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04070015 CITY OF CUPERTINO � ""Cow Y''O A N - BUILDING DIVISION PERMIT ,, y ,:� > ,. T, BUILDING ADDRESS: SEARS HOME IMPROVEMENT ""'b4070015944 LONG DOWN RD OWNER'S NAME: PERMIT LSSUBDATE HYSINGER E: SANITARY NO. CONTROL NO. (925) 245-2000 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH upp LICENSED CONTRACTOR'S DECLARATION O O O O �a 1 hereby affirm that 1 am licensed under prov'"ons of ChaPlc9(commencing Job Description with Secran 70fa)of Division 3ofthe 6uainem r cseions e.'.ad.,licenxiss Sp g� Z 'nf°" ne KITCHEN REMODEL--COUNT R I �L S FAUCET Lkenx I Lic.N n� Da¢ 0 Cant r - Cs eq D ARCHITECTS DEC ION z Z understand my plans shall x used as public records Licensed Pmfcssionel nFC 2004 �j Oat I am eU rept from DECLARATION E00 1 hereby.(Sere that 1 1. exempt from the Cssions or :Any c Law far the $C9 whichfollowingrine a French t 711315,Business and Professions Code:Any city m county which requires a Pormio to cures the eller,impmw,h permit t m a a sig any structure oo prior va its i licensed also req.the the applicant for such permit mice s signed(Chapter cm �p?m6 (mourn liccnxit PSectio 7 a)Of Division of the eBusiinessanittvc Law(CMpmr9 Sq.Ft. Floor Area _ a IIOn (calreis ngwithhereirom andlin Diviaionr the theBusiness and Professions Cud.)or Net he is mem pt aem(mm and Ne baso for the subjects t alleged seaman to Any violation of Section 703.5 Eve any applicant fora permit aubjeca the applicant to a civil penally of 3 44 4XNuW&er0 0 Occupancy Type not mom Nen ave hundred dollen($5001 ❑I,at owner of the property,or my employees with wages m their mic compensation. will do the work,and the structure is not intended or ahead for sale(Sm.7W,Business and Prefevaiom Cads:The Commmoes License Law dean not apply to an owner of - Required Inspections property who bu it ds or improves thereon,and who does s uch work himself or arough his own employees.provided that such improvements are net intended oroRered formic.if, however.the building or improvement is sold within one year of completion,the owner. builder will hese the burden of proving that he did oat build ar improve for purpose of salk.). ❑I.the owner of the property,em exclusively convening with licensed canuacmrs a construct the project(Sec.7004,Business and Professions Cade:)The Cunuanor'a L4 come law dam not apply x an owner of pmpeny who builds or impnevem thereon,and who contacts for such projects with a communist licensed pursuant to the Carrington License Law. I sea mempt under See. Bk PC for this moon Owner Data WORKER'S COMPENSATIONDECLARATION 1 hereby affirm under penally of perjury one of the following decimations: have and will maintain aCordOcete of Consent to self-insure for Worker's Compere 1307M n,the provided for by Section 3700 of the labor Cade,for the performance of the for which this permit is issued. have and will maintain Workers ComPOINIUM Insurance,m required by Section of the labor Code.for the amformanc of the work for which this permit is issued.Workses Compensation Inamnce c 'cr and Policy nuh--sesr 0a. 9 II2'f 31 l . Ll Policy No.:W�a"��()_VO� -OLl CERTIF CATE OF EXEMPTION WORKERS' COMPENSATIONINS AN '( enation need nm x minplcmd if the pemtit is faronc hundred dnllan(SIM) or less.) I certify that in the performance of the work for which this permit is issued.l shall not employ any person in my mmnerw m in become subject to the Warkera Compensation Lawn of California.Dal Applicant NOTICE TO APPLICANT:IL after making this conifmax of Exemption,you should become subject he the Worker's Campensaaon previsions of the labor Cade,you must .',$ forthwith comply with such provisions or this Permit shall he lamed rovokcd. zCONSTRUCTION LENDING AGENCY [r I hereby affirm tat there is a construction lending agency for the performance of tai the work for which this Permit is issued(Sec.3097,Civ.C.) alender's Name z Lender's Addrms U Q I certify that 1 have read this application and state that the shove information is Iy F coned I agree to comply with all city and county ordinances and sax laws minting to O U building construction,and hereby authodm mprexmadves of this city to enter upon the Gmove-mcntianed property for inspection purposes. _ , (We)agrce to save,indemnify and keep harmdem the City of Cupertino against r rF.y HmiIrbWjudgma or casts and expenses which may In any way seem.against said City U,Z in consequence of the granting of this permit. ^' APPLICANT UN ER'/14NDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR REGU V;. t� 1 L� Re-roofs Signeam of Applicant/ n or \V Data HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will the applicant or future building occupant store or handle hazardous mmeriel ar detned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade,Samoa 25532(e)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant o fumrc building occupant tax equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove Will the Inflican,or;Future building occupant use equipment or devices which ha'randous air contaminants as dcanod by the Bay Area Air Quality Management all new materials for inspection. vitt? ❑Yes s 1 have mad the Intgodous maa:rialsaquiremems under Chapter 6.95 of the Califor- niaHcal"SafetyCode,genion 25505,25533 and 25530.1 undersand aatif ac building dam not currently how .ant,that is my rssponsihility x nodly the occupant of requircmemsw ch a met do issuenecofaCeniOca cu ry Signature of Applicant Date Ow or anm .ed reg nt Dax All roof coverings to be Class"B"or better CITY OF CUPERTINO M �s "yy 7�f 'jj �'e � BUILDING DIVISION PERA/0 A+� ��" " 'ANFORM s,L ', vim, 'aak�. BUILDINGADDRESS: _ SEARS HOME IMPROVEMENT PERMIT ND04070015 944 LONr DOWN RT) OWNER'S Mrr NAME: PEREdUEDATE HYSINGER E: SANITARY NO. CONTROL NO. (925) 245-2000 ARCIi1TECT/ENGINEER: BUILDING PERMMNFO BLDG ELECT PLUMB MECH 0 0 0 0 L0, LICENSED CONTRACTOR'S DECLARATION P 1 hereby affirm It 1 am licensed under pravi'ons of Chapter 9(commencing 16 a Ci I n wiOM1 Scaion 70fxB of DivixianJof the Busincse aPd Pr cssions Co c.end my license is y 3 M, infml�arae ifi r KITCHEN REMODEL �iBINETS/FAUCET uee�Z(a s. 0 3 Ue l Lia.» ^p Dam D'9 7 Comment esth' rv✓U 7W 1't1 ARCHITECTS DEC IDN DECZZ 2U�4 understand my plans shell be used as public records �yU jGy Licensed Professional .'� 3 OWNER-BUILDER DECLARATION BUILD I N <f i hereby affirm that I am exempt from Ne Contractors License Law for the Eno following reason.(Sadat 7 onstr Business and Professions Code:Any city a,c0umy :10 loch requires a permit re construct,altar.imprrsu tleermit t,m repair any statement strath m its issuance,also requires the applicant for such Permit m file a signed summent that he cache with pursuant to the of Division of Contractor's ad Porf Lew lChaptcr9 Sq.F[. Floor Area Valuation fir 9 that he is exempth Section 70nd or01viis for of due al aged Business and on.A ainbs Cade)Or y�^ Nm he is exempt Nemfrbm and dm basis for the alleged exemption.Any violation of Sectlon 7031.5 by any applicant for a permit subjects the applicant o a civil liability of 34da4Q412 6er00 Occupancy Type ' not mom Nan five hundred dollars($500). ❑L as owner of the property,or my employees with wages as their sole compensation, will dote work and Ne swmure is sot intended or offered for sale(Sec.7W,Business and Professions Cada The COntracmrs Litt.=Law data not apply on an owner of Required Inspections property who builds or improves thereon,and who does such work himself or thmugh his awn emplayeas,provided Nm such improvements art nor intended oroRered torula.if, however,the building istimproventera is sold within one year ofcompledon.the owner builder will have the burden of proving that he did not build or improve for purpose of til).). ❑1,as owner of the property,am exclusively contracting with licensed eonuaemrs to conswm the project(Sec.7W,Business and Professions Cadc:)The Contractors LL can=taw docs not apply m an owner of property who builds or improves Ihemon,and, who contracts for such projects with a commercials)licensed pursuant in the Contractor's License Law. ❑1 am exempt under Sec. .B&P C for this reason Owner Data WORKER'S COMPENSATION DECLARATION I hereby a)rmm under penalty of perjury one of the following declamtioms: have and will maintain Ccrtm u igcaof Consent sel4om insfor WaCoupon.s Coupon. tion,M provided for by Section 3700 of to Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Ins umrcc,as acquired by Section 37W of the tabor Code,for Ne performance of the work for which Nis parmil is issued. - MyWarkeriLLCompensati.a mirance ca mond Policy number arta:. Cartier. (,11 {'l ( Policy NO.:wv�_G�t��v ��� + CERTIJ x OF PnON,PRR WORKERS' COMPENSATION INS ANCE (TMs=anon need not he completed if the permit is for one hundred unit u(SIM) or less.) I certify Nal in the performance of the work for which this permit is issued.I shall at employ any person in any memncrsn as to became subject to the Workers'Compensation Laws of California.Dam Applicem ELIC' TO APPLICANT:IL after making this CcniOcale or Exemption,you should become subject to the Worker's Compensation provisions of Ne Labor Code,you must O forthwith comply with such provisions or this permit shall be deemed hawked. z CONSTRUCTION LENDING AGENCY F^ I hatehy affirm Nm there iso conawtli ction lennga6eney far the perrmmanee of Ga aNe work fur which this permit is issued(Sec.3097.Civ.C.) W�Q lender's Name z Lender's Address U O 1 comfy that I have read this application and sure Nal the above information is lt.H avnan.I agree to comply with all city and county ordinances and stoic laws relating to 0U building conswction.and hcrcby authorimrePossimminex or this city m cmc,upon the W show-no ntiumd property for inspection purposes. ^ , G (We)agree la save,indemnify and keep hurmless the City of Cupertino against `wyi� % liabilities,judgments,costs and expenses which may in any way aceme againslsaid City U Z inconuquem um""granting of this permit. r"+ APPLICANT UNDER NOS A WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGU 1 / 7 ��1 11 � I'N Re-roofs Signature of Applicant/ nit tar > Dau HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will Ne applicant or future building Occupant store or handle hmamom material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Hcalth and Safety Code,soa 32ss3z(an All roofs shall be inspected prior to any roofing material being installed. 0tWill the applicant a fnum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove hacardom air contaminants m defined by the Bay Area Air Quality Management all new materials for inspection. rin, ❑Yes O I have read the hmardous materials requirements under Chapter 6.95 of the Califor- risHead&Safety Cade,Sections25505,25533 and 25534.1 understand that if the building deet not currcndy haw ran,that' s my responsibility m n ily the u:cupen regaimCmgw ch u met do riaadyea.raCarafiamc�nf�ccnp�a Signature of Applicant Date O room 4edasanl "/�� Date All roof coverings to be Class "B"or better L( CUM MED 11 Vj �9 of CUPERT r - `� OFFI E copy p,PPRo!/E Cm OF rcTn IN ACC ROANC WITM pINANC `' SIf3N p ns MUST be ( _: d d vt Is on at Tni; set t Plob at all tones 8 on sante • lceoi on ne 1 changes or soloing t_ make m anY mout ar tten penmssion d avocewns I).oartm' Ian n of this P to be an ;; stamp g rtrut or 1ALL NOT be held to Pe awns of 4 ;royal of the violation of any Pro a y City Ordinance or State Law. OCITY OF CUPERTINO* F CUPEI�TINO PERMIT APPLICATION FORM APN# Date: Bui i g fls: (�o� y� Mailing Address (if different from building address): Own is Name: a j� Pho e#: r g Co tor: Lic #: n e I &-erg--t Contact: Phon Fax: el gq / upertino Business License#: �f l0` � Buildi4k Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job Description: �+ {may` 7 COl t,l ct.(riot I Y St Residential Gf- i Commercial ❑ U C Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: y1�7 Occupancy Group: _ Type of Construction: V f Y �T l Please check this bo • project is a f5 �' , W �e cond-sto addition: ❑ ro•ect Size: Standard ❑ Large ❑ Ma'or ❑ 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 Energy BENERGYADD Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 07 3 5 7, WITY OF CUPERTINCO CUPEIZTINO PERMIT APPLICATION FORM Quanti 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 BOVERTWE 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/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 BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 lWow ■CITY OF CUPERTINO* CUPEIZTINO 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 Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIN4 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 • 3'of3