03010194 (2) CITY OF CUPERTINO M �_;
BUILDING DIVISION PERMI CONTRACTORgINFQRMAT a'
BUILDING ADDRESS:
PERMIT NO.
10846 NORTHRIDGE SFINAI 01010194
OWNER'S NAME: APPLICATION SUB DATE
IRENE Z BOWLBY APR 20 2nQ4 O1 30 2003
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
OPOp LICENSED CONTRACT'OR'S DECLARATION
<Umu 1 hereby efflrm Nat I am lim it u der provisions of Chapmr 9(commencing lob Description
<i with Secsinn]000)nf D' on 7 of me Burins nth fafcuiom CnJc,end mylicenu is
Zp�z< in mum deffect t ��w / BATHRM REMODEL
LiccnscC 3 Lm.M
�o � Vdo /dmy plc uscgA
;?LAR TIO
public records
LLOF_ L¢cnud Pmfcsstdnal
11
OWNER-BUILDER from
DECLARATION
<f 1 hereby affirm that 1 am exempt from slid Cssions rc s:Any
Law fou the
i 00 following reason.(Scedot ]onstr Business and Professions Cods:Any city or county
$� which requires a peraftt.also ac construct,alcor,improve,demolish,or repair any structure
:zC primloits iuesed Palusat'a res theappcant for Contractor's
file A censeLaw(Cned hacmcm
cs That heislicensedpursuammtheprovisionsoftheCemracmrsLicenseLaw(Chapmr9 Sq.Ft. Floor Area $20 tion
le (commencing with Section 7")of Division 3 of the Business and Pmfeasiona Code)or
y�..
that he is exempt therefrom and me basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to acivil penally of
not more than five hundred dollars(g5)B) e Occupancy Type
❑ I,as owner of she ppeny,or my employees with wages u their sole compensation,
will do the work,and the strvctute is not intended or offered for sale(Sec.7044,Business
.and Profusions Code:The Contractors License Law does not apply to an owner of
p10 2 _ PIERS equtred Inspections
progeny who buildsor improves thereon,Intl who does such work himself or through his
Own employees,provided mat such improvementsarenot intended moil forsale.If, 103 — UFER
however.me building of improvement is and within one year of completion,the owner-
builder will have the burden of proving that he did not build of improve for purpose of 104 - REBAR
,ale.). 105 - ANCHOR BOLTS
❑L u owner of ct Sec.70,.B exclusively contracting with licensed convectors to
dnnawdt me project(see.]al,,Baainess and Ihnresamna cotle:)The Contractor's Li. 106 - SEWER & WATER
veru Law does not apply to an owner ofproperty who builds or improves Imac.n.end 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a commedor(s)licensed pursuant to me ConvecsorE
can.Law. 203 - UNDERFLOOR MECHANICAL
lam exe Se. ,B&P C for this reason 204 - UNDERFLOOR FRAME
own oaac 3t7— 205 - UNDERFLOOR INSULATION
\ O IS COMPENSATION DECLARA ION
Ihereby.0irm
on derpenaltyof1dToyoneofm towing declarations: 301 — ROUGH PLUMBING
Ihave and will maintain.Cenificam of Ccasenuo self.iWara for Workcr's Compen- 302 — TUB Fie OR SHOWER
cation,as provided for by Section 3700 of me Labor Code,for me performance of the 303 - ROUGH MECHANICAL
work for which this permit I.issued. 304 - ROUGH ELECTRICAL
❑I have and will maintain Worker's Compensation Insurance,as required by Section 305 - FRAME
3]00 of thla
e bor Code,for me performance of me work for which this peu ch is issued.
My Worker's Compensation lasuccom carrier and Policy number are: 306 — HOLDOWNS
Carrier PNo.:
307 - INSULATION
CERTIFICATE OF EXEMPTIONION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
orleac.)
(Ems section need nm M completed if the permit is for one hundred dollars C$11) 309 - EXTERIOR LATH
310 - INTERIOR LATH
e certify that in the pert once of the work for which this pe it is iuued,l shat l not
employ any pe n mannersAsstu�ec�esu�ta�woukcri Compensation 311 - SCRATCH COAT
Laws
Ili 313 - ROOF NAIL
Law of
N OAPPLICANT:-1[oftcrmakingNisCertifcascofExemption,you should 501 - FINAL ELECTRICAL ENERGY
Mcn a subject to the Worker's Compensation previsions of the Labor Code.you must
OO forthwith Comply with such Provisions Or this permitshall the deemed mvoked. 502 — FINAL PLUMBING ENERGY
z
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
H Ihesbyan!.thetthem isac.maractionleading agency fill 0.ist,mmaneeof 504 - FINAL BUILDING ENERGY
947 me work for which this permit is issued(Sec.3097,Civ.CJ
wzLender's Name 505 - FINAL ELECTRICAL
Z Lender's Address 506 - GAS TEST
U 0 I certify mat I have read this application and All that the above infmmedon is
d, F cotsreel.I agree to comply with all city And county ordinances and spite laws totaling to 507 - FINAL PLUMBING -
pU building conswcsion,and herebyaudamriverepreuntativesofmiscitytoenteruponthe FINAL MECHANICAL
above-mentioned property for inspection purposes.
F y (We)agree to save,indemnify and keep harmless the by of Cupertino against 09 FIN
.y cn liabilities,j udgments,costs and expenses which may in any way accroc against said City CJ G
U z in con2tence of the granting of this permit.
ti SOPLICANT UND RSTANDS AND WILL COMPLY WITH NON-POINT Issued by.-51 WORKS Date
nam nfAP canVCOmravIOf —V Re-roofs
Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant store or handle harallous matcnal
At
rlofinetl by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safely
Carlo
Seams zss3xa)7 All roofs shall be inspected prior to any roofing material being instal d.
❑Ycs
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 emove
mitict? usairwnmminantsasdefinedbytheBayArcaAirQualityManagcmcnt all new materials for inspection.
District? /
❑Ycs
1 have and me havamous materials acquirements under Chapmr 6.95 of the Califon
ria Health&Safety Codd,Satioas 25505,25533 and 25534.1 understand that if Bad Wilding
hicalnn,,o,,�gcpppurrently have a actual,that i t is my responsibility in no the occupant of the
rcqua dh c mel prions issuance of a Ccnifiwth ", Si
V Signature of Applicant Date
o of or hnrnaed agent Date All roof coverings to be Class "B" or better
f�
TITY OF CUPERTINO � o3 c>1
CITY kT
CUPEI�TINO PERMIT APPLICATION FORM
all APN# /
-- � Date:
Buil in A ess � /
Viet
Owner' Name: Phone#:
WL i
Co r: I Lice e
Contac_ 44-
�L Phone
Applicant1contr ctor:��3
Fax #:
E'L o s `�i FlZ3 - 5'FG Z
-Ruit 'ng Permit I fo:
Bldg) Elect Plumb
Mech
J escription:
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupanc r
YKr
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other A liances MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
BCONSTAXBQ Con. Tax for B Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax RResi/Mobile BUILDING
13ELEC1000 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
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-P--;,-Res MECHANICAL
BNEWMULTI New Multi-famil Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
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666. f,a
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'- CITY OF CUPERTINO
c'TM°F PERMIT APPLICATION FORINT
• CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BNUMULTI New Multi-family Res PLUMBING
BOVERTIME Ins ection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pbl 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 Pi e PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reins ection Fee BUILDING
BREMACOVER A/C Unit> 10,000 chn MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI LAppliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFFURN Relocation of Furnace MECHANICAL,
BREMFURNOV Relo Furnace> 1 OK btu MECHANICAL
MBREMTHEAIR
EAT Heater Installation MECHANICAL
HOOD Installation of Hood MECHANICAL
ISC Misc Apparatus ELECTRICAL
RAPP Rem Non-Res Appliance ELECTRICAL
OLE Pole/Platform Fixture ELECTRICAL
OWER Power Device/Apparatus ELECTRICAL
RECEPT Rc tl, Switch & Outlets ELECTRICAL
ELOCA Relocation of Hood MECHANICAL
EPALT Repair/Alter HeatingMECHANICAL
ESAPP Remodel Res Appliance ELECTRICAL
IGNAD Rmdl Signs Add Branch ELECTRICAL
IGNS Remodel Signs,Marquee ELECTRICAL
HEATR Theatrical Li ting Fix ELECTRICAL
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CITY OF PERMIT APPLICATION FORM
• CUPEkTINO
want' Fee ID Fee Description Fee Group
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSF&2FAM Single &2 Family BUILDING
BSFNA Single Family New Add BUILDING
BSPECIAL S ecialInspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Tem orar Power . ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Dec 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
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> 1.75 M Btu MECHANICAL
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129 -
I "UpFaTI S Dl 1 QrcS AN iNACCCM
s set of Awns and specifications MUST
kept on the job at all times and it is un
J ,`ul to make any changes or alterations
ame without written permission from
)ui;ding Dept., City of Cupertino.
41056 Vo•omuadno stamping of this plan and specifications
'b8• a8puyyrol494801
Acumo9'Z aua.rl * nLL NOT be held to permit or to be an i
.oval of the violation of any provisions
yt City Ordinance or State Law.