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04020040 CITY OF CUPERTINO �^�rg.„4� ry<.»' � �gm �f BUILDING DIVISION PERMIT � C� Rt� � RATQ1� 1•'. BUILDING ADDRESS: FERMIT NG0 4 0 2 0040 R's;; PERMIT k55UE DATE 104 JNE: SANITARY NO. CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO pp BLDG ELO PLO MO J O O LICENSED CONTRACT'OR'S DECLARATION N 1 hereby affirm n 1 em licensed under previsions of Chaper 9(commencing Job Description �i with Sccdon)gg))of Dividen7of Ndnc e Buu aR�Profednn GOdC,and my license is z<5� LieDoc °" `f _G n 521 95� KITCHEN REMODEL n ARCHITECTS DECL&BAT•iOn CONTRACTOR: KI ZER CONSTRUCTION ��ea I do nd��Bla a us rtenme 3Q�n Licensed Professional 3 OWNER-BUILDER DECLARATION I I hereby affirm than 1 am excmpl from the Contractors License Law for the 0 0 following muon.(Section 7131.5,Business and Professions Codc:Any City or county $ which mold.A Permit In constmct.ellen improve,demolish,car per any premum Fiy prior or its issuance.alw require the applicant for such permit to file a signed statement Nat he is licensed pursuant to the provisions of kc Contractor's license lsw(Chapter 9 Sq.F[. Floor Area VahlB[it-11000 $ (commencing with Section 7000)of Divsion 7 of the Business and Pmfesalnns Code)or 4 that he Is exempt therefrom and the basis for the alleged exemption.Any violat)on of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of . AFN Number Occupancy e not mom Nan five hundred dollen(5500). p y�p 01,as owner of die preNny,Or my employees with wages,As their sole eanpensation, 36638008 . 00 will do the work end NeaWmurt isnot inended or offered forsale(Sec.7044,Business and Professions Code:The Continues Licntse Law does not apply k an Owner of Requlr�d_;Spcctlon5 property who buildsore, ireprew theorem.and whodeusuch workhtmselforduough his F .py$ a� ��D Own employeprovided Nre at such improvements anot intended oro@rand formic.If. Agar however.the building Or improvement is veld within one year of completion,me owner. p buuk.�will neve the IUNcn of paving that he did nm build or improve for follow,of APR 8 ❑I,m Owner of the property,am exclusively convening with Retread mnvar ams to 2004 cnnuuct the pmjm(See.7046,Business;and Profession Cotler)The Conusecwrs Li. Came law does not apply to an owner of properly who builds or lmprown demon,and, BUILDING Contracts for such ponecu with a conuxkw Nec r(s)licensed puma., e Convtor's License Law. ❑Iameaemplunder See. ,B&PCforthismmon er Date WORKER'S COMPE.NsRFoN DECLARATION 1 hemby affirm under penalty of perjury one of me following dulatetion: I have end will maintain a Certilkson of Consent to self-insum for WorkersCornpcn- Wine,As provided for by Section 3700 of tbe Labor Code.for the Ndmmance of the work for which this permit is issued. ❑1 neve and will maintain Workers CompenSadon Inmrance,u required by Section 3700 Of the labor Cade,for Ne performance of the work for which this permit is issued. My Workers�Comperwdan Insurance carrier and Policy number art: C° 'er. �o,: IVIJJ / 1 CERTIFICATE OF EKEM OM WORKERS' COMPENSATION INSURANCE (IMS section need not be completed if me knell Is(mane hundred dollars($lip) or Ire.) 1 certify Nn in the performance of me work for which this permit is issued,I shall not empinyanypersanlnanym4azpnn,.5ooulnn cumcaubjeetsO the Worker:Compeneadon Laws of California,Dan L N O Applicant 4L 1` C T/ ce'�.* — NOTICE TO APPLICANT:If,after making this CcnlOenc of Eacmption.you should become subject w the Worker's Compensation provisions of the Labor Code,you must fordwith comply with such provisions or this permit shall be dccmW mvnked. 'Z O CONMUCf10N LENDING AGENCY (.n► I hereby affirm NU Bert its conmmadinn kndingapney l'nr the cufunnance of > due wuA for which this permit u issued(Sec.3097,Civ.C.) lJjQ Lcmice,Name Mz Lander:Md. U Q T Modify that 1 have mad this application and one N°I NC above information Is IL P COOICCL I agree to comply with all city and county eminences and sum laws mining to DU building connotation,and hereby Unhodn:represemaloCS Of due City to Amer upon mA t27 shove-mjudgedpreperty forInspectionpurposes. (We)agree to Save,indemnify and keep harmless the City of Cupcnbm against asN liabilities,cnuence of graumd expenseswhich may In any way accrue against said City [„)'L A consequence of NA RSTA g of this lermll. APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL Issued by: Date r N5. N Re-roofs ApplicanuCOnuscmr DOW HAZARDOUS MATERIALS DISCLOSURE Type of Roof the applicant or future building occupant Arco,or handle han"ous material t e Cupertino Municipal Code,Chapter 9.12,and the Hulth and Safety n zss32(a)7 All roofs shall be inspected prior[o any roofing material being installed. �Nothe applicant or fuwa building aaupam irk cyvipmcm or dcvims whichIf a roof is installed without first obtaining an inspection,I agree to remove uS air conuminanu m dcfacd by me Bay Arca Air Quality Managcmcnt all new materials for inspection. �cJ C]Yes Ilj'Nu I have reW doe hvamous makrlela requirements under Chapter 6.95 of me Califon Ala Health&SafetyCode,Section 25505,25577 and 25534.1 understand dust iflbc building does not currently have a mount,that it is my onponsihility to notify the aceupanl of the k menta ien uxbcmnpoior00ju..Ce Of a anificn,ofOccupancy, Signature of Applicant Date Z-14-401-1 Owner Oramhorind agent Dam All roof coverings to be Class•B"or better CITY OF CUPERTINO /. +"''"-7Awt+* ' ' ' ' ,y t" n's BUILDING DIVISION PER COIV''t tA.G tt AAL[A✓RrY1.�, '`�1, �rtnir„�s..�:�. 9'.a. BUILDING ADDRESS: PERMIT NOo 4020040 �' NER'S NAME: PERMIT ISSUE DATE 04 PHONE: SANITARY O. CONmOL NO. ARC HITECTIENGINEER: BUILDING PERMff INFO BLDG ELECm PLUMB MECH go car LICENSED CONntAC1OR'S DECLARATION O O O 1 hereby anhin that I am licensed under provisions of Chapter 9(cemmene ng Job Description Ir with Section 7")of Division 3 of NC Business anQProfcssi...Code,and my license Is << �'' ° ° `f `' ncL .nE 2195a KITCHEN REMODEL Dam @ntrxcm� bale alis CONTRACTOR: KIZER CONSTRUCTION ARCHITECTS DEC R,2.ION as Was a 1111[re,We 3 G Licensed Professional 3OWNER-BUILDER DECLARATION �+{ I hereby.(Sinn on 11. exempt from d r rmahms Co License law for the ip0 which mcrcawn.(moult t 7031.5,Businessand w,deoli Coca:Any city or county °$ which its issuance. a Permit no construct,pImo Improve,demolish.lire.sig any tamctum H �^ prlorm.licensed pursuant M the lM applicant for such Commurmit toicanse aw(Chned mment (cotual mmencing licensedpuration7 the Division the eBusiness License Law(Code)9 Sq. Ft. Floor Area Val Ufi[i011Qoo $ (cam els exemptherelon70nd basis for of dre alleged exeand pton.Any Code)or `7 that he b exempt timm(rom and dm breis for dm alleged exemption.Any vialWon of Section 7031.5byany applicant for.parmRsubjects the applicant to a civil penalty of APN Number Occupancy Type nod more than(caw hundred dollars($301y, ❑4,M owner of[be property,or my employe"with wages as their sale compensation, 36638008 . 00 will do the work,end thummmtwe ix at nuanced or offered for sale(Sac.706x,Business and Profnss+ons code:The Canoaatar.License Law do"no,apply to.n owner of Required Inspections property,who bui ldx err im prows thereon,and who do"aoch work himself or through his own employers.provided slat such improwmwu art nat Intended oroRemd fm sale IL h,,swever,Ne building or impmwment is said within one year of completion,dad owner. builder will have the burden of proving that he did not Wild or improve for puoof tale.). ❑I.as owner of the propsny.am udmively cormanclog with Ilcerawd contractors b C construct the project(Sec.70W,Business and Professlors Code:)The Conuacmr's L6 X comer:Law do"not apply in an owner of properly who Wilda or improves thereon.and, who convects for such project,with a contractor(s)licensed pursuant to the Commences Lkeuve law. I am exempt under Sec. .B&P C far thH mown No, Data WORKER'S COMPENSATION DECLARATION 1 hereby a1Bon under porosity of perjury one of de,(allowing dalaeations: Q 1 have and will maintain a CerliOcam of Consent o self-insure for WorkefaCompcn- satlun,as provided far by Section 3700 of the Labor Code.for the performance of the work for which this permit1.issued. ❑1 haw and will maintain Worker's Compensation Insurance,as mquirod by Section 37W of the Labor Coda,fm the performance of the work far which this permit is issued. My Workers Compensation Insusan¢carrier and Policy number am: h Ca 'er. —t4PL-"J,!>PL^ --ffWWttgg Na.: —) 1?r40005a.ad� ff CERTIFICATE OF EKEM MON FROM WORKERS' COMPENSATION INSURANCE (mils rection axed not he completed If do permit is for one hundred dollars($101)) lir less.) 1 certify that in the performance of the work for which this permit is lammed,I shall am employanypersoninmyin yusslastohecomc.ubjectlo Ne Workcn'Compeovdon ser Laws of Califp .D N 01 Applicata �A ";,7, iii.— NOTICE TO APPLICANT.If.sMr making this Cardinale of Exemption,you should Mcome subject he the Worker's Compensation previsions of the Labor Code.you must .JZ forthwith comply with such provisions or Nis permit shall W deemed mvnkcd. „z,i Q CONSIRUCm10N LENDING AGENCY I hereby aRrm that them I. construction lending agency for the Performance of ' N. Nc work for which this permit is issued(Sec.3097,Civ.C.) VJQ Lander',Name it z Iandeh AM. t)Q I certify that 1 have mad this application and stam that due show informadun is ' Drs f" correct,l agree to comply with all city and county ordinances and state laws relating to Q V building construction,and hereby authorba representatives of this city in antes upon the W ahow-merimmed property for inspection pugwses. p1, (We)ogres to save,indemnify and keep harmless the City of Cupertino against r+ti Ilabilitlesjudgments.corts and expenses which may in any way acemc againstsaid City U 7 In consequence of the Standing of this permit. r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NPN-POINT Issued by: Date SOURC 1, Ns. Re-roofs B' afore of ApplicanVCamncmr Dem HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will due applicant or future Wilding occupant atom at handle harallous mucnal as defined by tW Cupertino Municipal Code.Chapter 9.12,and the Health and Safety -num,seedon zss3apj? All roofs shall be inspected prior to any roofing material being installed. Vca �No 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 emit ha andnus air contaminants as dcfmcd by the Bay Arca Air Quality Management all new materials for inspection. District? ❑w. i Nu 1 haw mml Ne haaaNaus mamriah myuimmenu under ChaPmr 6.95 of the Califor- maHcolth&9afetyC0de,Secdor,E5505,T5533and15534.1 undcomnd thatifthe Wilding Most not currently haw a sena,that it is my msponsihility to nntily the acuPam of the m 'rtmenta rich un be mm priortuissuanccahCc ream afoccupanay. Signature of Applicant Date Owner or authorizctl otiose Gem All roof coverings to be Class "B" or better _ PLOT PtA Nlk AP I I60 1 DsL I 2EAAOV& OLD FwL4"- ! cZW-r I `t &wrS Fkam 500�FVT AU4 I IN k \AF Pij0 MotAj-r l4eW 1A N D6tZ "C&J&1tj'G-r 1 CI(P. T VCE DATI D Car SIGry� S J1 his set. f pl1n;3 .. ys", GEC• ` i.._ d e kept a� id cootc pp �M�cea ECi i Wful to J tt all "i��t Ctu W l ociJ :.) I I WAv6 ' '^} a �ntip th bui out Wiii[en s4e °f a-`Etatam• Th staff D4pt., 'C44' ra issi. cX01c�•OP S moping,wilks, °r Qu ta r o Opp, pTl A.ana,d �, o y6 '�ire kheltl t0'Der q ori o ,l tiG" — i �IGt�' i �LC'11irU . a�y � p ar (STAY or'Sraelr,lfor.�". / � es,FLA —I ' INb T/�l L n)i 23"e�s5 uGkrr� ` ..._ . _. '•' i y.;7 (.. LY L - OF-FiCE COPY r *CITY OF CUPERTINdb CUP TYOF O PERMIT APPLICATION FORM JI APN# Date: v 6 ?90062 -2-ray Building Address: j Owner's Name: Phone S4 M & (L&r Y hJ l l pLi,J0 00 Z S`1 $bL(I Contractor: License #: K1ZL`�- Calj - 2u c , J 5Z I Qi 50 Contact: Cupertino Business License#: MAP-5)A UL f Bui'lddI'n Permit Info: 2) Yd CJ1 El Plu b M c b cription: Residential Commercial ❑ i R•Sq.Ft. Floor Area: $/Sq.Ft.: � Cost of Project: Occupancy Group: Type of Constructi n: Sflr APPun. c1 P �>^ ro �oPS, Lw-��tJG & �•bL. F1X� :e,s> , 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 1 M Btu MECHANICAL r 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 1of3 111 a (C - *CITY OF CUPERTIN(* CUP TYOFINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL 13MNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL 13NUCON2 M New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g 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 cfrn MECHANICAL BREMAIRHAN 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 Devi ce/A aratus ELECTRICAL 2of3 amm, WITY OF CUPERTINOSI CUP TYOF O PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group 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 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 UZ EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL EEO PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BMISCELL Building Mise Fees BUILDING 3 of 3