04030159 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMI . COiTiAC)ItX �
BUILDING ADDRESS: PERMIT N0.
ANDERSON INSTALLATION 04030159
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY T OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
p t� 0 0 0
LOO LICENSED CONRACfOWS DECLARATION
i I hereby grim that I sen licensed under provisions of Chapter 9(commencing Job Description
u< with Section 7").fDivision Sofm.Business ared Profession,Code,and my license is
< in full foam and orfocL
LIcensecias, Lic.x WINDOW UPGRADE
q Dam Contractor
ARCHITECTS DECLARATION
I undmatand my para shall be used as public records
u.
1L ensed Professional
OWNER-BUILDER DECLARATION
4 1 Wahy from Nal I am exempt fru.the Contramors License Law for the
a0 following reason.(Section 7031.3.Business and P eficaS Ins Code:Any city or county
$ which requires a Permit to convect,elmr.Improve,demolish,ser term,my structure
prior to its issuance,she requiems the applicant for such permit to file a signed statement
�< that he is liccmod raiment In the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuatl n
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he Is exempt therefrom and the basis for time alleged exemption.Any violation of
Section 7031.5 by any Applicant for a permit subjects the applicant to a civil penalty of 3 (�Iy2Tger 0 0 Occupancy Type
eat moa Nm five hundred dollars(5500).
❑leas owner of the property,.my amployco with vngeam their cele componution,
will Pr Bmwons endo:TheCmiaeotinkndad Lt.ddfoual Apply In in
Required Inspections
and anywhona Cade:The Canfeearer's License Law dace not apply lf rt owner of q P
manproertywha s,preceded met
himprove ets dorsa innandk mroffrarthrough his
ownemployees,provided pr suchimprovemanuareneyou afcoro@ad for sale.B, _
however,He haw
Lim or improvement Is mid within one you ser improve
for Ne owom-
builder will have the boNm of proving Hat W did not build m improve for purpose of
samJ. /
,u owner of ct property,am exclusively confessions with licensed Cameraman's
U.
��/O�
"w s La the project(see.7040,owner
or and professions Code:)The Cs daemon.
Ld
who lawdotsnotapply.en ownerof enclady who Wildsarimprows Contractors who contracts for pmjeeu with a eanvactor(q licensed pursuant to tie Contndori
License Law.
❑1 am exempt under Sec. - B k P C for this mason
nee � —on.227 10'1
•WORKER'S' P A
1 hereby of iren under Penalty of perjury ore arms fol ins decimatimm
I haw and will maintain•CertiOcee of Consent to self-insure for Worker's Comped-
. moon,as provided for by Section 3700 of ie IsWr Code,for the performance of da
work for which this permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,an required by Section
37W of me Leber Cade,for He perfurmanee of the work for which this Pemdt Is issued.
My Workers Compensation Insurance cannot and Policy number me:
Canter: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need notheeompleted time permit is fmanebundred dolls.(SIM)
or lees)
Ocenify that In He perfmmance of the work for which this permit is issued,l shall not
employ any person in my mmnerm An in Wmme.ubjectu to Workert'Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT.If.Arm,making this Cenifica c or Exemption,you should
Accome subject to the Worker's Compensation provisions of He Labor Code,you mum
.7. Z forthwith comply with such provisions or this permit shell W deemed revoked.
z O
CONSTRUCTION LENDING AGENCY
[-t 4 I hereby affirm tot Hem Is a construction lending agency for tie performance of i
rl> the work fur which this permit is Issued(Sec.3097,ON,C.)
W Q Lender's Name
Lender's Address
U Q T codify that I have sad this application and sum Har the above Information is
tar cadecL I agree in comply with all city and county ordinances and mute laws reading in
Q building convection,and hereby authorise representatives of this city.cuter upon He
W above-mminkmed property for Inspection purposes.
Lyv W (We)agree to saw,indemnify and keep harmless the City of Cupertino against
);y`yam Iiabili0es,judgments.costs and expenses which may in any way accrue against mid City
U APPLICANThis permit.
in eOf the Ing Of t
UNDERSTANDSAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULATIONS. : - 3))7/0y
17 Gy
Re-roofs
gnatu.of APPlimmUCco wr ate
HAZARDOUS MATERIALS DISCLOSURE Type of ROOF
Will the applicant at future building occupammore or handle havrdous material
an defined by IW Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cade,Socctim.25532(,)7 All roofs shall be inspected prior to any roofing material being installed.
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 remove
it hazardaus air contaminants an defined by He Bay Arca Air Quality Management all new materials for inspection.
I9ri.0 m5/�,,
❑Yes No
I have mad the hazardous materials requirements under Chapter 6.95 of me Califor.
nia Health k SafmyCode.Sections 25505,25533 and 25534.1 undersand me,ifine Wilding
dace not currently haw a Wrest,that it W my responsibility a artery He mcupent or me
requiter
equire nuwa nmpemetpn 0 SS AA, or. III amafaap3 . Signature of Applicant Date
a�C1l6L t,7 t
Owner �rnrama eae�5 �/ eerie„`-� /1�7'U l All roof coverings to be Class"B"or better
lf-ULA L,U I 1J i I-KK3 Q 6U'6U- V11QK, vILLry- �r�
t( U<9l X255 -- 650) r ��
y
ro o vh rppPROVS0
fq'ACCDRDO C WITH THE CIIY'0A
.� GllP.ERTIN C
o DATE
t- a MUST
This set of Pl�r'� �d 'pe "c
a Ion be kept on ?hNlob at ap a
as and it is un
lawful t� N. any, �as or alteretion�
e it out WN,-
the
Permission frgn
the y I ing Dept., CitY of r rtino.
The stamp' of this plan an, sped heinar.
gllpl.l N0T be held to Permit or
• _--------__...___._. aonreval of the violation of 011V sron
r nnv City Ordinance or Mate -aw
cp � .
Lj
� MAR 17 2004
�
• 3o so �
s1�d�rLy
in ARCHITECTURAL APPLICATION
Nome of Association: VJ E a 1 MCLQ1 RA R K. V I )_ 1 A
me of Owner(s): f) I I A 1p 0 & I?A) L�
Address of Unit; R' 8G RPI RK C_Q Cliff C-1'i i ti
Work Phone: _ Home Phone:`�i��� `� — C I
Applicant agrees and understands.that the application does not fulfill all 19 ktghe;con �nse�neats for an ap-
proval. In addition to this completed "Archirectural Application" form, the 3 liensColn
to (ime Architectural
Feview Committee (and/or Board of Directors) a set of plans and spedficahodtst houuirgthture, kind, shape height,
materials and locations of the proposed architectural alteration. It is also understood by the applicant that the submis-
Sion must be in writing. There may be additional information required as deemed necessary to make a decision. Until
All information is submitted to the committee, the application will be deemed to be incomplete and the application will
stand unapproved. Llu.s ' 5e.e- wt1'o_t.-hu1 P`1,05. (`�)
,.
O�NF.RAL DESCRIPTION OF PROPOSED WORK(INCLUDE DRAWINGS, IF APPROPRIATE) 0
RI(kc e 01 a;,nfjn(0 'i RMJ Dlz to JeNOr 1Ai +k iYJrj n/ykJ J-00y',
i,Y't1Vy flrlti. .�� o1 5��r��,41„ rl�nnr lrni rr:�n�'2r r•,� �;vin� 're;r,rnn ^� y4 �J ,, r+�;,,,,i 'lQi.
�'�,u't�, 4�v?wld I�ruvP IS � f1QY1,1,� d9{- qli�Y2 Nr1�il . TYIr `.�llYV1J1,�(zP C, ', `�Ir Cl<_i^ ��� •���"nG �ocILJ
cA_:1(7 Vii' C
ri
Applicant agrees and understands that, in the event the modification is approved by the Committee or Board, that they
may impose "Special Conditions" of construction and maintenance on the approved work. Any special conditions shall
ttached and be a part of the approval. Any deviation from the approved plans, specifications or special conditions
cause the permit to terminate and become null and void. Applicant agrees and understands that failure to conform
to these requirements will be automatic authorization by the applicant to have the work brought into conformance with
the approved plans, specifications, and specal conditions. Applicant further agrees and understands that all costs in-
curred by the Association as a result of bringing said work into compliance shall be a charge against the owner's lot.
Such costs shall include costs of construction, reconstruction, administration, fees, attorney fees and reasonable cou t
costs, if incurred. It is also agreed that no work will be initiated which would be a violation of any of the provisions of
the Association's Declaration of Covenants, Conditions,.and Restrictions or any applicable building code;be an annoy-
ance to the residents, or increase the cost of insurance. Applicant agrees to indemnify the Association against any and
all acts or claims arising in connection with the improvement, including but not limited to any and all acts, omissions, or
claims arising in connection with the approval, construction, operation, maintenance, repair, use or removal of the im-
pruvem°at, including attorney fees and costs of litigation in connection therewith. Applicant agrees that, in the event
the application is approved, all maintenance, repair or replacement of the approved item will be the sole responsibility of
die unit owner and further that any expense incurred by the Association that is the direct or indirect result of the ap-
proved change shall also be the sole responsibility of the unit owner. All work should be initiated with consideration of
the grounds, esthetics, time and noise factors. Applicant understands that all necessary permits and approvals from mu-
nicipalities or other jurisdictions are the sole responsibility of applicant and that Committee/Board approval of this ap-
plication is subject to the applicant receiving all such necessary permits and approvals.
Applicant agrees too/the foregoing conditionsand accepts those conditions as evidenced by the owner's
Signature: -7 =9,1-=9,I.uv-CG.� ,o, .� � Date:
rRUSE OA'LY:
OVED: 1/ 1 Den
ied: Date:
Signed: t l Z
0
CITY OF CUPERTINO
I* 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng : Sub: Blk: Lot :
APN . . . . . . . . : 35610019 . 00
DATE ISSUED. . . . . . . : 03/17/2004
RECEIPT # . . . . . . . . . : 24861
REFERENCE ID # . . . : 04030159
SITE ADDRESS . . . . . : 8086 PARK VILLA CL
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER QUINTERNO PAULA J ET AL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1125
RECEIVED FROM . . . . : PAULA QUINTERNO
CONTRACTOR . . . . . . . : JOHN SCALMANINI LIC # 22780
COMPANY . . . . . . . . . . : ANDERSON INSTALLATION
ADDRESS 696 AUZERAIS AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95126
TELEPHONE . . . . . . . . :
.E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- ----- -- ------------- ---------- --------- - ---- ------ - ------- -- ------- ---
BENERGY PERMIT FEE 117 . 00 35 . 10 0 . 00 35 . 10 0 . 00
BPERMFEE VALUATION 6 , 000 . 00 117 . 00 0 . 00 117 . 00 0 . 00
BSEISMICRE VALUATION 6, 000 . 00 0 . 60 0 . 00 0 . 60 0 . 00
BPLANCHK PERMIT FEE 117 . 00 99 . 45 0 . 00 99 . 45 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 252 . 15 0 . 00 252 . 15 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
------------- - --- ------------ ------------------
CHECK 252 . 15 1017
TOTAL RECEIPT 252 . 15
•
(P
A, aquiv -, WITY OF CUPERTINO♦
CITY OF PERMIT APPLICATION FORM d
CUPEkTINO
N# 0 �_ G Date:
Building Address: Mailing Address (if different from building address):
aY i` r 9501
Owner's Name: Phone#:
Po uA uiYno yon aS - 0501
Contractor: License#: .
hder5oh w` 160r
Contact*4 11 D. _ 3 a o Phone: Cupertino Business License#:
Q 2S Fax:
Building Permit Info:
Bld Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑ ��� �� Comm cial
Sq.Ft. Floor Area: $/Sq.F .:
Cost of Project: -x-�._-,� �. Occupancy Group:
U v CJ
Type of Construction: Please check this b the is a
second-story addition:
uanti Fee ID =50OK
Description Fee Group
BAPPLOTHER liances MECHANICAL
BBLDGFEE ts . foot BUILDING
BBOILER1 0,000 Btu MECHANICAL
BBOILER2 to 500K Btu MECHANICAL
BBOILER3 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 - - _...Ener - - - - - BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation£ee BUILDING
BMITIGATC Comm. Housina Mit. Fee BUILDING
ot3 `.s—
i
WITY OF CUPERTINO*
CUPEI�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description .Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTMIE 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
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 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 din MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM13USWAY 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
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs,Marquee ELECTRICAL
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*CITY OF CUPERTIN40
CUPEf�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMTHEATR Theatrical Ligbting 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 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
i
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