05020145 CITY OF CUPERTINOx' h' " - "4o �.
BUILDING DIVISION PERMIT ; CONTRACTORnINFORMATION k:
BUILDING ADDRESS: CRW INDUSTRIES PERMIT INb5020145
OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
LOO LICENSED CONTRACTOR'S DECLARATION
m❑ 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
iW with Section70M)of Division 3 ofthe Business and Profusions Code,and my licensee
„« in have(vena and effect.
012z License Class Lica REPLACE PATIO DOOR (BEDRM) '
nFti Data cmarriermTSDECr
'�-g ti ARCHDla,tate DECLARATION s,
¢ I understand my plans shall be used as public records
J0V
3LL Licensed Pmfcvlonal
On OWNER-BUILDER DECLARATION MR
F 0 0 I hereby remo .('Sham chat I oar cBtmpt from the Pr Contractors License law for mhe
y
F.po which re mason.Permit
Or construct.
Business and improve,
de um Cate:Any city or moue p�A pyyQ 9 9nyys
Q.ff which requires a pewit m cnnmmcL aloha,improve,demolish,or repair any structure
prior u its issuance,also requirrs the applicam far such permit m f le a signal suumcm
t E-i thwheislicensedpuanuo Nepmvls(omofthe Conwcmri Licesela
nw(Chapur9 Sq. Ft. Floor Area �'7 /p Valuation
y rsu
I-S (commencing with Section]u xe000)of Division 3 of the Business and Professions Code)at yy�
_ that he empt therem basxe
froand the is for the alleged emption.Any violation of //��aryT ll O
Section 7031.5 by any applicant for a permit subjects the applicant In a civil penalty of 3 2A61' 1195 8be0 O " 'Otto ane T e
not mom gen five hundred dollen(5500). �� P� y yp
I,as owner of the property,or my employees with wages u their sole compensation, ATO
will do Ne work.rnd the structure is not intended proffered fetish,(Sect.7W Business Required Inspections
and Professiom Comic:The Contraemer's License Law does not apply in an owner of q p
property who builds or improves thcrcon.and whodoes such wart himself or throughhis
own employees,provided that such impmwmcnv are not intended oroRered forsao.If,
however.the building or improvement is mid within am year of completion.the owner-
builder will haw the buNen of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct One pmjcct(Sec.7B4a,Business and Professions Code)➢m Contractor's Li-
carve law docs not apply to an owner of property who builds or improves Ihemon,and
who contracts for such projects with a eammetor(s)licensed pursuant to are Contractors
License Law.
Owner r Dau
� WOR R'S MPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dethummns:
1 haw and will maintain a CertiOeme of Consent to sel-insure for WorkeesCamper-
drn.as pmvidcd for by Section 3]00 of the labor Codc;for the performance of the
737
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as mquimd by Section
M of the labor Code,for the performance of the work fm which this permit is issued.
y Workers Compensation Insurance carrier and Policy number sun:
rrier. Policy No.:
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Daissection mad not beeompleud Tribe permit is foram hundred dollars(SIM)
.,less.)
1 canary that in the performance of the work for which this permit is issued,I shall not
employ any pcPan many manner an as w become subjeo to the W.rkeri Comperoa0on
laws.f California.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Cenificau of Exemption.you should
hecome subject to the Worker'a Compensation provisions of the Labor Codc,you must
.,z f.Mwide comply with such pfnvlalOm.r this permit shall IN,deemed rooked.
z CONSTRUCTION LENDING AGENCY
F (hereby M.Nat then is.coourneion lending agency for the performance or
me.,it fur which Nis pc.it is issued(See 3097,Ci,C.)
Itl Q Lends is Name
z Lender's Add.
V Q 1 cenify that 1 ham read this application arW sunt that the about information is
Cf~ cower 1 agree to comply with all city and county ordinances of and save laws relating e
C beve-gconmmctioaand herfor moruthorimreoses, utives.f Niscirymrnurupon the S
r W above-mentioned property for mortify an purposes.
(We)agree is cove,indemnify and keep harmlesom tiro City ro Cupertinoagents,said
againstfiabil
FN inconsequence rruecraving of this permit, may in any wayaccrue agairataud City
U z A consequence UNDERSTANDS
of this permir.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2
rbb.y
s W. Z2f US Re-roofs
A HAZARDOUS MATERIALS DISCLOSURE tor Data Type of Roof
Willthe applicant or future building occupant store or handle hanNous material
the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
n zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
s ❑Nothe applicant or future building Occupant use equipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
us air contaminants as dcened by the Bay Area Air Quality Managementall new materials for inspection.
s ❑No
1 have mad Ne eaard.m materials reyvirtmcros under Chapter 6.95 of the Califm-
niaHealth h Safety Co/c.Scmom 355)5,15533 and 25534.1 undcmvd that it the building
does not currently hat a remain,that it is my reswouniny to anti ly the occupant or the
ryc.a which Ikmst,pr;rr In inaame of a ccnireme or aer y ,� Signature of Applicant Date
(/ 2
Civil',in amh 'ed aF t Dau All roof coverings to be Class "B"or better
f b Community Development
e J
10300 Cupertino
Torre CA 95014
If
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPERTINO
Building De artment
JOB ADDRESS: PERMIT #CSS OHO 1 4�
1 Dq 31 l� ` Oc�1-
OWNER'S NAME: t CLnle-i-\ PHONE # qD —
GENERAL CONTRACTOR: (Z VJ FAX #
I am not using any subcontractors:--� g—/2-2 os–
SigWah e Date
Please check applicable subcontractors and complete the following ' ormation:
21 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
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Date:
10510 ,
Building Address: Mailing Address (if different from building address):
Oq 3� Luck, Cod. i
Owner's Name: Phone#:
Tam C \ue _ X40%
Contractor: License#:
YYl2 DH_ —
Contact: /� 1 Phone:40% r Cupertino Business License#:
I,ZGt`VQZ Fax:
Building Permi fo:
Bldg.'C] Elect ❑ Plumb ❑ Mech ❑
Job Description: r2plciCJ?, ]n bWR5Dm
Residential 931, -r h epg& ct?D r Commercial ❑
Sq.Ft. Floor Area: S/Sq.Ft.:
Cost of P 03,ecq-7Occupancy Group:
Type of Construction: Please check this box if the project is a
6?"'
/ second-storyEDaddition:'
Proiect Size: Standard 6? Large ❑ Major ❑
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
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
7
1 of 3
4V23. �
G�1 CITY OF CUPERTINO
CITY OF' PERMIT APPLICATION FORM
CUPEkTINO
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
BOVERTHAE Inspection Overtime BUILDING
13PBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPIN ERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Re eat 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 Reins' ection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIltHAN 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
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
m, CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTlNO
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 Insection 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
3of3