04090052 CITY OF CUPERTINO F "' r " ^ "7 ''
MI
BUILDING DIVISION PERT CONTRACCQR INTORMA.TIQN :
BUILDINGADDRLSS: l \ fl PERMITNOO40900 SZ
N N Q
OWNERS NAME: PERMIT ISSUE DATE
RODNEY BEAVERS
ryE; SANITARY No. CONTROL NO.
IT IT
D BUILDING PERMIT INFO
ARCIi1gECr/ENGINEER: BLDG ELECT PLUMB MECH
YOp LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Section TME of Division 3 of Inc Business and Pro(esshms Codd.and my license is
infull mneand effect. SERVICE UPGRADE
,n? License Class Lic.a
�Ca Dam Contractor 200 AMPS
< A
y planss shall halLTSDECLAR TION
l undcl W CONTRACTOR AZAR ELECTRIC PD BL 9/09/04
rsund m used as N' mNs
,yU
3�� LiccnuJ Pmfcssionvl
OWNER-BUILDER DECLARATION
K OO 1 hereby.(firm 1 am exempt from the Contras Co :Any c Law for the
0O following mason.Permit
(Section 7 cost O.sindsaor. and Preimprove.
de n li h.or Any tiny or county
$ which myuima a pdnnit ed cnnss the eller,impmw.demolish,or repair any structureToon
prior so its issrosed pursuant
also mgmms the applicant far such permit to file a signed statement
da
that he to the eBusinmrandPrarlaw(emperor Sq. FL Floor Area Valuation
rc�ct (Commencing exempt
therefrom
and the
Division 3 the al Business and Professions Code)tion or
Of
Nat Theisexempt tMrt(mm and Ins baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant(or a permit subjects the applicant to a civil penalty of APN Number Occupancy�I e
mol mom Nm
an eve hundred do]]..(E5IXT. P y ']p
❑La sownerof the property, re is employees wish wages r Their Solt 0144.8 Business will do the work,and The structure Cmu is not intended or offered wdo Torula(Sec.70an Business
and Pmfcssions Code:The Cnnnncmri License law dam nut apply m.n owner or Required Inspections
progeny who builds provided
that such impr and was ar essucn work himself edthmugn
his
vin employees,provided that such imprnwmenu are not intended m peered the oformic.r.
builder Nebuil The orimprovementis sold within one year of completion.the owner
builder will haw the burden of proving Nat he did not Wild or improve for puryau of
sale.].
.1.as owner of Ne property,am exclusively contracting with licensed convectors to
' consaucr the project Site.71H4.Business add Professions Code:)The Cmdracmr's Li
me Law docs not apply Ir an owner of progeny who build&or improws Bureau.and
won contracts for such projects with a eon recmr(s)licensed pursuant In the Conuxetors
License law.
❑1 oro esemp smile Sec. .0&P C for this reason
.^. Datil
,/ Wp COMPENSATION DECLARATION
1 hereby eRnn under penally of perjury one of the fnllUwv&d clantinns:
]have and will maintain a Cent Beam of Consent to self-insure for Workers Compere
cation,m provided for by Section 3700 of the labor Code,for the performance of be
work for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance,as Imputed by Section
37W of the labor Com,for the performance of Ne work for which this permit is issued.
My Workers Compensation Insurance carrier and Polity number ate:
Cartier: Poliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W comp drool if the permil is for one hundred dollars D100)
or less.
1 certify that in the performance of the work for which this permit is imam,I shall not
employ any person in any manner sr a to become subject o the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.IL after making this CatlBCale of Eaem prion,you shoe to
become subject to the Worker's Compensation provisions of the Labor Cote,you must
.JO fonhwith Comply with such jewiton&or this pem
permit hot]W deemed revoked.
'z CONSTRUCT ION LENDING AGENCY
P4 1 hereby affirm that Nem i2rduruction tenth ng agency for the performance of
04> the work fur which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Dz lender's Address
U C) I certify Nat I have read On apuicmion and slate that the show,information is
Is, Cmmm.Iagree m comply with all city and county ordinances and sum laws relating to
(]U building convection,and hereby awhorin repetenmtives of this city m Hoer upon the
above-mentioned property for inspection purposes
(We)agree In save,indemnify and keep harmless the City of Cupertino against
F" V) Iiml fides,judgments,costs and expenses which may in any way acme against said City
U in consequenm:of the granting of this perm t.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE A ONS.
Re-roofs
ign r of APPltcxnV tree �— Dem
RDOUS MATERIALS DISCLOSURE Type of Roof
Wilithea plicamorfumre building oceupantsoud orhandle havafduusmaterial
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
COU.,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑YsNu
Will the applicant or future building OCCUpanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmil havardous air contaminants ex defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes J No
I have mad the hsaamousmamrtals requiremcnu under Chapmr6.95 of the Califor-
nisHealth&Safety Code,Saxons 25505,25533 and 25534.1 modOmind thmifthe Wilding
does not currently haw a Imam.Nm it is my mmominility m unuly Inc mzupanl of Ne
regaimmenlx whieh lot tnissuan face fee arnxeppah', Signature of Applicant Date
-' - o_
ovine� mnadzed, ' �, � ,m All roof coverings to be Class"B" or better
CITY OF CUPERTINO
I* 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rug: Sub: Blk: Lot:
APN . . . . . . . . : 35931013.00
DATE ISSUED. . . . . . . : 09/10/2004
RECEIPT #. . . . . . . . . : 26998
REFERENCE ID # . . . : 04090052
SITE ADDRESS . . . . . : 1135 KENTWOOD AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RODNEY BEAVERS
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5807
RECEIVED FROM . . . . : RODNEY BEAVERS
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
___ __ _ _____ __________ __________ __________
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 .86 0. 00
BELEC200 METERS 1.00 29.43 0.00 29.43 0.00
BPERMFEE VALUATION 2, 800.00 83 .16 0.00 83 .16 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0 .00 38.37 0. 00
BSEISMICRE VALUATION 2, 800.00 0.50 0.00 0.50 0.00
__________ __________ __________ ----------
TOTAL PERMIT 186.32 0.00 186.32 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ __________---_____
OTHER 186.32 VISA
TOTAL RECEIPT 186.32
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL
• r�.GGa--
CITY OF CUPERTINO
CUPI YO
EI�TINO PERMIT APPLICATION FORM
s
APN# / r Date: /
O-O
Buildin ddress://, s ,L / Mailing Address (if different from build address):
�/�
ell/w000 . r71- o (2,-
Owner's
Owner's NaPhone #:
�v/�o�s1e at ve rs
Contractor License #: r�zee,�f-,�oi0000/ossl
�z /-F�ec)6-;C
Confa Phone:ve8 58-9`3'6y Cupertino Business License#:
rit Inyrs a S Fax:
Building ermfo:
Bldte, Elect Plumb ❑ Mech ❑
JobDescription:
Residential ® Lj raCommercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
i
CostofProject: Occupancy Group
Type of Construction: Please check thig box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER] Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOTLER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOTLER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUTLDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elee 600V > j000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
6T1 OF PERMIT APPLICATION FORM
CUPERTINO
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
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 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 clip MECHANICAL
BREMAIRHAN 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 Fumace > 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
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CITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Tbeatrical Li itin 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
BS WIM 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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