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0509008812 �C z - CITY OF CUPEWFINO " ' " ?'.? BUILDING DIVISION PERMIT �aCONTRAC�TOR4INFORMATION , BUILDING ADDRESS: PERMIT NO. 05090088 20916 HOMESTEAD RD # C OWNER'S NAME: PERMIT ISSUE DATE CHECH INTO CASH ____02Z13/2005 NE: SANITARY NO. CONTROL NO, ARCHITEC'ENGINEER: BUILDING PERMIT INFO - BLDG ELECT PLUMB - MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description Chapter 9 (ceme. 1 Mich, alto. Nat I am licensed under provisions of Chammg P with Section 70(lo) of Division 3 of the Business and Professions Code. and my license is infull mrceand effmL �� p ADD 6 RECEPTS./1 SWITCH uttnre Cl f_ Contractor Date f—contracwr CONTRACTOR: ' ADAL ELECTR•IQ & CONSTRUCTION INC. RATION I understand my plansshallshall used as public records ll FBe� Licensed Professional OWNER -BUILDER DECLARATION I hcmhy 1 from the Contramrs License Lew for the / (1(t G'T P / alirrn that am exempt following mason. (Section 703 1.5, Business and Pmfessinns Calc: Any city or county which requires a permit in conswc, almq improve, demolish, or .pair any structure prior.. its issuance. also requires the applicant for such Permit o file a signed statement that he is licensed pursuant o the pmvisirnunf de Cammnur's License Uw(Chip., v Sq. Ft. Floor AreaI �ry� Valuati$1i 000 M (commencing with Section 700(1)of Division 3 of the Business and Proressimns Cafe) or 'I r' `C3/ that he u exempt boatman and de basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 1031.5 by any applicant for a pewit subjects he applicnno a civil penalty of not mom dao Bw hundred dollars ($500). 32609052.00 ❑ I,asowner of the propcny, or my employees wins wags asthcir sole eompensstimn, e Required Inspections will do the work, and dac structure is notimmndedmrmifered fertile (Sec. 7W, Business and Professimns Code: The Conuaelm', License Law does not apply to so net of 9 P property who buildaorimprmves thereon, and whudas such work himself or through his owncmployees, provided mat such improvements sure not intended mofferod fmsak. if, however, the building or improvement is sold within one year of completion, the owner - builder will ban the burden of proving that k did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting wit licensed contractors to conswct the project (Sec. ]014. Business and Prafeuions Code:) The Contractor's Li. cense Ladocs not apply to n owner of pmperiy who builds or improve thereon, and. nsw who contracts for such projects with a contractor(s) licensed pursuant to the Contractors List. La W. ❑ I am exempt under Sec. . B k P C for this mason Owner Dam WORKER'S COMPENSATION DECLARATION 1 hereby amrrn under penalty Of perjury nee of the following declarations: I have and will maintain a Certificate of Consent to self -insure for Workers Compen- sation, as provided for by Section 3900 of the Labor Code. for me performance of the work for which this permit is issued. ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for the ptrformnce of the work for which dais permit is issued. My Worker's Compnwtirm Insurance carrier rad Policy numberse: Carrier. Policy No.: /;I'? �q s tf CERTIFICATE OF MEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not W completed if the permit is formic hundred dollars ($BK)) or kss) 1 cu4fy that in the performance of the work for which his permit is issued. I shall not employ any person in any mourner so as to become subject to he Wofken'Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: IL after making his Certificate of Exemption, you should become subject to the Workers Compensadon previsions of the Labor Coac, you must ' forhwih comply with such provisions or this Permit shut be deemed .voted. CONSTRUCTION LENDING AGENCY I hereby that there iso 3 lending agency Ins he performance of cErm ed (Sec. ' the work for which this pewit is issued (Sec. 3091, Civ. CJ Lenders , ' lender'ress ha's Add. Lcm I renify that I have read this applicai tar and sum that the above information is ' cormcL 1 agree to comply with all city and county ordinances and sum laws relating to building convection, and hereby authorim nepresenutins of this city to nmr upon the above-memiuned property for inspection purposes. (We) .,me h saw, indemnify rad keep harmless the City of Cupcnino against j liabilities. Julugmcn¢cos and eaperues which they in any way accrue against said Ciry in consequenec of the tin this ' APPLICANT U.ST S A COMPLY WI ALL NON -POINT Issued by: Date1�—�.7 SOURCE REGU ON Re -roofs - Cyt Signawreo Date ppmanVComramm HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will he applicant ur fuum building occupant same m handl. ha,,anous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Cork. ❑tYoen 25532(a)? Jm All roofs shall be inspected prior to any roofing material beingInstalled. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant use equipment or devices which mit hazardous air contaminants as derined by he Bay Ama Air Quality Management all new materials for inspection. Disarm' El Yea I have maul the ha sudous materials requirements under Chapter 6.95 of the Califor. nia Heald&SafcyC iso 15, 25533 and 25539.1 undersand that ifhc Wilding docs not cumnmly w san"osponsibilily h nmily the axupnt of the requircmeoil m noissun¢o�CC� Fla. mrgtopncy. Signature of Applicant Date // / o All roof coverings to be Class "B" or better Owner rnmmriysdagem m m CITY OF �UPERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: `� //D� S) _�� 2 �y /-� PERMIT # br D `l 0 0 d OWNER'S NAME: Cke c k I h Cop S PHONE # GENERAL CONTRACTOR: 4 0 qL OZ FAX # / t — 2 -> 2 I am not using any subcontractors:�r'/� `jam !,/ - l 6 s- Signature Date Please check applicable subcontractors and complete the followine information: e 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 Signature Date U • �6 y�� w G'� ! a T s•a F=,�� t!EtIF;I��JJJf Ltdf!l�tt M60 4L096 WD'ou4yadno alinS peoa PealsawOH 9 L60Z 4seo O)ul 40040 a,wwnwvw wwmm.w & s c = fiE wremJw�J RECEiVEED) SEP 12 2005 revue U - 'I, [�[lry A �6 m O IN ACCORD pmo eke �U^F; pry0 CODES OND GT RNU OY OR �A RDINANCES 3IGNe) f� This set of plans and a, '01 ton the job at all ti Specification M ful to hake and ' QST n same any changes it un �'ihout or alteration, ne building De: Wren Permission the camping of thiscliy Of cuperiaofrons SHALL NOT be held plan and specification, approval of the violation of nrrr or to Y City Ordma any p,.o�be ar V sn nce oc spte 1"' "W0174 sm - 1 of 1 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 32609052.00 DATE ISSUED.......: 09/13/2005 RECEIPT #.........: 31174 REFERENCE ID # ...: 05090088 SITE ADDRESS ...... SUBDIVISION ....... CITY .............: IMPACT AREA ...... 20916 HOMESTEAD RD # C OWNER ............: CHECH INTO CASH ADDRESS ..........: 20916 HOMESTEAD RD # C CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: A DALEBOUT CONTRACTOR .......: LIC # COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... , TELEPHONE ........: OPERATOR: conniew COPY # : 3 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL BPERMFEE , VALUATION 1,000.00 83.16 0.00 83.16 0.00 BENERGY PERMIT FEE 1.00 34.86 0.00 34.86 0.00 BREMRECEPT NO. OUTLETS 7.00 8.40 0.00 8.40 0.00 EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 BSEISMICOM VALUATION 1,000.00 0.63 0.00 0.63 0.00 BUSLIC FLAT RATE 1.00 102.00 0.00 102.00 0.00 TOTAL PERMIT ---------- ---------- 267.42 0.00 ---------- 267.42 ---------- 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ OTHER 267.42 ------------------ AMEX TOTAL RECEIPT 267.42 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- 304 ROUGH ELECTRICAL -------- 501 ---_-----___________-------- FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL . is F r L R CITY of CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM N# 2 GDate: i S ) 9-l2 -0.�_ Building Address:/ �� ¢ti } �� Mailing Address (if different from building address): 2b /� �7o N c s a Y S'cc ( +e q Owner's N e: ntTeLO: t iw4u �� C lo' Phone #: y2 3 9`7 2 300 Contract Contract EZ"c)�- c �C S �&Z, License #: S S 2 (�U Contact: / Phone:gl 2S_-ySs �ai Fax: s6 / qL 3 Cupertino Business License#: Building Permit Info: aid _ a --.f 1 S cu i c Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential ❑ Commercial LTJ Sq.Ft. Floor Area: q.Ft.: &00 Cost of ProjecV!n t�(' / L V 2 Occupancy Group: Type of Constru ion: Qec �kcCQ Please check this box if the project is a second -story addition: ❑ ro'ect Size: Standard ❑ Large ❑ Ma or ❑ BBOILER5 Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 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 / 7� 1 of 3 z 67. /0Z a CITY OF CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2 of 3 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 BOVERMIE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum . PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pbl 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- PLUMMING 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 HeiterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAiRfiAN A/C Units <= 10,000 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY 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 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 2 of 3 "l CITY of CUPERTINO CITY OF CUPERTINO 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 Seb 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 EPERMTTFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Cbange BUILDING 3of3 •