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03040081CITY OF CUPERTWO • ,� P;;ia x n ��tid � v� � - "C®NTRACT{O,R NT BUILDING DIVISION PERMIT -10 Y.%a ✓.+;4ACP�#., �,.Yv'.'Cd.Y w?>..,.5.tx-.GAJ . afffil"WItADOW PL KATJA & MICHAEL DE GROOT PEI""°03040081 'k,' UV& MICHAEL DE GROOT 5/2003 ONE: SANITARY NO. CONTROL NO. ARCHITEC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 1thereby that Iam licensed underprevisionsprofessions Chapter 9(rommenseis Job Description ion700).f salt Section 0 d cf of Division 7 of the Business and Profcssim Cade, and my license 6 I. full fame and effect License Class Lu. I Dau ConlMor r ARCHITECTS DECLARATION 1 urrdcnunJ my plain shat) he used As public records LL' CJ�(�r-�r�[ LTL �\ J ✓.�J ✓ / Licensed Pmfcssumal OWNER -BUILDER DECLARATION 1 Wmby eaimr that 1 exempt from Ne Contractor's Law faulty Any whovwhich ng mason. t 7 1. Business and 1.5, r.". res Ode: Any can car county : C which MIL ran aur, impmw, de Wa a permit nae ,. improve, or nasir any awmun its Line also acquiree the Applicant of for such admit W ices signed statement h Permit t Prior b its licensed tathe Is auwamlodw provisions to snd Sq. Ft. Floor Area $�'s"ion mentCeMed beCode) or ProllawsCade)9 (commencing with Sections, And of Division 7 the the Business and.a. Any Nn he u stamps therefrom and the buts fm lou alleged cacmption. Any vlo6don at Section 1071.5 by any applicant for a Permit subjects Ne applicant W a civil penally ofA not mom Nan five hundred delta. pM N y. 34 ED10101et 0O Occupancy Type ❑ 1, As owner of to pmpeny. or my employees with wager As their sale Compensation, wilt do the work, and On cwctu. Is nut intended or offered for sale (Sec. IDM. Busince, and Pmrexans iCoo: The Conulano acter's License w does t apply W 101— D psbagyd Inspections an owner of properly who builds or improves thermamd whodoes such work himsefor through Ms 102 — .s _.•_ PIERS own employees, provided that such Improvements Are ami inteeded or offered forale.If. 103 — IJFER howew:r, the me building or impmwnt Is old with. enc year of aompiman. Nawn so. awr• Wilder will haw du burden of proving tat he did not Wild or Improw: fn purpose of 10 4 — REBAR Bale,), I, n weer of progeny, convening with licensed epntaman m 105 - ANCHOR BOLTS CI , B siness and Contractrej 106 - SEWER & WATER Cause law dots not je is wear of property who builds or impmw Nemo.. atl, who contracts far such prohcu wlNacanuacma(pliamed pursuam rete Camm�orS 202 - UNDERFLOOR PLUMBING `W` w' am eaemPt and See. k P C fa Nis reason 203 - UNDERFLOOR MECHANICAL ' ,o q��/� 204 - UNDERFLOOR FRAME saner WOR SCO ENSATIONDECLARATIONam —""G 205 - UNDERFLOOR INSULATION I hereby Kinn coder penalty of perjury aro of the following decluetmiu: 301 — ROUGH PLUMBING L. I haw and will maintain a Ceninnu of Consent o self -Inure fm Warkeh Cempen• 302 — TUB & OR SHOWER .tion, As provided for by Sccr on 7100 of the labor Code, for the performance of the work for which this Permit is issued. 303 - ROUGH MECHANICAL ❑ 1 haw and will maintain Walaces Compensation Insurance, As required by Section 304 - ROUGH ELECTRICAL ' 37M of Nc labs Code. far lou Performance of the wank Tor whim this permit is Issued. 305 — FRAME My Warkefs Campeaation lnurnnce artier and Policy number art: 306 — H(OLDOWNS Carrier.CERTIFICATE OFEXEMPIONFROM WORKERT 307 - INSULATION COMPENSATION INSURANCE 308 - SHEETROCK or less) CMTS auction reed not W completed if the permit is far as, hundred dollars ($100) 309 - EXTERIOR LATH 1 certify Not in the Performance Of tc work for which this permit is issued. l shall net 310 - INTERIOR LATH employ any person in any moarm at W become subject W lw Workces'Compenvtian 311 — SCRATCH COAT laws of Califomia. Dau Applicant 313 - 501 - ROOF NAIL .FINAL ELECTRICAL ENERGY NOTICE TO APPLICANT. If. After making this Certificate of Exemption. you should become oW subject t e Worker's compensation provisions of Ne labor Code, you mute forthwith eamany wilo,nch provisions or this permit shall W Memed rtwkea. ^ 502 - FINAL PLUMBING ENERGY CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY I Wnby alrvm tat Nen ba cocconclon I.adinggcncy far the imformarccuf the work fur which Nis permit is issued (Sec. 7097. Civ. C.) 504 - FINAL BUILDING ENERGY ``"dee'"`m"r` 505 - FINAL ELECTRICAL Lcrd.es a ess 506 - - GAS TEST I Certify lost 1 solve read this Application am sum lots theabows rt information U carnet, l qme w comply with all city and county ominameund sou lamuting to 507 - FINAL PLUMBING Wilding construction. and hereby autorio nopresenutiw of this city to emel upon to Bbove-anemioned property for inspection onfams TN — FIN L MEC ICAL (We)judgments.to (Wc) ague to ave, indemnify and keep marinas the City of u rtin — F IIlablli0 coats and apeman whieh may in anyway came e against mid aid Cityin �01 consequence of 1be grun ng Of tis permit APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: NG C WORKSDate SOURCE REGULATIONS, Re -roofs Type of Roof Signature of APPlicaunufConitatoo pats HAZARDOUS MATERIALS DISCLOSURE Will the or future Wilding store or handle h maudtl As dc. a Cupem eaNaus the Cupertino Municipal Code. Chepur 9.17. inti to Health and Sa(ety e, Chapter and Sec io GWe. Section 25571(a)1 ) ❑Yes QINu All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building acupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove ammmus air contaminants As defined by the Bay Area Air Quality Management District? all new materials for inspection. 0Yes No I have read to h.. us. ,ialsmquimmenuundcr. Chapur6.95ofthc Califor. niceHe.ltb,$Sal. ty COdc. Sections, 25505,35577 and 25574.1 undersand that it un,Wilding 've arcs not On t a unapt that h is my rtaponsihility W notify the =upot of lobe mquhe iehfustbenot pot missuo .CcnincaWafOccupancy. Signature of Applicant Date C All roof coverings to be Class "B" or better ler car .at r<d agentW m 0 M, 57nl VN N 7z, LA -, rlo 0 M, 57nl 0 M, ,6a 1 CITY OF CUPERTINO r L CITY OF CUPERTINO • 03 0 �� PERMIT APPLICATION FORM PN # rBuil Fee Description Date: y�a� 0 3 ding s. Az '/,o . O"Addres/3ac.o to v BUILDING Owner's Name:Phone N Boiler <= 100,000 Btu #: yo8/as3-7/-7/ Contract4: Boiler > 100K to 500K Btu License #: . BBOILER3 V l 1 LdFi(� MECHANICAL Contact:? - G Boiler> IM to 1.75 M Btu Cupertino Business License#: Building Permit In : MECHANICAL Bldg Elect Plumb Mech ❑ Job escnption: Ind/OfFCOmm/ uasi BUILDING Residenntial—� Commercial ❑ Sq.Ft. Floor Area: Hotel and Motel $/Sq.Ft.: Cost of Project: �% V y Occupancy. Gro Type of Construction: Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances . MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K -to 1M Btu MECHANICAL BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/OfFCOmm/ uasi 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 BMITIGATC Comm. Housing Mit. Fee BUILDING CITY OF CUPERTINO `� "" ' ` a•r a y '-• "' XONTRACTORANFOR ATION: BUILDING DIVISION PERMIT Tffff1WtADOW PL KATJA & MICHAEL DE GROOT PERMIT NO. 03040081 OArNERS-NAME& MICHA&L DE GROOT FE "E'S'd S/2003 .NE: "� MAY a 2 2903 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 9 BUILDJob Descri tion p I wacby air". Thai I am licensed under provisions of Chapter (commencing wish Scaion 7)(B car Division Infuse a and D.Amen Faurcasinm Cede. end my licenx is in full ionic and cfrmL mTTT TT^T 7Sa� Licenw Class Lie. as Dam Contractor ARCHITECTS DECLARATION �• Gr CTao�i�sr� (J.T'��%� 1 understand my plans shall W used as public accoms Licensed Pn rkssional OWNER -BUILDER DECLARATION I hereby alfirm that l am exempt from the Contractor's License Law for the following mason. (Section 7631.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improv=, demolish, or repair any structure prior tar IB issuance. also requires the applicant for such permit to file a signed statement Sq. Ft. Floor Area that he is licensed pursmnuo the provisions it[ he Contractor's License Law (Chapter 9 $�f§"Ion (commencing with Section 7(17) of Division 3 of the Business and Professions Cade) of Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of 34M D19141171eC 0 0 Occupancy Type Section 7031.5 by A, applicant for a permit subjects the applicant to a civil penalty of not more Nan five hundred dollars ($500). 1, is owner of the pmpcny. car my e.play. with wags a their sole mmpronal 101 _ UND�i� d will do Ne work, and On structure is not intended of offered forsalc (Sec. 7614, Business and Professions Cade: The contractor's Liceme Law docs not apply to an owner of Inspections property who builds as improv thereon, and who docsswh work himselformrough his 102 — PIERS own employees. provided that Such improvements art not intended or offered forsale.If. 103 — UFER however. the building or improvement is sold within c m year of comphomm. the owner builder will have due burden of proving that he did not Wild or improve for purpose of 104 — REBAR .I.) 105 — ANCHOR BOLTS O I, as owner of Ne runway. am exclusively contracting with licensed contractors m consumer the Pauper (Sea.70a. Business and Professions Cod,O The Coconut Li 106 — SEWER & WATER Rena, taw does not Apply as an owner of property who Wilds or improves thaawn, and . 2 02 - UNDERFLOOR PLUMBING who contracts for such pmj"u with a comnetor(s) licensed pursuant de, Con socmfs Li=en taw. 203 — UNDERFLOOR MECHANICAL am ea,mpt an sec. aaPCC/ror or, t,aan 204 — UNDERFLOOR FRAME caner ate 205 - UNDERFLOOR INSULATION WOR �R'SCOMPENSATIONDECLA0.ATION I hereby alrum oder penalty of perjury one of the following declinations: 301 — ROUGH PLUMBING ❑ I have and will malarial a Certificate or Coaenuo selfdnsum far Walker' a Camper- 302 — TUB & OR SHOWER sation, in provided for by Section 3710 of the Lattice Code. for w performance of the 303 — ROUGH MECHANICAL work for which this permit is iaued. 304 — ROUGH ELECTRICAL ❑ 1 have and will maintain Worker's Compensation Insurance, a required by Section 37W of the Leber Code. for ew performance of the work Tor whim this permit is issued. 305 - FRAME My Worker's Cam ranadon lmumnce carrier and Policy number arc: 306 — HOLDOWN.S• Cartier: Policy Na.: CERTIFICATE OF EXEM PTION FROM WORK ERS' 307 — INSULATION COMPENSATION INSURANCE 308 - SHEETROCK (This section wed not he completed if the Permit is for one hundred dollars (S 100) 309 - EXTERIOR LATH or less.) 310 — INTERIOR LATH I ratify Out in me porformancri of the work for which mice permit is issued.I shall nit employ any return in any manner An As to become subject to the Workers'Compensation 311 — SCRATCH COAT Laws of California. Dale 313 501 — ROOF NAIL — ELECTRICAL ENERGY Applicant n, you ld catc NOTICTOAPPLICANT Coed you mast became oftWor:If. con,ackirumnP visinsofofEabor Crum. becomeh comp y the Work.,', fa Comp; mr his previsions of the deemed forthwith comply with melt pmviainm or his permit soon Wdcemed revoked. SOZ ,FINAL — FINAL PLUMBING ENERGY CONS rRUCT10N LENDING AGENCY 503 — FINAL MECHANICAL ENERGY I hereby affirm Our them is a convection lending agcory for the Performance, of 504 — FINAL BUILDING ENERGY the work for which this permit Is issued (sec. 3797. Civ. C.) Lender's Name 505 506 — FINAL ELECTRICAL — GAS TEST UndersAddreas I ceniry mat I have rem this application and sum that the above inromiadan is 507 — FINAL PLUMBING comply with all city and county ordinances and slate laws relating correct. I agree m m building convection, and hereby authorim repmsenmdves of this City to enter upon the — FIN L MEC ICAL above-mcmioned partially rot ins,acdon purpows. (We) agree to save, indemnify and keep harmless the City or Cupertino against O — FI liabiI tick, judgments. costs and expenses which may in any way accme against said City 5 NG in consequence of the granting of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: _ C WORKSDate SOURCE REGULATIONS. Re -roofs Type of Roof Signature of ApplicaDam HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building material Imre or handle h ealth e. Chapter a az defined by me Cupertino Municipal Code. CAapmr 9.11, and the Health and Safety ni Calc, Section 25532(x)?�% All roofs shall be inspected prior to any roofing material being installed. fMYcs 1-4. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or✓fWore Wilding occupant use equipment Or devices which it, haiardnm air contaminants a dcfincd by the Bay Area Air Quality Management all new materials for inspection. Disuict7 ❑Yes -' Nn r lhave rem the bva lremenmundefwapter695 or be nds n505.2553als boning nice Fkalthd: Safety Crude. Sccduuhat it 13And 25536.1 Off Wilding is does not cu t ata: a tenant. that it is my respomihilitY to nodly IW txcupant or me to entry ¢quirt ichmusthmUptiurmissuanccyn�yeeninea¢arOcgapancy. Signature of Applicant Date 1 C All roof coverings to be Class "B" or better wncf or authred .,cut Via