05090009 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC'�TOR NFORMAUON
a ✓, n3.gal „ 1 vl�.EJYa"Iti, ,j',�
Bu1WINGADDRESS: ANTIQUE TERMITE & PEST PERMIT ND'05090009
41 ROSE BLOSSOM DR
•OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
408 995-6300
ARCHITECDENGINEM: BUILDING PERMIT INFO
• BLDG ELECT PLUMB MECH
3Gp LICENSED CONIRACnOR'SDECLARATION JobDescri do
II I thereby atRrm Ne71 am Ilanscd under provision of Chapter 9(rommencin{ p v ti
with SecWn7g1U)ofDividon Sof de Business and Pruesalons Code,and my license is
LED
Lifull form entl cff�p} (o�s'Z UPGRADE ELECT. PANEL (200AMP)
j License Clesa fG Lk.t
Dau —/� /��Contractor-
-
f ll�V
ARCHITECTS DECLARATION 1005
Ni 1 understand my plain Mall he need as public recants
y c� Licensed Profession) Ip3 StI�Z��q` �"l
OWNER-BUILDER DECLARATION
Contractor's
onti ON UI p j{� I�J,..�.
i 0 I hereby.(Siem that 1 1. exempt from the Cssions c :Any c Law for tiro kkk`VS L+.FY���JJJ li\"✓kl
3:00 following motion.a (Semite 71D 1.4 B.Also. and 0ofeai0ns Code:Any roily as county
$P which rxunti a Permit in emmrvet glue Impmw,demnlW,or inpaig any suocmm 3 200
'4P pdormitsiensedpahunt Mt he preisiois ofthe CoblmfmrH001ass Law(atamment
< (comm) licensed pursuer 7000)prevision)ofofe,Business
Llaawssi(Chapter Sq.Ft.Floor Area Valuations
$
(commencing with Semlon7f00)andth basis n3 of Neeged exe andon.My
COdc)of
that bs ts esempt thert(wm and the buts for the Alleged exemption.My Wolation of
Section 7031.5 by any applicant far a permit subjects the applicant 0o a civil fanshy,of -3 APN
not mm Ma Bva hundred dollars($500). r Occupancy Type
❑1.As owner clubs property,or my employees with wages As their ale compensation,
will do dewotic and the stwcttrre is not In endW oroffered furaale(Sec.7044,Sainw
And Professions Code:The Conscience,ra License Law dnot apply An an owner of Required Inspections
property wlm W ills erimproves Hereon,andwhc dassahwokhlmself w Wen{h his
own employees,provided Net such Improwmeme art out intended inoReced for We.If.
however,the building or improvement la sold within one you of completion.the owner.
builder will Mw the burden of proving that he did int build or Improve for purpose of
sato.).
❑1,As owner of the property.am exclusively contracting with][caused contra mors in
construct the project(Sec.7044,Business and professions Cade:)lbs Contractors Li.
cense law dm not apply in an owner of property who Wild,or Improves thereon,and
who contracts for such projects with a eanuactorp)licensed pursuant he Me Contractors
License Law,
❑I am exempt under Sea ,B B P C for this meson
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under p uaky of perjury,one of the following decimations:
1 have and will maintain a Certificate of Consent to self-iwum for Wormi's Canpen.
.
no.,u dcd for by Section 3700 of the IAWr Code.for de Performance of the
rk fo ich Nie perm l i,leaned.
w and will maintain Wokers Compensation Insurance.u excited by Section
0af Ne Labor Cade.far use Performance of tbs work for whits Nu permit b itsued
Worker.Compacts . nlnwn carrier and Policy number are:
eeier._ v_ TCC�4 Policy No:rxy x N-•Z06
CEIMFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not uncompleted If tbs)mrmit is forow hundred dnllata($11K)
or
1 certify,that in the performance of the work for which this permit is handed.I MJI nus
employ any person in any manner An As to become subject to the Workers'Compensation
Laws of CJifemla.Dam
Applicant
NOTICE TO APPLICANT:If.arm,making this Compote of Exemption,you should
became aubjes0 to the Workers Compensation previsions of the IAuo Code,you must
0 forthwith comply with such provisions or this permit shall W decreed invoked.
Z CONSTRUCTION LENDING AGENCY
OG? the(.n Ibsr whaRrm Nat Vert tsaansSm.30lendin{ageemy(car Ne performance of
•� Le dAurl,ors for which Nm permit is iaued(Sec.NN'i,Co.CJ
Q Lenders Nemo
z Lender,Address
U C 1 certify than I haw read Ws application and sum Nat the absw information is
it, comm.F l alpine in comply with all city and county odinanas and Mm laws relating to
C V buildingconsWction,andherebyauthorisempresenutivesofthiscityinenteruponthe
[i7 .hove-mentioad Property fee inspection pugmsea
Or (We)agree to ase,indc.Mty and keep hamlus the City of Cupenirm against
i•y r/) IIMIIWes,jWgmenu.cau and expenses which may In ay way acerae against saidCity
V 7A in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date U
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of Appllcacine Dam
NATdItDOUS MAT ALS DISCLOSURE Type of Roof
Willtieapplimtorfulure Wil " go.up, tamuobsndle heaedaw mamriJ
Iladefrnc l by W Cupertino Mumri Code.Chapter 9.17.and the Health and Safety
use.Section 25532(4)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will the applicant"r
lure Wild(1p mupant use equipment o devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haysrdcua air anuminsnu a tined by the Bay Area Air Quality Management all new materials for inspection.
grim?
[3 Yes
u
I have testi the Md rdoa mamrialsrequmements under Chapmr6.95 hide Califuo-
Health@Safety Code,SucWns 25505.35533 md125534.1 understand metirthe Wilding
not crrently haw a tenant that It u my meponsi ILY m notify W occupant of the
uotincrus which muubs et hr m hauan)e or a cerMlmate or occupancy. Signature of Applicant Date
7 ���rAll roof coverings to be Class "B"or better
ner or aumonsea agent Dow
Community Development
10300 Torre Avenue
aClOF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPEkTINO
Building De artment
JOB ADDRESS: �J PERMIT#
/gyp S�laSS'o10:1� Q�O e7 O 6
OWNER'S NAME: m h c A PHONE # Q 9S — G3 00
GENERAL CONTRACTOR Arr� e .r, AX # 5F rj S —0.5-Y 7
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 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 qq
Owner/Contractor Signature Date
�® CITY OF CUPERTINO
CUP TYOFFINO PERMIT APPLICATION FORM
APN# 2 S 7-0 9; D 3 7 Date: mow.
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone#:
Contra e- kLicense#: / 5 SZ Oz-
„ [o O
•Contact: Phone: 479S-6300 Cupertino Business License#:
L[% Fax: 9S-Q 5
Building Permit o:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:/ P �' Ci ; 9���
Residential fid' /V �� 2d0 <S+�zv/fie Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Inc-) Occupancy Group:
Type of Construction: Please check this box if the project is a
—/ second-storyEladdition:
Project Size: Standard 2 Laze ❑ Major ❑
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 hid/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
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CITY OF CUPERTINO
PER
CUPERTINO MIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BNETIGATC 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 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 Repie 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 InstaWAlter 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
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace 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 . I 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
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f: CITY OF CUPERTINO
CUP
EfZTINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
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
BSWIN4 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 Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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