04070056 CITYOFCUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
CUSTOM EXTERIORS INC. 04070056
nc;n?. RAMPART A74
OWNER'S NAME: PBRMIT k49UE DATE
EDD
ONE: SANITARY 0. OL NO.
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
F i Mmby union that I am licensed under provisions of Chapter 9(commencing Job Description
with ilto Section Division Sof the Business Profcaiom Co@.and mylic49 is ■ ■■ ,��111011111
�OOR
in full forte and cffjGt.
License �t Lk.M 78x53 b ,REPLACE 8 W
ANO Dat Con r
g ARCHig11
8 1 understand my plans shall he as
public records
Dyu /n /y�
3Q Licensed Prolessimod AI II'J I V 004
OWNER-BUILDER DECLARATION
EW1 bemhy affirm that 1 am exempt from the Contractors License Law for the
following reason.(Section 7031.5.Business and Profcasium Code:Any city or county
$ which requires a permit t construct.altar,improve,demolish,or repair any structure
prior m its issumce.also require the applicant fo....h permit m file a signed smtement
Fs�< thathe is licensed purouanuo the provisionofthe0moramm'sLiom.law(ChmLr19 Sq.Ft, o r Valuate on
pe (commencing with Scalon7000)of Divistoo3ofthe Bmimenand Protaainna Code)or
that he is exempt therefrom and One,buffs for Use ailoged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6NP2V9t01*Cr0 0 - Occupancy Type
not mom than Ove hundred dollars(5500).
v
0 1,o owner of the property,or my employees with wage as their sole compensation,
willdo the work.and the smacture is not intended oroneted Russia(Sec.7044,Business
and Professions Code:The Conwaut's Liceue Law does not apply in an owner of Required Inspections
property who builds or improves thereon,and who does such work himsel f or through his
own employee,provided Outreach improvements am not intended mortared for sale.IL
however,the building or improvement ie sold within one you of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cade:)The Comments Li.
came law does not apply m in owner of property who builds or improve thereon.and.
who contracts for such projects with a contractor(s)licensed pursuant o the Contractor's
License La-
0
a W.0 1 am exempt under Sec. .B&P C for this ration
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations:
1 have and will maintain a CerdOcam of Consent to self-insure for Worker's Compen-
tion,as provided for by Section 3700 of the labor Code,for to Performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as mquimd by Scedon
700 of the Labor Codc,for the performance of the work for which this postai,is hound.
My Workers compensation Insurance pccarrier and Policy number are:
Cartier. !V4Ju^R Policy No.:/7 41 _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This motion need not he completed ifthe permitisforooe hundred dollars(SIM)
or loss.)
1 certify that in to performance of the work for which this permit is hatted,l shall not
employ anyperson in any manner so as to become subject to the Workers'Compensation
Laws of C.1ifmnis.Date
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become Subject to to Worker's Compensation provisions of the Labor Cade,you must
Q O forthwith comply with such provisions or this permit shall be deemed revoked.
„z„ CONSTRUCTION LENDING AGENCY
P m P. I hereby alfuthat there is a construction lending agency for the Performance of '
C4 7 the work for which this permit Is issued(Sec.3091,Ci,C.)
WQ Lender's Name
a7 z Lender's Add.
V Q I certify that 1 have rad this application and sum that Ne above information is
{7. F cones.)agree to comply with all city and county ordinances and state laws relating to
Q V building construction.and hereby authorize repreamlativer.(qua city to cntar upon the
W above-mentioned property for iupecdon purposes.
gL (We)agree t.ave,indemnify and keep hermleo the City of Cupertino against
sal liabilities,judgments.costs and expeuea which may in any way starve against aid City
(,`z in carm ocncc ofN raining of is ,
�--� APPLICANT U RS N LL CO Y WITH ALL N N-P NT Issued by: yDate
SOURCE E
o� Re-roofs
Signature of ApplicanUContmctor Dat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applies.,ser future building occupant nor.or handle hersrdous material
u deOned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode,Scetion sss3x(a). All roofs shall he inspected prior to any roofing material being installed.
❑secs No
Will the applicant or fumes building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
m '
i, avaNnus air con mants mu defined by the Bay Area Air Quality Managcmcm SII new maCOTIaIS TOT inspection.
istrict?
❑Yeallo
I have mad the hazardous materials requirements under Chapter 6.95 of the Califon
7.i.Health&SaRlyCode,Sections 25505 25533 and 8534.1 understand thatlithe buildingoel not curton ave a tans th my mapo bitity,y notify,hc mcupmt of Joe
remcnu chmua et or issum aC 'O M "I" SignatureofApplicant Date
S">6041- 4All roof coverings to be Class"B"or better
Owner or authmized agent - Dam
CITY OF CUPERTINO
CUP TYOF O PERMIT APPLICATION FORM
N# -3 I Z J` —O C) q Date: -7
Building Address: /
Owner's Name: 'Phone#:
E 4944_4:1 l,,eA_ 2 S5 - 6 k4/
Contractor:(
/ - License W'#:
5 3 (o /
Contact: Phone.#:
I,La,ry 92-5 2-q9 -2_ 2- e0
pplicant/. on F
Sal / -/ 2 Z
B ' mg Permit Info:
ldg Elect Plumb Mech
Jo Description:
Residential: i Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Ar chitect/Engineer: Valuation: e13 a
,.
e of Construction: Occupancy Group:
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 IM 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
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.J
CITY OF CUPERTINO
cuP TYOF o PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family 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
Mr BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER WaterHeater/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 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM13USWAY Remodel Busways ELECTRICAL
BREMFIXT Lfiahtiniz 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
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I' .• CITY OF CUPERTINO
CUPEtZ7`Iivo PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
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
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
BSF&2FAM Single &2 Family BUILDING
BSFNA Single Family New Add BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING.
BTEMP Temporary Power ELECTRICAL-4
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
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