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03090078 CITY OF CUPERTINO „a "-: BUILDING DIVISION PEMI RT • �C0 TRXTnR INF(JRMA BUILDING ADDRESS: PERMIT NO0 3 0 9 0 0 7 8 OWNER'S NAME: PERMIT ISSUE DATE HRTC;TQT, 7AM7,q T AND ANN R.11 /1 o/qtnn NE: SANITARY N0. CONTROL NO. ARCHITECrIENGINEER: BUILDING PERMIT INFO BLDG ELECr PLUMB MECH I CJ 0 100 LICENSED CONTRACT'OR'S DECLARATION Job Description ,£0 I hereby affirm that I am licensed under previsions or Chapter 9(commencing P with Section'IOfg))or Division 3 of I,Business andPrac tens COJc,and mylicenseis ± � in nnrn can ernes. g X33 REMODEL (RAISE SOFFIT REPLACE 2 DRS) Z Liccnx0 TSD I + D'/°/J„']' ea^tree CONTRACTOR: CLIFF W COUEY CONST. v� ARCHITECTS DECLA T i-I IaU demand my plans shell he used as puhli nrds tau. Licensed Pmfcssianel / . h 5 v OWNER-BUILDER DECLARATION 01 I hereby affirm that I R-exempt from thee Contractor's License Low for the —'•/r 00 following reason.(Section 703 I.S.Business and Pmressiuns Code:Any city or county Q 5 m which requires a Permit to construct,alter,improve,demolish,or repair any structure -ir prior to its issuance.also requires the applicant far such Permit o file a signed onismem 6 lbe,he is licensed pummnlm the pmvisimmI the Conlmehirs Liccnx law(Chap.,, Sq.Ft. Floor Area Valuat 700 ' FFG Kemmmencing with Section 10(o)or Division 3 of the Business and Professions Code)or $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section7031.5 by any applicant for apumlt subjects the applicant macivil penalty of 3"N30ffi8ea00 Occupancy Type not more than five hundred dollar I,as owner or the property,or my employees with wages an their sole compensation, wi 11 do the work,and the structure is not intended or offered for sale(Sm.7014.Business e aired Ins and Professions Code: Contractor'seContractor'sReQueCt10I$ P Contractor's License law does not apply to an owner of 101 - FOUNDATIONir property who builds or improve thereon,and who does such work himself or through his own candayeas,provided that uch improvements are not intended or offered for sale.If. 102 — PIERS however.the building or improvement is sold within one year of completion,the owner- - wilder wilt have the burden or praying that he did not build or improve for purpose or 103 — UFER .[a). 104 - REBAR ❑1,as owner of the incapacity,am exclusively contracting with licensed convectors to 105 — ANCHOR BOLTS consumer the project(Sec.7044,Business and Professions Cars:)The Contractor's Li- ceme,Lawdoes not apply manowner ofpropenywho Wilds orimproves themon,and, 106 — SEWER & WATER who contracts for such projects with a contractor($)licensed pursuant to the Contractor', weenx L,w, 202 - UNDERFLOOR PLUMBING ❑ l am exempt under See. ,B&P C far this..an 203 — UNDERFLOOR MECHANICAL owner D^re 204 - UNDERFLOOR FRAME WORKER'S COMPENSATION DECLARATION Ihereby.M.undcrpcnalty of perjury one or the muawfvg deda.a6... 205 - UNDERFLOOR INSULATION P, hevemd will meinCertificate orconxm meets-maom ser Worker's Co.,.. 301 - ROUGH PLUMBING ,.Iran,as provided ser by Section 37M of the Later code.for me perrarmmea of the 302 - TUB & OR SHOWER work for which this Permit isissued. 303 - ROUGH MECHANICAL E]I have and will maintain Workers Compensation Insurance,as required by Section 37W of the later Cole,(mthe pcdorromee of the work for which Nis permit I,!..ad, 304 — ROUGH ELECTRICAL My Worker's Compensation Insurance carrier and Policy number are: 305 — FRAME Carrier: Policy No.: 306 - HOEDOWNS CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATIONINSURANCE 307 - INSULATION (ITis section need not W completed if the perm it is for one hundred dollars(EIM) 308 — SHEETROCK Irenify 309 - EXTERIOR LATH 1 ccnify that in the performance of thewq k far which this permit rk issued,1 shall nm employ any pe KIM, m cr a b;omc subject ro me wmrkeri Compensation 310 — INTERIOR LATH Laws n,m�nI me d 311 - SCRATCH COAT N ¢.m No A GA . f,after making enc teat of Exemption,you should 313 - ROOF NAIL been tabject to the Workers Campenseti p visions of the Labor Code,you must �z fonhwirh comply with such pravisinm or this mit hall W deemed revoked. 501 — FINAL ELECTRICAL ENERGY ti O CONSTRUCTION LENDING AG ENCY 502 - FINAL PLUMBING ENERGY I hereby rapport that mem is a convection lend!ng agency lerr the performance of 503 - FINAL MECHANICAL ENERGY 4i , the work LenZamrwMantelepermifisisseed(sa.3D97.cit.c.) 504 - FINAL BUILDING ENERGY .2. Q Lende'a Namc � Z :unser'sAaareaa 505 - FINAL ELECTRICAL J p I ccnify that 1 have seed this application and sts¢Lost the above inf amnion is 506 - GAS TEST ,r comm.l agree to comply with all city and county on inmces and otste laws relating to jU building construction.and hereby munonre representatives or this city to enter upon me - FIN PLUMBI G a .have-mentioned property par inspectionpurnxa. OS FI L (We)agree to save,indemnify and keep humieal dm City of Cupertino eS.imr fq Iimilities,judgments,costs and asPensea which may in any way accrue against sold Ci ly 5 JZ in consequence of the granting ser this permit. " APPLICANT NDEB ANDS D WILL COMPLY WITH ALL NON-POI Issued by:5 ING Date SOURC GU TION . 79!1e 03 Re-roofs / Signature of Appa. CanRmff T HAZARDOUS MA ft LS DISCLOSURE Type of Roof Will the applicant or future building drearier store or handle hassrtlaus material a defined by the Copenim Municipal Code.Chapter 9.12,and the Heade and Safely Code,Section 25532(a)7 `� All roofs shall be inspected prior to any roofing material being installed. ❑Yes ld Will the applicant or future wading occupant use egviprcrl at devices which If a roof is installed without first obtaining an inspection,I agree to remove th htodous air emmominmu as defined by the Bay Arca Air Quality Management all new materials for inspection. District? J C]Yes Nin 1 have read the buraNnus materials requirements under Chapter 6.95 of the Cali for. ria Hc.lm&Sarny Codc.Sccdo 25505.M533a^J25534.Tundcraundthatifthe Welding h R that does not currently a at 1,is my rcapomTillry to andly the mxupam of the airemen ich 7,pKal prior toiam...ofaCerdficamo( cy Signature of Applicant Date - O nerurauthon'radagcm D.le All roof coverings to be Class "B" or better Ci C*Y OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM 3 7Building 0 v O Date: Q � v Address: s L_, Owner's Name: Phone#: 1 I Z c Contractor: License#: 3 � 3 ue I 33 Contact: �� ` Cupertino Business License#: Building- ermit Info: Bld E ct Plumb ❑ Mech ❑ Job riptio Atyy o rca_ esidential e yy�u ,,u, -2Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: C� --�0 O Occupancy Group: T e of Con truction: G a o ' Ca uanti Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 1 OOK 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/Coram/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 > IOOOA 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 COY OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM ISQuantity I 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 BNUSFD New Single Family Res BUILDING BOVERTRYIE Inspection Overtime BUILDING BAC LOW 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm 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 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 2 of 3 CITY OF CUPERTIl* CITY OF PERMIT APPLICATION FORM CUPEkTINO . Quantity Fee ID Fee Description Fee Group 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 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 Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection 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 • 3 of 3 5b ; 1 SS;i,+, � t '�tri: ✓ � •A11 }. : .�-• �a ',l sy 3 ? ! ..-,•�. .:Ir.i. .:•1 /moi.'.',,^• � .. i .. - ii W V + 7 C r N �i�o 0 0 U � 1. C '.✓/ � �� , r m -: _.. -.. ��,• _..:p. ' , _. N...m G.—�'1�C ,� . is N 1 LOc J� -ZA `^� RO 40 AS, Lv VC.5 -54 4S I. FAIII-7A tin 7e :"ts U0 v 10 a' las E 41 43 T1 r• � c.P. � p � N � fi 71 o C � � � �U N "I 0 tr iij 11 ......... I-V 4L S C. (---- DD ��()JJe� ) 2�g ,cls ��Z#-igz� RECEIVED l7, n8x -- q' SEP 1 0 2003 B[�GM110 - ' BY, - - _ G ,s,Skk rxw ew o BICE L,vlh rp ID(�Ilk ffi ��OfiDA.r�ICEG; fa'f#?E�l .,�.'3 GUP-ERTIN^ C MES A' D,DROO' In kTE - - f SIGNED_• _ ---- -- This set of p 's and spec fic2 ions MUST De kept on tsa p,i1 at a;{ 4,ges ohd • IlU - lawt 110 make ! r:'rvi> 9 altereG nE on sat:e with tf a buitding ➢ani., Ca, cT COO-tino: siMpitt8 of ZS y,A =n3 5f4-64ail ly �*Wft MT :e b2A :10 Pe:mit �lf 1, gi r AW A I d mw,vicl ±lot Di V.Y I"hl 4 VK 21ty(M-Amance Of CITY OF CUPER'rINO ^�tvs+se� sm` BUILDING DIVISION PERMIT j°CONTRACTOR INFORMATION. I� g se S a R BUILDING ADDRESS: - PERMIT N003090078 OWNER'S NAME: PERMIT ISSUE DATE , E: SANITARY NO. CONTROL NO, ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMBMECH +op Lm that CONTRACTORSunder of CON in 1 ionhereby70 affirm that 1 am Inds,Bu under provisions of Chapter 9(commencing Job DeSCrIpI1O❑ <n with Scnion]glt)uf Diviaion3ofdm Business and Pro inns Code.and mylicenSe is <.,,, inrwlmBean ansa. X33 REMODEL (RAISE SOFFIT/REPLACE 2 DRS) S Y),? LittnxO L-m -{- D - cmmrao CONTRACTOR: CLIFF W COUEY CONST. I;q CI3ITECTS DECLA T ■ ��A�� JcrstanJ my plans shall w used es pud, rams F '01 Licensed Pmfcuianel �Oaq 5 OWNER-BUILDER DECLARATION I 1 hereby affirm that 1 am exempt from the Contractors License Law for the Y 1 It O following mason.(Section 71131.5,Business and Profcuions Code:Any city or county 5$ which requires a permit to construct,alter,improve,demolish,or repair any al ucmm prior to its issuance,also requires the applicant for such permit to file a signet statement at that he is licensed pursuant to the ponvisionot of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area filaqw!"PI �t- (commencing with Section 7")of Division 3 n(me B usinw and Professions Code)or $ that he is exempt shemfmm and the basis for the alleged exemption,Any violation of Section 7031.5 by Sq applicant for a perrnitsubjects the applicant to a civil penalty of U e Das mom than five hundred do])..4500). "-' "' - -3�hY3QdIB�crO O Occupancy Y TYP ----- 0 1,u owner of the property,or my employees with wages u their sole compensation, will do Ue work,and me a,ructum is not intended or offered forsale(Sec.7044,Business Re IC d Inspections and Professions Code:The Cmusi mri License Law dens Das apply to an owner of 101 - FOUNDATI uONc P properly who huildsur improves import.and who doessuch work himself or through his own employees,provided that such improvements are not intended metered for sale.If, -- 102 - PIERS however,Be building or improvement is sold within ane year of completion,the owner builder will have she burden of proving Nat he did not Wild or improve for purpose of 10 3 - UFER 01, 104 - REBAR co I,a owner tan the properly,,B exclusively contracting with licenced et=.', to - comwcsmepmjea(Sec.]004,Business and Rofnsioni Code:)The Conuxmr's Li. 10 - ANCHOR BOLTS came law does not apply to an owner of property who wilds or Improves lhctnon.and 106 — SEWER & WATER who contracts for such projects with a conuanor(s)licensed pursuant to the Contractor's License Law. 202 - UNDERFLOOR PLUMBING ❑ lam exempt ad.,See ,B&PCf this reman 203 - UNDERFLOOR MECHANICAL owner Date 204 UNDERFLOOR FRAME WORKER'S COMPENSATION DECLARATION I hereby elnrm under penalty of perjury one or the following declarations: 205 — UNDERFLOOR INSULATION ae and will maintain a Cool fcam of Consent to self insure for worker's Compen. 301 - ROUGH PLUMBING on,as provided for by Section 37M of me labor Code,for me performance of the 302 TUB & OR SHOWER work for which this permit is lamed. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 0.3 — ROUGH MECHANICAL 3700 of the tabor Code,for the performance of the work for which this permit is issued. 364 — ROUGH ELECTRICAL My Worker's Compensation Insurance carrier and Policy num bar em: 3 05 - FRAME Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' 306 - HOIIDOWNS COMPENSATION INSURANCE 307 - INSULATION or (This Section need not becompleted Edo permit is for one hundred dollars(SIM) 308 - SHEETRtOCX lcss.) 309 - EXTERIOR LATH I certify than in the perfmmanec of mewqrk for which this permit is issued,l shell nm employanyrcla,Oin ym cr 9 M1c�n3te vrabjecuo dm workcri Compensation 310 — INTERIOR LATH Ap ug ar In+t ate 311 - SCRATCH COAT Ap ¢ant N TOA H ANI. La(mrmaking' cm mal of Exemption,you should 313 - ROOF NAIL bac subJen to me Woheh Compcnseti p visions of the Lever CMe,you mons 501 - FINAL ] Z furlhwimcomply wrthCONSTRUCIONLENDINGAGENCvmedm.raked. 502 - FINAL PLUMBINGAENERGENERGY IV) I hereby affirm that more is a consometion lending agency for the Performance of 503 - FINAL MECHANICAL ENERGY CI da.work for Namewhich thispermitlsiuucd(Scc.309],Civ.C.) Ianderi Name 504 - FINAL BUILDING ENERGY '31 j z nder'sAedrexs 505 - FINAL ELECTRICAL p 1 ccrlify Use I have mad this application and Stam that the about inf antaiwa is 506 - GAS TEST Fcorrect.I agree to comply with all city and county eminences and state laws relating to V abomngaomwaiogandhoimanmonp representatives mtivesofNiscitymentoruponme FIN PWIN! U show-mcndowil propertyontracion,and hereby anianpureprs. III. (We)agree to arc,indemnify and keep humleu the City of Cmpenina!gaine, 0 8 FI L �(q liabilities,judgments,costs end.peau,which they in any way same getout sm 'y 5 ;)7 in consequence of the granting of this permit. r7 APPLICAN NDERSgANDS///rrrII1000D WILL COMPLY WITH ALL NON-P01 T Issued by:5 Date SOURC ^�I,( 7 -- �' / 7� bi4 - NAL PUI;=WORK // ( 1 9r P Re-roofs / Signature of Appl'ica W0.1o¢I� Dam HAZARDOUS MA R ILS DISCLOSURE Type of Roof Will Uc epplica'ser future building occupant Store or handle heuNuus material as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safely Code. Iafenzss3z(')I All roofs shall be inspected prior to an roofing material being installed. ❑re, �ra P P Y 8 g veru me applicant or future branding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove harardnos air contaminants as dcfned by me Bay Area Air Quality Management all new materials for inspection. 4 Fly., I have mad the hmaNcus materials requirements under Chapter 6.95 of the Califon Dia Health dd Safety Code,Savour 253115,25533 and 25534,1 understand that ifthe wilding Jte�Ihdm te mot u is my respomihiliry m modify the axm ant of the dpdormismanccof.cenificamofOc cY Signature of Applicant Date nt Dam All roof coverings to be Class "B"or better