CUPERTINO CITY°F' PERMIT APPLICATION FORM CUPEkTINO Ift qFPN# 32–&-, ( 3 Date: BZw z 'ff in Act res : Mailing Address (if different from building address): I� Owner's Name: Phone '�go� Z^ G Contracto . F l License#: L(72- Contact: Phone: Log z19d7Z-Z. Cupertino Business License#: Fax: 4o13 2? 011 Building Permit Info: Bldg ❑ E ct I( Plu Mec Job Description: Z� (L Residential – W 2Z0V6)LT — Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: pip Occupancy Group Type of Construction: Please check this b ect is a second-story addition: ❑ Quantity Fee ID FeeVescri tion 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 IM 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 <= IOOOA 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 Iof3 c Z�� A CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM \ CUPEkj1NO Quantity Fee ID Fee Descri tion Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspec Overtime BUILDING BPBACKFLOW Atmos beric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interce for 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 Dis osal 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 BgEMAgHAN 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 BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPp Rem Non-Res A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/A aratus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Hea ing MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL 2 of 3 EC CITY OF CUPERTINO cuP TYOF PERMIT APPLICATION FORM r Quanti Fee ID Fee Descri tion' Fee Group 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 Ins ection BUILDING BSWIM Swinuning 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 • 3 of 3