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05080023L_ r CITY OF CUPERTINO �tCOP1.,tl2ALCTORc� BUILDING DIVISION PERMIT syr,,^TI£O" BUILDING ADDRESS: R L BRACKETT CONSTRUCTION NO. 05080023 10735 PINOLE CT OWNER'S NAME: PERMIT ISSUE DATE DAN COOK & KELLY DAO 3400 DE LA SNE: SANITARY NO, CONTROL NO. (408)235-8852 ARCHITECffENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description o Nat I licensed under provisions of Chapter 9 (commencing I hereby affirm w P with Section 7010) of Division 3 o Me Business and µProf/esQsion/s }Code, and my license Is infull and effect. . UPGRADE ELECT SERVICE (200 AMP) �(nree ucg 7/Lgf O�15 LmrDam�Co mcuar l'[ ARCHITECTS DECLARATION I understandmy plans shall he used u public tecords Licenced Propossionsi OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from me Couractor's License Law for IM following moon. (Section 7031.5. Business and Rafcstlou Codc: My city of county which requires a permit to construct. atter, wpmse, demoRah, or mpalr any stsacture $2500 prim Or its issuance, also requires the applicant for such permit In file a signed statement Thu he is licensed poseam to Me provisions of the Conlracmr'a U..e Law (Chapter 9 Sq, Ft. Floor Area Valuation (commencing with Section 7000) of Division J of to Business and Premiums, Code) or that he is exempt Mmrefrom and Me, basis fm the alleged co mption. My violation of r U U Occupancy Type Section 7031.5 by any applicant for a permit subjects Me applicants to a civil penally of nal more Nut law limited d.lws (SSW). 1, u.wratr of the pmpeny, m my employm withwge u deir mlecmnpe=6m, e Required Inspections MlldolhewarkmdtM=OumisnotinwWedmanuedf., a (Sa.704/.Busitma and Patients.. Code: The Cmummme, Llcerue e law donut apply m an marcor of q P property who build, orimprows merton.and whodae,mh weekhimselfor through his seea.I foredo. If. owneer. es,oedm.nered Is mid widen souyear ofwmpleforthe.wer- theuiprovioriIprvehimpro id wit bolder. the buildingor mimpmrement Wilder. will have Inc WNm of proving Mut be did run build or Improv for purpose of isle.). ❑ L as owrcr of the See property. ,B sinus aidvely cunessi n, with IleeNeC mmunes U. Mat protect (Sec. n, Business and Profemom CadeI The Communes til cease D C^ cense law dose not apply m ts owner of property who sedds rs improve thneon, rod, La o a for such projects wiNarnmraclm(s)Ilmnsed pmsuantmlhe ContractLkCmors wbom `C. 2O Law. ❑lam uemp untlerSec. ,elPCfm Chia namn oOx/ Mer Dau WORKER'S COMPENSATION DECLARATION .'+[ I hereby air= under penalty of perjury aro of the following deeiantions: �� of C.nu huum (m W.hNS Camper. I nsw prowled msinwn action V 3nm Cod .an. provided for by Section 37W of the labor Coda. fm Me performance, of Me Labor work rte which this pc,mit is iasce4 , r ❑ I dive and will menten Worker's C.mpensauon Irnmmm. as required by Section 37W of Me labor Code. fm the performance of the work for which this permit is wised. My Worries Comparasu a I.urance tinier and Policy number ate: CuriaeSfri0 l.ea..t..Q PolicyNm.: CERT�PnONFl OM WORKERS' COMPENSATION INSURANCE rnh section rated out becompecud lithe permit Is formic hundred dollars (SI W) Or Iso) 1 certify that in the performance of the work for which thispermit is issued. I snail not employ any person in my mncrm as in becommm at e bject the Worked Compe.adon Laws of Ceifomit Data Applicants NOTICE TO APPLICAND IL after making this Cenifieu of Exemption, you should become subject in the Worker's Compensation pmvisions of we Lear, Code, you muse forthwith Comply with such provisions or this Permit mall be demand evoked. CONSTRUCTION LENDING AGENCY I berehy affm that them is a construction lending agency forme performance of Me ..,it for which m s permit is issued (Sm. 3097, Civ. C.) ' Lamio's Name Lenoir'. Add. I certify this I have fend this application and sum that Me above information Is ' cmucL I agme to comply with all city ad county oNlnanaa and sum laws misting an Wilding mnswction, and hereby authorise mpammatiws of this city to enter Open me pbow-mentiomd property for impaction purposes. (We) ague to save, indemnify and keep harmless tie city of Cupertino apia Id WiliOu,Judgments, eats and expense which may In any way we= aealmtmed City in Context of the granting of this permit. APPLIC AND WILL COMPLY WITH ALL NON -POINT Issued by: Date souR k�5 Re -roofs Type of Roof Signuurt of ApplieaneAZARDO Dead HAZARDOUS MATERIALS DISCLOSURE huaAous material �ort.,and WIII the applicant or (alum Wal as defies by the Cupertino Municipal Code. Chapter 9.12, mtl me Health and Safety Co e. Chapter b ode, Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed, ❑ Ym If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future Wilding occup nt use equipment or devices which It ha..dens aircunuminenu as dcbned by be Bay Arca Air Quality Management all new materials for inspection. 81f1c17 ❑Yea —IRK. I have mad the hamardommaudals n lul,cmcnts under Chapmrli.95 ofthe Califor. nu Health afOtyCade, edonn25505.255JJ and 23536.1 unde.and thul(Me Wilding dose ml m h mou this my mipooshility, re notify me aceupant of me ax Lw . ce.facertige,lep[Oc�nOm� Signature of Applicant Date r�C l oo.�{� l All roof coverings to be Class "B" or better ow.r.f.mlWriud.genl DOW 8 n I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock ile Date C' o CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM OSS 0 u 3 N# (OC(_ 3� _ 0` Fee Description Date: ,/3ios Building Address: rnole CoC•4.r-I- Mailing Address (if different from building address): 0-7 Boiler <= 100,000 Btu MECHANICAL Owner's Name: DAA )e--1 Kell DcLo MECHANICAL Phon #: g05-2— a 5- ontrac r: I ILicense L-&Lko+' - MECHANICAL BBOILER4 #: C ta-c� :- Phone a3 / Cupertino Business License#: ��" �t kt ►�(t✓� l3 Gf C Fax:4 Y5 3 Construction Tax Building Permit Info: BCONSTAX Ind/Off/Comm/Quasi Bldg ❑ Elect BCONSTAXBQ Plumb ❑ Mech ❑ Job Descriptio Residential n Qf✓1 � 1"as� a c v C;o jln. ;ercial ❑ Sq.Ft. Floor Area: BCONSTAXR Constax — Resi/Mobile $/Sq.Ft.: Cost of Proje �� cJ ELECTRICAL Occupancy Group: Type of Construction: ELECTRICAL BELEC200 Please check this box if the project is a Qoa� 41c BENERGY Energy second -story addition: ❑ BENERGYADD ro'ect Size: Standard Laze ❑ Major ❑ BiNVESTIGA �F Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 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 3JK-3 -6 1 of o Z 661 CUPEII;TINO 1 a CITY OF CUPERTINO 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 BOVERTRAE 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 Stom]/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER InstalUAlter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reins ection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAiRHAN A/C Units <=10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREWURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Fumace > 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 Rcpt], Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL PA `ono W CIN F CUPEP,TINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Si2M, 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 Inspection 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—--Plumbin -Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3of3 i