04110044 CITY OF CUPERTINO COL CRACr QR T �
BUILDING DIVISION PER rq+a' q ,w, „ , < -•y" *^"
PERMIT NO,
BUILDING ADDRESS:
ROCKY LOWELL CONSTRCUCTION 04110044
PERMIT ISSUEDATE
A
SANITARY OL NO,
YHON
—648 BUILDING PERMIT INFO -
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
A
ypQ LICENSED CONTRACTOR'S DECLARATION lob De
w 1 hcrcb affirm that 1 em littnsed under provisions of Chapter 9(commencing
n< with Saelianl 7p(Divislon3of Ne Bumncu and Profeasinnx Codd,and myliccnae6
ALEU
in full forte t t '
5gz Licen class Lic.g-�p HALL BATH. REMODEL
D _ 1-5Wf L DEL, 2o- 1004
pp A HITECT DELLAR ON
y R under�st9ra�d•my plan shJlt s p li m ods
BUILDING
p Lica 1 Woupal
W NER-BUILDER DECLARATION
5 a 0 I hereby.(firm on 11. exempt from tit Contractor's License Law for the
i p D following recon.(Section 711315,Business and hvleaainau Code:Any city or county
w m FZ' which requires a permit,,etmat mel,Jtor,improve,demolish,m repair any xuueture
Fly prior to its isiuelme,alsorequirestheapplicant(orsuchPermittfileasigned statement S Ft.Floor Area Value
that he is licensed pursoam to the provisions of the Conlru:tr's Limnse Law(Chamer9 fi-
re 0 (commencing with SCe11un7M0)mf Divubm3 nfmc Businassand Prafcienns Cadc)ur
.. that he is exempt th refrom and me basis for de allcgcd asereption.Any violation of ,�F�I-w�q�'W'..u,y6 l�
Section 7031.5 by any applicant fora permit subjects Ne applicant to a civil penalty of 3 G O 4 7 V V L e U 0 Occupancy Type
mat more Nan Bvc hundred dollars($500).
❑1,m ownor work,the Me am,,ar my ut plans una cared for dteir sole compensation,
and Pr thensands: ah Contra nmtl Clean.unaltered does at apply 7o ad,Business Required lDSpeCt10DS
and Professions Code:The Centaaor's License Law such
not apply lf an owner is
propeuildsorimpmveach impr and whowments aressuchwnrk himaeVer ahmugb h{f, i
..,.employ..,providedmrsuchimissold itarcnet ear atdmolTered for manor-
builder me building or improvement is sold did one year of comple,on.for meowneo
builder will have the burden of proving Net he did not hula or improve for purpom of
sal.l.
❑1,as owner of me properly,am exclusively contracting with licensed contactors in
construct dm project(Sec.700x,Business and Profession Code:)The ConussOmen Li-
cense law dors not apply to in owner of property who builds or improves Mamen,and
who contmcn for such pmjecn with a commuccons)licensed pursuant In Me,Contractors
L'ansa law, -
IamexempiunderSee. ,B&P C for this mason
wool Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following decimations:
1 here and will maintain a Cmdfscat of Consent a self-insum for Worker'sCompen-
.M...as provided for by Section 37W of the labor Codc,for me performance of die
work for which this permit is issued.
1 have and will mainlsin Workers Compensation Insurance,as required by Section
3700 of me labor Code,for the performance of me work for which this pemait is issued.
My Wade,'a Compensation Insurance carrier ad Policy mnatoo a:
%Cattfe[' Po No.:
(" CERTIFICATE OF EXEM WORKERS'
COMPENSATION INSURANCE
('This ared.....d not M completed if the permit is retreat,hundred call.(SIM)
less.)
1 certify mss I me perfonnanec of the Walk to,which this permit is issued,1 and]Out
employanype ymenne snazm{+)2o ;nano me Workers'Compensalion
Laws of Calif. atc�sa
vp�licam (.V
NplyCp TO APPWCA Compensation
pimisoiftatc of Came Cods,y you
.
b
subject t the Worker's Compcnsstion Provisions of the Lahnr Code,you muxt
,J Z forthwith comply with such provisinv nr this permit shall be deemed mvoked.
zO CONSTRUCTION LENDING AGENCY
(—a l hereby affirm tradition is a construction lending agcn,for me perfurmmcc of
(�7 me work for which this permit is issued(Sec.3097.Ch,Cd
W Q Lendcr's Name
Landers Address
V Q 1 certify that I have mad this application and sat that tit above of-m-ties is
W (•' correct 1 agree to comply with all city and county ordinances and sate laws relating to
building construction.and hereby audomixe mpresenmivcs of this city to enter upnn me
0
purpo
�11W above-mentioned property for inspection which s. �/`^�/`+a/v
D.t (We)agree to save,indemnify and keep harmless the City of Cupertino against
teaz inconsequence or Me
expenses thispcnnit. may inany way accrue against said City
Uz in consequence of the gmating of this permit Date fV
NT UN ERSTANDS AND WILL COMPL WITH ALL NON-POINT Issued by:
` S R REGUL IONS. �,`
Re-roofs
Si wrcofApplic Cc a r Dat eofRoof
RDOUS MATERIALS DISCLOSURE Type
ill the applicant er future buildin6 occupant smm orhandle hevardous mattlal
as defined by the Cupertino Municipal Code,Chapter 9.12.end the Hcalm and Safety
Code,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Y a
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applivant or
Kim occupant use equipment or devices which
trait harmdnus air cmatam.nanm dcfocd by me Bay Asa Air Quality Management ew materials for inspection.
District?
❑Yes
I have mad the harardmu atrialstquimmcnmun&rChaptr6.95ofmc Calif -
ria Hcaldi&Safety Code,Sections 25505,25533 and255]a.lunticrsand thuifdic builJing , `l
of emmm y have a tnanl,that u is my responsibility m notify thc occupant of me
ui menaw chn tbemetpriortuissu Co fa Ccnihcat or0c ancy. 5' g ture of Ap Ic nt Date
Da,e All roof coverings to be Class"B"or better
0 n r Or aame gnet
I �, BICE
N
d
1•
r O NOV 0 2004
Y.
s
`{'N 6V\ e cz- s pspPRoVED
u A ACfABDAN WITH THE C fff 00
gppERf1N.
CGI��eCtn� a� ert-0 A
1031 ��. �r^� .n•,.�
`�� . Ffiia . plans and specifications MUSL
ba go the job at all times and it Is MCI
t�pcfi� tr r, C t Cv �/�/ �wfYul any changes or.
alterations
to
s waout written permissiOR from
lre
50649 Dirt., City of Cupertino.
she sta"Ov 4 its plan and specdicatfoo8
lN�d�li Vii; tv held to permit or to be A
Q i,of the yKoa8on of any prw
OGO
.a WW r"fv 0141^4" er trete law.
•
a•
a;61.
*ITY OF CUPERTINO
ct CUPEkTINO
PERMIT APPLICATION FORM
APN# / Date:
Buildin Address: Mailing Address (if different ffrom building address):
i � N Mak,.413 DZ
Oer's Name: Phone#:
-t i vt e -m V
trac or: License#:
C� ECO
Phone: H09 Cupertino Business License#:
Fax:
Buil ing Pe t Info:
Bldg I[— Elect 11 Plumb D-- ` Mech 0�-
Job Description: 14-a
r �„� �S
- Residential Com'` e - �-�'✓k� Commercial ❑ `
Sq Ft Floor ea: $/Sq.Ft.:, , 1
Cost of Project: / Occupancy Group:
Type of Construction: — - Please check this oject is a
secon&sto addition:; ❑
Pr
o'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee 'Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERl 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
BBOILERS Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAX13Q 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
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WITY OF CUPERTINO
CUPE�- PERMIT APPLICATION FORM
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
BOVERTIME 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
BPINfERCEP 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
a 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 Furnace MECHANICAL
BREMFURNOV Relo Furnace> I 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/ Iter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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IwoWITY OF CUPERTINCO
CUPEI�TINO PERMIT APPLICATION FORM
uanti 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
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL _
BTEMPPERM Temporary B1Permit 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
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