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0508027402 z v_ C> yC s,2 UC OF Fa U2 - CITY OF CUPERTINO�s-«�'-'--' °"%y````" ' BUILDING DIVISION PERMIT CONTRAC"`TOR INFORMATIQN:� BUILDING ADDRESS: PERMIT NO.0 5 080274 OWNER'S NAME: PERMIT ISSUE DATE RODNEY FERNANDEZ 08/31/2005 ONE: SANITARY NO. CONTROL NO. - ARCHITEC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION lb Description o 1 lumby affirm that 1 am licensed under provisions Of Chapter 9 (commencing with Smite. 7Wlq of Division 3 of NC Business and mfessinm Cndeanl my license is in (full forte and �hilC OQL qq �r REPLACE DRYROT/SUBFL./RIM JOISTS/STUCCO L. N ate cam ore CONTRACTOR: THRASHER TERMITE & PEST CONT. (#177 ARCHItb DECLARATION use - 1 understand my plans shall he used as public records t Licensed Prrfcss mad OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from Ne Conwetor's License Law for the following moon. (Section 703 I.S. Business and Professions Cale: Any city or county which re idoses a permit to cnnsvuet, alter, improve, demolish, or repair any scommon prior to its issuance. also requites the applicant for such permit to file a signed statement that he is licensed puretlanl to the provisions mf the Comuaemr's IJTnSC Law (Chapter 9 Sq. Ft. Floor Area - Valuati$2750 (commencing with Section 7") of Division 3 of the B usi• and Professions, Calc) or that he is exempt therefrom and the hasu for the alleged exemption. Any violation of APN Number Occupancy Type P Y YP Section ]031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mom man five hundred dollar, (S500). 35614043 00 of the Pmpcny,of employees wirewagesutMe'v sole eompensallan. Luhe Required Inspections ' will do wm isnots .11tred too in, Burrow I, work, ands: he Cor defan :(Sec. Proponents; Cade: The Conuanon, License Law dao tort apply lf an owner of and property emy who builds or improves meson, and who doessuin work himselfor througbhis own improvements sennot eaofcmplded eered for sale. If. of me owner- howemploYttuilding or improvement owner- builder daebve of v +A Wdhl improve builder will have the burden of proving that he did not build or improve far purpose of the burdenofpmemuhat ba, did salc.l. ©p/ ❑ h u owner of the property. am exclusively contracting with licensed rnntnnors in construct me project (Sec. 706,1, Business and Professions Cade:) The Contractor's U. cense law docs not apply to an owner of property who Wilda or improve daemon, and 1p ?0 �a S who contracts for such projects wit a comment(s) licensed pursuant the Contractors License Law..k' f -1I am exempt under Sm.. B & P C for this mason IYNt V'TL � Ly Owner Date VG WORKER'S COMPENSATION DECLARATION I hereby affirm under Penalty of pe jury ane of me following declarations: 1 hs a and will maintain a Cenificam of Consent to self -insure for Worker's Compen- sation, u provided for by Section 3700 of thelabor Cotle, for the peAonnanc, of the work for which this pcnnit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as printed by Section 3700 of me labor Code.for the peRormane, of the work fm which this permit is issued. " My Worker Compensatiom an rsncccanicrd Policynu ILL, am: f Cartier. iE. UNa Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thusetheaneed no lWeomplemJRtic permit isrosette hundreddollars(SIW) I cenify that in the acrfonnamcc of me work for which this permit is issued, 1 shall not employ any person in any manner an as or become subject o the Workeri Compensation Laws of California. Date Appliant NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should become subject to the Worked Compensation provisions of the Labor Code, you mast ra"with comply with such provisions or this permit shall M deemed revoked. CONSTRUCTION LENDING AGENCY that mite is a 1 hor t30L lending agency for the Performance of which ad (See IM work for which this permit is issued (Scc. JW7, Civ. CJ ndr's Name Lendeer's Addrw U I 1 terrify that I have rad thia aPPlicmion and Lost, that the above information is COMM I agree to comply with all city and county ordinance:and state laws relating m building commotion. and hereby aorprim represcmalives of this city to enter upon to above-mentioned property, for inspection purposes. (We) agree to Save. Indemnify and kap harmless the City of Cupertino against liabilities. judgments. Cos¢ and expenses which may in any way accrue against said City ncansequenaafercipa mgofthispc t. APPLICANT UNQERST DS AND ILL COMPLY WITH ALL NON -POINT Issued by: Date 5/ --vs SOURCE pts`i}J'(a--t�LIJ I S p/3t Oi Re-roofs Type of Roof Signature o! cSnambocrr V Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future Wilding occupant marc or handle hsomous material u defined DY the Cupertino Municipal Code. Chapter 9.Iz, and the Halm and Safety ode. 0 enzss32(gL All roofs shall be inspected to any roofing material being installed. Year Na prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or mean building occupant use againm meor devices which it ictrardnus air contaminants as Ikfincd by the Bay Arca Air Quality Management all new materials for inspection. tsuin? ❑Yes No (have read the ha anlnus materials requirements under Chapter 6.95 of the Califor- nice Heal"Saft,,Codc,Scene.25515,8533 and 25536.1 understYW that if the lathing dues not cu dy hove a mmam, do t rs my msponsibllily m notify the occupant Of the q mmmme nm tba armiLSaan„eracertifieatcor acneJy. Signature Appli ar Date ' 3//o r All roof coverings to be Class "B” or better Owner `�� ser au redo cat Date IE Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: 109 36 G.Nnn ✓,s,� inn. PERMIT # DS oho �2 7 OWNER'S NAME: BUSINESS LICENSE # PHONE # 35 q -4 v y y GENERAL CONTRACTOR: FAX # 315 - 74 3 d I am not using any subcontractors: g/3) 105 Signature Date Please check applicable subcontractors and complete the following information: Owner/Contractor Signature Date 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 (exm-- CIN of CUPEkTINO CITY OF CUPERTINO .. PERMIT APPLICATION FORM 1 of 3 #-I 2 , S� N # 35G ( y 0 4-13 Date: 9131105 Building Address: ' / Mailing (dress (if different from building address): �oQ3(o 1♦ r,DA Y15�` plL �6 P15,xr-W Owner's Name: �o�4F�e�la anti Phone #: 3`19-689°1 Contractor:` / TWO-ASNFR- ZiLt ,rf— Y' p / ESr�`"'�r' License #: OP2 99.21 Contact,: Phone: 35 -y 9'4 I'UI16✓El- TOP -PCs Fax: Cupertino Business License#: 177(0`1 Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job Description:I Residential &A r R—s /� &-Pcac(1_J4-A4. r A 144 �1S� S"B«Commercial ❑ +-Srvccv Sq.Ft. Floor Area: 1107-475✓gac.ae 16 Rim Jn,s/s. $/Sq.Ft.: Cost of Project: 7 1 5 Occupancy Group: Type of Construction: 16 , of PLA _£ S✓SFL��2 Please check this box if the project is a second -story addition: ❑ 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> 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 > 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 1 of 3 #-I 2 , S� 0 s CITY OF CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 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 BPINI'ERCEP 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 Water Heater/Veut PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfrn MECHANICAL BREN AIRHAN 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL 2of3 amilla CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description 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 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 Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3 of 3 t 0 t