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04050129'CITY OF CUPERTINO Cf)NTRACT,_I2 i�.iMATIU1�%' BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMTrNO04 0 5 012 9 OWNER'S NAME: PERMIT ISSUE DATE MICHELL REYNOLDS NE: SANITARY NO. CONTROL NO. ITE MNGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 ip LICENSED CONTRACTOR'S DECLARATION JobDescri tion I hereby affirm that I am licensed under provisions of Ch rax, 9 (commencing P ;„ whin SccIIor7ragT.r Divi 'on3 Hua Bustmunand ProfesioulCode,and licensia in full famean`cnect. ��� 3 WATER DAMPAGE REPAIR ON FLOOR qz a«nmclpe Lo'nb p Dam GOnlraPmr ONTRACTOR: PRESTIGE BUILDERS 2� I understand my s abed he used u�uhl¢mrnrtls BATHRM�DRYWALL�DOORS�FLOORING U piARCHITECTS Licensed Professional s 3 OWNER-BUILDER DECLARATION 10 I hereby .(ince that 11. exempt from the fesnunctors Licence Lew for the e o so 7031.5,Business and Professions Any city or county following mourn. (Smit g ;y e$ -< t h. or which its i ms a permit re construct, alcor. improsu demch olish. t are a tirmy attucnm prior In tensed .also .SnLto Us the o,ioth anteof the for Compactors License Law (Chapter cpmvisiskm3of0.Bui Sq. F[. Floor Area Valuation [ lecannwenilnmdpurstion7 maxamctnselntw(ChaPScr9 that he be xemtthemlMaland du Dosis n3 ofthecifed esantl Professions Co de) or that r campy therefrom and Ne aper Ne exemption. Any vlolatibn of. $25000 io for it Subjects and Semina 7031.5 ay any permit mbjcma Inc applicant to a civil peachy of APN Number Occupancy�fy e Type l red dollars(a not mom than Bw hundred drllam (5500). ❑ 1. as; owner of Ne property, or my employees with wages as their sole compensation, will do the work, and the structure is not Intended rroBend far sale (Sec. 7044, Business , Required Inspections and Prorepeions Cade: The Denhdcmr's License Law dace not apply W an owner of eny who builds who dmasuch wmkhim through his . d moRemd own provided thasuch Improve fitted own employees, provided Nautica Improvements arc net our of theintrinsic. r. however, the building or improvement is sold within ore year of completion, the ownmf builder will have the Wrden of proving that he did not build or improve for purpose of 1 ❑ 1, owner of the properly, am exclusively Probations l. w?� u Cod :) The Cmnbamars andProbationsKatie) The Contractor's construct thews not (Sec.oan / weer of owner of property who or improves Centra. and whom Intra docs not apply So nd v sed p who contracts for such prolecta with acrnusmr(q licensed pursuant do Contractors U / Lkevreame x ❑lam exempt antler Sec ,B@PCfar Cin rcpeon Owner Dale WORKERS COMPENSATION DECLARATION , I hereby affirm under penalty of perjury one of the following declinations: 1 have and will maintain a Certificate of Covent to Self-insum for WorkefsCompen- . as Provided for by Section 3700 of dm Labor Code. for the performance of the for which this permit is isucd. I have and will maintain Worker's Compensation Insurance, pe required by Section 3100 of Cc labor Code, for dm performance of the work for whichthispermitlm x isd. My Worker' .ore ensauon Insurance carticr and Paliry number am: -7/ 2 Cartier. Policy Na. O 2 / m J CERTIFICATE OF MEMPr1ON FROM WORKERS' COMPENSATION INSURANCE CTSIS section need not Wcomplmed if the Permit is fromm hundred dolsam (5100) comes.) 1 ccnify that in the performance of the work for which this permit is issued. l shell not employ any person In any marnerts a in become subject to she Warker5Compensadon Laws of Califomia. Dem Applicant NOTICE TO APPLICANT: If, after making this Certificate or Exemption, you should become subject to the Worker's Compensation previsions of the Inthm Code, you must Oforthwith comply with such provisions or this Permit shall he deemed revoked. ti CONSTRUCTION LENDING AGENCY I hemby eMrm Cat Cert I.. construction lendins agency for the performance of r7 the Work for Which this permit is issued (Scc. 3047, Civ, L'.) Name Qlenders Lenders Address z Q I certify that I have read Nie application and spin that the Shout information is ' comm. 1 agree to comply with all city and county ordinances and Stam laws misting to ' V U building construction, and hereby authorim representatives of this city to enter upon Ce shove-mentioned properly ror inspection purposes. gys (We) agree to on, indemnify and mor, hurni s the City of Cupertino against NImbilitiu.judgmcnta,cos and expenses which may in any way imeme against SaidCity ,Z in no of the ming of this Permit. APPLICANT UN STANDS D WILL COMPLY WITH ALL NONPOINT Issued by:9 Date SOURCE REGU ONS. es ^2� Re-roofs Type of Roof Signature Applicant/Conbactor Date HAZARDS) PALS DISCLOSURE Will the applicant or cut (ding secupem amrc orhandlchmaNaus manual as defined by the Cupertino Municipal Codc, Chapter 9.13, and Inc Health and Safety Allaw.k. se25532W?ON. ? All roofs shall be inspected to any roofing material being installed. ❑mYeaen prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which hanamous air contaminants s defined by the Bay Arca Air Quality Management all new materials for inspection. ❑Yes ❑Nr1 have mad the Noncoms materials roquimmerem under Charter 6.95 of the Califor- Ill althASam Codc. Sections25505,15533 and 25534.1 uderstand thatif the building notcomeham a moan et ismy rcaponsiM1ility mnrul'ytheoccupsl ofthe rcmen ichmusSbc Ipd issamceoraCemilm.to CePapmcg t ��� Signature of ApplicantDate All roof coverings to be Class "B" or better r per amhorimd age. Dam CITY OF CUPERTINO w` `�.' BUILDING DIVISION PERMI t 0Nb&`GT0*1NF©1�M.A.T, 9 ,., v. rte x^V`-4iA BUILDING ADDRESS: 0815 P7NINSTMAR AV PERMITNO04050129 EWS NAME: PERMIT ISSUE DATE MICHELL REYNOLDS ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION - IU Description OI 1 hereby i firm the' I am licensed under provisions of Chapter 9 (commencing P wiNSOCtmt7")of Divi 'on fac Busincasand Profcasiom Codc. and Iicenacis m ten rorte anTerreC,-_ 7Cl j WATER DAMPAGE REPAIR ON FLOOR Liccnsc Clas cmc Dam r Contramor ONTRACTOR: PRESTIGE BUILDERS AR I crsDEc N er I undcraunJ my plans shall he used as CLR records BATHRM/DRYWALL/DOORS/FLOORING Lkcnted Pmfcssional OWNER-BUILDER DECLARATION 1 herebyalTmmthat am exempt Item the Commerce$ License Law for the following mason. (Section 703 1.5, Business and Professions Code: Any city or County which rtgWrea a permit to eon t.t, alter. improve, demolish. or .pair say .sim.m. prior ma its issuance, also requires the applicant for such permil to rile a signed statement that he is licensed pursuant tothe provisions nrthe Contractor's License Law (ChaPm9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any vlalali6n of. $25000 APN Number Occupancy'Iype Section 7031.5 by any applicant for a permit subjects the applicant lo a civil Penalty of. pt mo. sen Bvc hundred dollars ($500). ❑ I.asowmroftMpmpeny,ormyemploycmwiNwagesss0wirsoleeompensatian, 3 2 ES 0 3 0 2 9 , Required Inspections will do the work and the structure is not intended an offered for sale (See. 7094, Business Professions Code; The Contractor's License Law dors and not apply . an owner of I;;=1 property whobuildsar improves themomandwho does such work himulfar through his l +two employees, provided Net such improvements art notjnended proffered forsale.IL ®`�f {� however, the building or imp .venom is sold within one year of completion, the awncr- buiider will have the borders of proving that he did not build or improve far purpose of .[a.). SEP 2 d 2004 ❑ 1, as owner of the property. am exclusively contracting with licensed eontrators to construct the pmject (Sec. 7044, Business and Pouf esiois Code:) The Contractor's LI- 000K Law docs not pply . an owner of propery who builds or improves themon. and, BUIL®'N6 BUILDING S who contracts for such projects with a pormse.r(s) licensed pursuant to the L'on Vactai G Lkenu Law. ❑ 1 am exempt under Sec. . B & P C far this reason er Date WORKERS COMPENSATION DECLARATION I hereby affirm underpentlty of perjury one of Be fallowing detiarasians: ❑ 1 have and will maintain aCer00cmc ofComenuo self-Insure for Warker's Compen. setion, as provided for by Section 3700 of the labor Code, for the performance of the work far which this permit (.!aimed. ve ❑ I haand will maintain Worker's Compensation Insurance, u h mquired by Scon 3700 of the Labor Code, for the performance of the work for which this permit !tissued. - MyWmkeY mP sadon lnunnce carrier and Policy number J' 2 �QT �jr n Cartier. Polity No.4002a/ (k CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (ITissection need nmbe completed if the permit is forms hundred dollars (5100) ' or too.) 1 cenify that in the performance of ac work far which Nis permit is Wood, I shall not employ any Person in any mannerso as w become subjecuo the Workers'' Compensadon Laws of California. Data Applicant NOTICE TO APPLICANT: V. after making this Cendiicam of Exemption, you should become subject W the Workv's Compensation provisions of the labor Code. you must forthwith comply with such provisions or this permit shall Im deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby alarm Oat there is a construction lending agency for the performance of tho work fur which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address 1 certify that 1 have mad this application and slow that the above informinlun is correct. I agree to comply with all city and county ordinmets and state laws relating to building construction. and hereby author!he rcprcscnuGven of this city to enter upon Our above-mentioned property for inspection purposes. (We) agree Ir save, indemnify and keep h.less the City of Casper ino against liabilities, judgments, cos and expenses which may in any way accrue against said City in conuqucnec of the nlin6 ofthis permit. APPLICANT UN STANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGI ONS. 1`�'2G Re-roofs Type of Roof Signalu. ApplicmVConuactar Date HAZARDO RIALS DISCLOSURE Will the applicant or fum- Jan, occupant store or handle hauumous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety ode,exss3z(a)7 All roofs shall be inspected to any roofing material being installed. C] Yes No ❑ ❑ prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future build! ng occupant use equipment or devices which emit hazardous air concomitants as defined by the Bay Area Air Quality Management all new materials for inspection. Dlwicfl ❑Yes ONO 1 have mad tholu ardous materials requirements under Chapkrb.95 ofthe Califor. &Safcl Codc, Sections 25505, 8533 and 75534, 1 undersand aatifthc building nice H�Lm docs une ha. a knsn at tis my rcspenslbility. amiry the occupant of the .quin ichmuslbc tpd issuance of aCenificaeOf0ccupancy. Signature of Applicant Date . —Ili j'2i:eL All roof coverings to be Class "B" or better Owner ser authorizcJ aFen �. Date • MFY.12.2004 6: 11PM FIMPI<CiRL 117f: BROKERS P. MICHE'_.LE t -O. 716 P.2 MAN SKETCH ADDENDUM forrower/cro.1i_i Ill erry_e ,ItyCU Y t7'iNo —" rw tr n' AVF C�Mounun—NSA GLAFA elate CA Zipe under _ -- I 0 BUILDING SKETCH . t� 22 J �� BEDROOM BEDROOM likr6 nR/� tL BATH 3 0 GARAGE BEDROOM i 15 c s KITCHEN LIVING ROOM toK� DINING ARL% 23 %1. ! 24 FAMILY ROOM t, y 3Md'to 15 I. '� Ism Y� CITY F CUPERTINO An OITY OF CUPERTINO 0 PERMIT APPLICATION FORM APN # L` 8 I n 2 (y b 13 Date: , Building Address: Mailing Address (if different from building address): io2ri5 P�Nsuc�R -AJ c�P R �© 0A L Owner'same: Phone 1e��Jo i��A o'� 25- — l)z Contractor: PPC -3'T-16 le 6b/ Lp e13i9S1 License#: S-5- H-10- Co t: Phone: 6v) Zq-Y227 Cupertino Business License#: 1 IA Fax:,gOnT -yy BBOILERI Building Permit Info: Bldg Elect Plumb Mech Job Description: r Residential biAT-€7f� I)Rolk (f R (�N k Commmeerci 1(❑ Sq.Ft. Floor Area: $/Sq.Ft.: BBOILER3 Boiler > 500K to 1M Btu Cost of Project: Occupancy Group: 2SDod MECHANICAL Type of Construction: Please check this box if the project is a pTN-pdoe-r d1ooRS F'LOC,,QifjG, second -story addition: ❑ Project Size: Standard Laze El Major El BUILDING 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> 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 1 of 3 4 �C2 S3 -' ,) tv CM OF CUPEkTINO TY OF CUPERTINO 0 PERMIT APPLICATION FORM 2 of 3 uantity 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 I PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piging 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 iinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER InstalVAlter 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 BREJV.Lk N 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 2 of 3 '?, �� *CITY OF CUPERTINC* CUPEf�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance ELECTRICAL 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 Bldg Permit BUILDING , BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Busifiess License, BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance '. ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance :> MECHANICAL PPERMITFEE l Plumbing Permit Issue PLUMBING PPLBG Plumbin Fees .foot ,;,' i 4,PLUMBING ZADDCHG Address Chane BUILDING k] Me c3 W