05050022 CITY OF TCUPERTINO
BUILDING DIVISION PERMIT °^CONTRACTORaINFO,itMATIQN
BUILDING ADDRESS: PERMIT NO.
TIMBERLINE BUILDERS INC 05050022
NER'S NAME: PERMrT ISSUE DATE
YUVAT SC'ART AT
NE:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�+Oo LICENSED CONTRACTOR DECLARATION Job Description
C 1 homby affvm Nat 1 am licensed unp
der mvisio�ss or chapter 9(commencing p
U with Seetion 70(K))of Division Sof Ma B.m.and Pmrommus Cotle.and my he..a is
morn mmnrana.nderram Lic • �r-JL�S'� REVISON--ADD 2 SKYLITS
j n z License Class
Contractor
Dam ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. 402080091
M I understand my plans shall M used u public mcmds
DyU
get; Licensed Professional
3 OWNER-BUILDER DECLARATION
I hereby of rm that I am exempt from the Contractor's License taw for the
_O O following moon.(Sadun tt131.5,Business and Prmfamsines Code:Any city or county
5 m� which requires a permit to construct,alter,improve,demaliah.or mpair any structure
prior to its issuance,also requires the applicant for such permit to rile a signed statement
-�< that he is licensed pursuant to the provision¢or the Contractor's Uccnm Law(Chapter 9 Sq. Ft. Floor Area Valuati1
,s (commencing with Section of Division 3 of the Business and Proressinns Crrde)ur IIS
y $ that M u eacmpt therefrom.6 the basis for the alleged exempdon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicanu0 a civil penalty of APN Number Occupancy Type
not mom Nan rive hundred dollars(M).
❑1,as owner of the property,or my employees with wages as their sale compensation, 35624004 . 00
will do the work.and Ne swetum isnot handed or ofremd for sale(Sec.7W,Businev
and Pmrassions Coda:The Conu iewes uanese law does nut apply ut an..,or Required Inspections
property who builds or improve thermn,and whodmes mchwmk himselfor through his
awn employces,provided On,such improvements art not immoded aro@red torsade.If,
however,Ne building or improvement is sold within one year of completion.Ne owner-
builder will have Ne burden of proving that he did not build or improve for purpose of -
sa1cJ.
❑1,as Owner or Ne property,am exclusively contracting with licensed contractors to
comwct the project(Sec.7044,Business and Professions Code:)TM Comostori Li.
case law dots not apply m an minor of property who Milds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant a the Contractors
e Law.
am eacmpt under Sec. .B&P C far Nis mason
130100
u Date
WORKER'S COMPENSATION DECLARATION
I heraby affirm under pastry,of perjury One of the following decimations:
have and will maintain a Cenifieam of Consent to self-insum for Worker's Compm-
n,as provided for by Section 37M Of the labor Code,for the performance of the
for which this permit is issued.
have and will maintain Worker's Compensation brsmana,as required by Section
of the labor Code,for the performance of the work for which Nis permit is issued.
Worker's Compneauon lomnntt carticr and Policy number are:
ier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(Thu sectio seed oat Mcomplc.d fine .it is(mane hundred dollars($100)
or less.)
1 certify that in the Performance of the work for which Nie permit is mimed,1 shall not
employ any person in any manner an az an become subject to the Workers'Compensation
Laws Or California. am
Applicant
NOTICE TO APPLICANT:IL ahcr making Ns Cerofiess,of Eacmption,you should
Moonie subject in Ne Worker a Com ienaaumn previsions of the labor Code,you most
Z forlwith comply with such provisiom or Nis permit shall M deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm Nat them is a construction lending agency for Ne performance of
D: the work fur which Nis permit is amid(Sec.301 co,.C.)
Under's Name
.7 lenders Address
U O I certify,Nat 1 have mad Nis application and sum that the above infomuuun is
F correct.I agree to comply with all city and county ordinances and amu lows relating to
O U building construction,and hereby authorise rtpo:xmativcs or this city to unser upon the
ala ve-mcnuoned pmpcny for impccuon purposes.
(We)agree to gave,indemnify and kap harmless the City or Cupenino against
y liabilities,judgments,costa and eapenses which may in any way ecaueagainst said City
U Z. APPe of Me limiting
LICANTUNDERt
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG ATIONS. J _
��U4 Re-roofs
Signoum of APplicanVCantractor i Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
r ed by
teCuemno Municipal
stomor handle Health asmnadal
as defined om the Cupertino Municipal Code.chapter 9.12,and the Health and Safety
Code.Section 25332(a)?
❑Yes �alu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or forme building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha gdum air conuminme,as defined by the Bay Area Air Quality Managemcm - all new materials for Inspection.
District?
❑Yes 9Nu
1 have mail theh=n ousmacrialsmquimmcnuunder Chapur6.95orthe Califon
nia Health&Safety Cmda,Sau=m M5.2533and25534.1 undemandthvifthc Wilding
does not currently hoc a mnanm that it u my responsibility m notify Me aeupant Of the
mquimmenm/.wmehmugM updormt amface rdrrtamoroccap ar. Signature ofApplicant Dale
�'`� �
Owner or authorireJ agent Date te All roof coverings to be Class"B"or better
CITY OF CUPERTINO
BUILDING DIVISION P T
5vkY.��- '?Nr..vs9?A -.` v"t,$e'�"s •°.ac=e+ib'Szw'
BUILDING ADDRESS: PERMIT NO.
TIMBERLINE BUILDERS INC 05050022
ER'S NAME:1 T PERMIT ISSURDATE
PHONE: SANITARY%5 1 194,12OL NO,
ARCHTTEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�000 LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm Nen 1 am licensed under provision of Chapter 9(cemmmeth-9 -
with Seanioo 70Ig))of Division Sof the Business and Profesalom Code.and my license Is
nfullfan:emdeffett 3L65
a'Z License Class Lic.M 5 REVISON--ADD 2 SKYLITS
Dam Camrecmr NO NEW PERMIT ISSUED/ORIG. 402080091.afit"o4'
3 ARCHrECTS DECLARATION
�i I understand my plans shall he used As public records
.;.cis Licensed Professional
v, OWNER-BUILDER DECLARATION
IRE<2 hereby It,.Nat 11. exempt from due Camnnar.L Any C law for the
i p following M.A.reaso (Section 7 o Ib,Rosiness and w.de o demolish.
Cade:Any city or county
which requires•permit m uses sh s alma Improve,demolish,fi repair any attuetum
_iy prior 0ftiheIucensedpursantWtutimapionso theCfor ohMrmrt to file a',Lim.Luedautsmcm Valuate
££YY< be me cing wait PursuemmlW of Division
of de Connsiness Lim. apter 9Code)
Sq. Ft. Floor Area Ou115
y+FO (commnndng with Scmion7000)of Division Jn(tW Business and Profnsriam Cn on of Yl
Nat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permh aubjecu the applicant to a civil penalty of APN Number Occupancy Type
.at more than five hundred dollen($500).
01,as owner of the property,or my employees with wages as then note compensation, 35624004 . 00
will do the workand nhe.vudum is no,lntandedor.rNnad fer.W.(Sm.70414,Basineu Required Inspections
and Profession,Code:The Commcmrs Liame Law does not apply at an owner W q P
property who builds orimpmvas thereon,andwho doessechwntkhimself or through his /5
own employers.provided that suchimprovemcnts are notir mMW moRcred forsale.if.
however.the building ar Improvement issold within oro year of..Piano..Ne owner-
Wilder will have the burden of proving that ha did not build ne improve for purpose of I'1
0 1,tie owner of the propeny,am eacladvely convecting with]!caused conuacton to
construct the project(Sec.IDM,Business and Professions Code:)The Contractor's I.I.
me law does not apply to an owner of property who Wilds or impmm Nemon.and, /
who contracts for such projects with a conuacter(s)licensed pursuant m the Contractors
ik e.ex. Law.
1empt undo Sea .B&PC far Nis nation
mer Date
WORKER'S COMPENSATION DECLARATION
1 hereby Arm under petulty of Perjury am of the following kelan0oaAC
❑l bamond will mainWn aCeniftnm of Consemmulf-imam for Wafker.Compeo-
ration,as provided(m by Section 3700 of the Labor Code,fm the performance of the
work for which this permit is issued.
❑I have and will maintain Worker'&Compensation Imuvuce,a required by Section
3700 of the LAW,Code.for the performance of the work for which this Permit is issued. '
My Workers Compensation Insurance carder and Policy number ere:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sermon need not W completed I(Ne Permit Is foroechundmd dollars($1001
At Tats)
1 ceNfy Nat in Ne perfoemaner of the work for which this Permit is issued,I shall am
creplcyany penin in any maancrm as m becomeaubjeaua use Worked Compensation
Law,of Califomla.ISam
Applicant am
rLIC - -
NOTICE TO APPLICANT.If,after making of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Code.you must
.,O fonhwith comply with such Provisions or this penin shall be deemed maked.
z 0 CONSTRUCTION LENDING AGENCY
(—t Ihereby.limn that Orem is a commucom lending agency for the performance of
{�> the work for which this permit B issued(Sce.3097,Civ.C.)
aQ Undoes Name
]z Lenders Address
V Q 1 certify that 1 have read this applicadra and sum that the above information is
W corre0.l agree to comply with all city and county ordinances and sum law.mlstint to
C) building construction.and hereby authorize representatives Clods city to enter upon the
LI) above-mentioned property for Inattention purposes
(We)agree to,an".indemnify and keep harmless the City of Cupertino against
t;y zy IlabI110u,judgments.casts and expenses which may In any way mmue against said City
O
APPLICANT 1. eUNDERSTANDS Aor the granting of tNDtWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE
�•�— �/`��U� Re-roofs
Signammof ApplicanuContracmrDTT we
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
f Will dte applicant or future building occupant room or handle hantdons mamdal
defend by tie Cupertino Municipal Code.Chapter 9.11,and dm HA.10 and Safety
.ado.Section 75537(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yoe ON.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmin honrdous air contaminants As unload by the Bay Arca Air Quality Management all new materials for Inspection.
Dlnfid7
❑Yoe flu
I hoc mW dm hamfdnusmamriaLs"uimments under Chapet A.95of the Celifor.
nice Health&Safety Cada,Sections 25505,75533 atd25534.1 underund Nm if the Wilding
dao not currently ham a i mesal.that it is my responsibility as nadfy the aaupmt of the
requirements which must be et prim3olsmanc.a.CeNlices,of QN er. Signature of Applicant Date
7z7z All roof coverings to be Class"Bt'or better
Owner or aunhorimda entDal to
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35624004 . 00
DATE ISSUED. . . . . . . : 05/04/2005
RECEIPT #. . . . . . . . . : 29552
REFERENCE ID # . . . : 05050022
SITE ADDRESS . . . . . : 11477 LINDY PL
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : YUVAL SCARLAT
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4814
RECEIVED FROM . . . . : TIMBERLINE BUILDERS
CONTRACTOR . . . . . . . : WILLIAM WILSON LIC # 24010
COMPANY . . . . . . . . . . : TIMBERLINE BUILDERS INC
ADDRESS . . . . . . . . . . : 2263 MIMOSA CT.
• CITY/STATE/ZIP LOS ALTOS, CA 94024
TELEPHONE : (650) 868-5291
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPLANCKREP HOURS 1 . 00 87 . 14 0 . 00 87 . 14 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 87 . 14 0 . 00 87 . 14 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 87 . 14 5901
TOTAL RECEIPT 87 . 14
•
CC'S 020 �00gt.�
Q CITY OF CUPERTIA
cuPErZTiNo PERMIT APPLICATION FORM
APN# Date:
2-
Building Address: Mailing Address (if different from building address):
Owner's Name: Y f Phone#:��o�� y8,z —SSS 3
Contractor: /2 �I License#:
Contact: /� Phone: 4>4)A,$- 529/ Cupertino Business License#:
/,I/// IA- Saq Fax:
Building Permit Info:
Bldg ® Elect ❑ Plumb ❑ Mech ❑
Job Description: n�/� f ��1�y�ZcS
Residential S 11 Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
ype of Construction: New Please check this box if the project is a
second-storyaddition: ❑
Project Size: Standazd ® Lar e ❑ Major ❑
QuantityFee 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 IM Btu MECHANICAL
BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTA)MQ 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
1 of
CITY OF CUPERTIl*
CUPEysio PERMIT APPLICATION FORM
QuantityFee 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
BOVERTWE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFD{T 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
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STY OF CUPERTINO
CUPER,TINO 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 Ventflation 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
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
•
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