04020082 CITY OF CUPERTINO +''
BUILDING DIVISION PERMITCQNTRACT,QRTNFOI.tMATT01�f, A;.
BUILDING ADDRESS: DALE HATFIELD PERMIT NO 04020082
OWNER'S NAME: PERbUT OSIfB DATE
DALE
ONE: T4ATPTRT.D
SANITARY NO. CONTROL NO.
ARCH]=IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
38j LICENSED CONTRACTOR'S DECLARATION O O O
Job Description
Ifi I hueby affirm Wt i sum litmus under provisions of Chapter 9(Commencing
x with Section 7=)I.(Division Sof Na Businusa and pmfessocos Code.and my he...Is
'^< in full forte and,(fact.
5'ga License Clean; Li.g CEILING WIRING/UPGRADE MOB & TUBE
Z� D.w G.mn for FIN�►L .0
A, hall roe DECLARATION
�i 1 undersand my plane atoll Mooed es public records
2,yU
w Licenmd Pmfuai.ns' 2 3 2004
G OWNER-BUILDER m the Commencer
FEB
.�no I hereby alarm o n I am exempt from the Contnctors License Lew for the
O o following moon,(action](131.5,Business and e u.Cade:Any city or county
$� which rcquirus a p.m0 m ennsuueh,Jur.Improve.
demolish.or.pair any.vena.
prior.its issuance.also requires the applicant for such permit to file a signed statement
p < M n
that he is licensed pmauaotto ism,provisions of the Conowler's Licenm LAW(Cooper 9. Sq.Ft. Floor Area 100
rd 2C� (commencing with Section 7000)of Division 3 of the Business and Profusions Code)or
3.- that he is exempt therefrom and II¢basis for dw staged exemption.Any violation of r�.ys�c,AA
Section 7031.5 by cry,applicant fora permit subjects the applicant ro a civil Penalty of 3 M N.avmaaVeiro 0 Occu ant
.at.om than five hundred duan(5.5110). P yType
❑Lasownuolthe property ormy uoployeec with wagu ntheirmic compensation,
will do the work,and the anchor:is not innoded or offend for sale IS",7044,Basion Required Inspections
and Professions Code:The Conuacwr's License Lew doe,ronst apply to an owner of q p
property whebuilds.,improvestiemon,and who doessuch work himself.,through his
.son employers,provided thmemb Improvements aro not Inwwed.,Offered for sale.IL
however,the building or Improvement is sold within one year of completion,she owner.
Wilder will have the burden of proving that he did not build or Improve for purine of
seem).
❑1,as .or of the propany,am exclusively conumring wish licensed.mecums to
common the project(Sec.70",Business and Professions Code:)The Connors U.
cense taw don not apply in an owner of property who builds or improve,demon,and,
who convects for such projects with a comracwKs)licensed pursuant In the Conlrmto's
C.Low.
aro exempt under S .B d:P C f'IMIm�ot4 '
tea WORKER'S a ON�ATION I `
1 hereby slum on puulty o perjury am of the following declarations:
1 have and will maintain e CeNrce ,accuser,to self-insuro for Workers ComKn.
Mich.or proviecd for by section 3700 0f tie Labor Code.for the performance of the
week for which this permit is issued.
❑1 he
and will maintain WOrkerl C.mPCnsmlOn Insurance,as myuirad by Section
3700 of the Labor Code,for the performance of the wmk for which this permit is issued.
My Workers Compe.aron Inseranca Cartier and Policy number tic:
Cartier. Policy No.: _
CERTIFICATE OF MEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This.coden need nor beeompleud If be permit ts fmanc huntircd dollar(SIM)
or leen)
I certify that in the performance of she work Ire which this permit is issued.I shall not
employ any person in any manner an as in become subject to the WOTICOW Compensatlm
Laws.f Csiforch,Dam _
Applicant
NOTICE TO APPLICANT.If,afuct making this Certificate of Exemption,you should
became subject to the Worker's COmperamon provisions of the Labor Code,you man
.,z forthwith comply with such provisions or this Permit shall k decreed ranked.
zCONSTRUCTION LENDING AGENCY
I hereby afrnm that then iso convection lending agency for the performanec of
!Yi the work for which this permit is issued(Sec.309'I,Civ.C.)
t.ender',Nam,
z Lender;Add.„
U 0 1 certify that 1 have read this application and slow that the,bore informatiun is
ty F .onto.l agree to comply with all city and county eminences and sum laws reading w
0 U building conawcti.n,and hereby md1Orim representatives Of this city to enter upon the
above-mentionW pmPcny,for inspection purpose
KF'+ (We)agree to Wave,indemnify and keep humles,the City of Cupcnino against
f�q liabilities,judgmcnu.costs and expenses which may in my way accrue against said City 0 �"
U z in consequence of the granting of this permit. (�
APPLICANT UNDERSTANDS AN ILL OMPLY WITH ALL$ON.POIINT Issued by: Date
CE ULA ONS.
Re-roofs
ig.turea ApplieanUCom for w
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant s fuwm building m cuptatsmm.handle hnsrdous mawried
o darned by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code.ny.xss3z(.)? All roofs shall be inspected prior to any roofing material being installed.
Yon u
Will the applicmt Or ft.building accupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it ha arl us air contaminants as dcfimd by the Bay Ama Air Quality Management all new materials for inspection.
District?
❑Yes u
I have mw Nehnamuu mawdalsmquimmcnuunder Chepwr6.95ofthe Califrr
nice Hc.10&SsctyCaa ..d5505,25533.d1534.Imuenr,undthmifde Wilding
docs nal Cuncntly hon a mount,don't u rihility w notify the.ccuP of Ne
ren which. be Cenrcawofac.p Signature of Applicant Date
Owner or auth.ind ego, w All roof coverings to be Class nBn or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
w , Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEkTINO
Building De artment
JO DD E PERMIT # 6 O�56
S:
`� S dna 5 %CT
OWN`ER'S AME: PHR<t #
4VI 71,136-
GENERAL CONTRACTOR:
I am not using any subcontractor
Signature Date,
Please check applicable subcontractors and complete the following ' ormation:
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
Tile \ /
iu -
ILX2
Owner/Contract r Signature bate
10/28/03
as
CITY OF CUPERTINO o Z
CUCITY
TYOF O PERMIT APPLICATION FORM v
N# Date: / b
Building Addre / Mailing Address (if iffe/rent om b ilding address):
/PG
Owner's Narr n g / Ph<ry
Contractor: / GG// l License#:
!�
Contac : Phone: 6 °j/ �7� Cupertino Business License#:
Fax:
Buildin Permit o:
Bld Elect Plumb ❑ Mech ❑
scription: G F t /t4 I (A(
esidential ❑ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project. �1 0 Occupancy Group: .
Type of Const ion: C/ . Please check this box i ect is a
second-story addition: ❑
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/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
BMITIGATC Comm. Housing Mit. Fee BUILDING
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tof3
CITY OF CUPERTINO
-,Sn'! ,
CUP TYOF O PERMIT APPLICATION FORM
Quanti Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
44 BPCESSPOOL Cesspool PLUMBING
UZ BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interc for 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 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
REMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> I 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 Si s, Mar uee ELECTRICAL
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CITY OF CUPERTINO
L So L
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Descri tion Fee Grou
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Sin le Duct MECHANICAL
BREMVENSYS Ventilation S stems MECHANICAL
BSCBLVD Scb S ecific 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 Plumbing Permit Issue PLUMBING
PPLBG Plumbin FeesI foot PLUMBING
ZADDCHG Address Chane BUILDING
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