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04080222 • CITY OF CUPERTINO '" r BUILDING DIVISION PERMIT COLRACTOR IN 'ORMA.TiONs;` BUILDING ADDRESS: PERMIT NO. 04080222 91 97r SAN FRERNANDQ A07 111"I"Ilk I AL. OWNER'S NAME: PERMIT ISSUE DATE NE: NOV 2004 SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH uo0 LICENSED CONTRACTOR'S DECLARATION Job Description UW 1 bemby affirm that I am licensed under provisions of Chapter 9(commencing am with station 7000).Miviskm Softho Bminemand Professions Code,mdmyimUmois < in full forte and cffen. ;�"z_ License Class Lick REPAIR ELECTRICAL CONDUIT Dam contractor VENT INSULATION-POOL ROOMS ARCHnSC75 DECLARATION I understand my plans shalt M used as public meurds NO FEES-CITY JOB 3Wp,U 3 C� Licensed Pe,famun al 3 OWNER-BUILDER DECLARATION Connector's <f I hereby moo .(Ston that 11. exempt from the famumlCo License Law for the - p o following mason.(Section]ID L5,Business and ver.de ion Cade:Any city os county which requires a permit m construct,eller,improve,h Permit t ore pair any sed tructure thatWor toiuiensedpalammu)the the the ovisioe of for anchpumiuoicense U.(Chapter < thommeningwit humoral to00)o(Diaiotuof the fthe Businessnd Poollaum;Code)or Sq.Ft.Floor Area Valuation zFG � (commencing exempthwe[ono and o(Division theegeinexeradon.Aninml.dan or mat be u exempt therefrom and the baso fm me alleged emmptim.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy Type not mom titan five hundred dollen($500). - ❑I.0 owner of the property,mmy employees wise wagesumeir tole c.mpensstlon, will do the,work,and theauuclum is notimanded oroffered formic(Sm.7044,Business6 . 00 Required Inspections and Pmfeadoru Code:The Contractors License Law does not apply m an owner of q p property,who Wilds or improve thereon,and who does such work himsel f or through his own employees.provided demsuch improwmenu are not immreded.,offered for sale IL however.me building or improvement Is sold within one year of completion,me owner, builder will have the burden of praying that he did not build or improve for purpose of tale.). ❑I.as owner of the property,am exclusively contracting with licensed convacmn to tantrum the pmject(Sec.7W,Business and Professions Code:)The Comncuu's Li- ante law dots not apply to an owner of property who builds or improves themon,ad who contracts for such projeM with a convactor(s)licensed purnusnno the Contractors License law. ❑I am exempt and.Sec. Baa&�PP�C is on t,3,w Cy O GaOen. 1N3- Date WORKER S COM NSATION DECLARATION�f I hereby alarm under penalty of perjury one of the following declarations: have and will maintain a Cenifiam of Consent to self-insure for WorketsCompcn- n,m provided for by Schon 3700 of the Labor Code,for vm performance of me k for which this permit is issued. have and will maintain Worker's Compensation Insurance,as requited by Section 0 of the labor Code,for the performance of the work far which this permit Is issued. Workers Compensatin Insunna crrier and Paliry number are: iu: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (ILis section need not be completed if Ibe permit is foram,hundred dolun($10() less) 1 certify mal in the pufarmance of the work for which mice peonit is issued.I shall not employ any person in any manner an as in become subject to the,Workers'Compcmadon Laws,of California,Dam Applicant NOTICE TO APPLICANT.If,after making this Cenificam of Exemption,you should became subject to the Workers Compensation pmvisions of me labor Code,you must QD forthwith comply with such provisions o,this permit shall be deemed revoked. „Z,t"" CONSTRUCTION LENDING AGENCY [ti 4 I hereby affirm that Here is acomtructinn lending agency for the perfurmance of lYi> me work for which this permit is issued(Sec.3097,Civ.C.) 6Wi Q Lender's Name .7 z L correct. Address V Q 1 cenify Nat I have mad this application and start don the above info mtOt.is 0 F wilding I agree to comply with all city and county ordinances and sum laws relating e Q U above-mentioned ove-meding nnsnedpro and hereby eumonp rposesentatives of Niscity mcnmr upon the Q4 shove-mentionedproperty(orinspectionlump ea. G (We)agree to save,indemnify and kith harmless the City ofagainst against W liabilities,Judgmenu,costa rue against end expenses which they In any way accsaid City V Z in consequence of me Starting of this permit. "a APPLICANT UNDERSTANDS AND WILL COMPLY WITE �.L N N-PQQQINT Issued by: Date SOURC�EO�ILATIOIIS. &��M h, ��// �J�" Re-roofs Signature of Ap IicanVC.m DO Dem HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicanttarfuture building Occupant erre0,hurdle Healthy material as tle0ncd by dm Cupertino Mun cipel Codc.Chapter 9.12,and me Health and Safety Code,Station 25532(4)? All roofs shall be inspected prior to any roofing material being installed. ❑Yu Nu 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 it hem does air contaminants defined by the Bay Area Air Quality Management all new materials for inspection. Dlatrlcl7 Yes 1 have read the hn milm.memrmis myvimmenu under Chapter 6.95 of Oc Califor- nuHealth&Safety Cask,Sections 25505,25533 and 25534.1 undenand Out if me building is ts � donot currently haw a tenant.that it is my responsibility m rm the axes tot of me - G� rcyaim m hien mus}' pynortoi umceofa Cenifle. of a Signature of Applicant Date r{ C .W Ino 2�J¢ Owner or adtP66,.vdagent I All roof coverings to be Class"B" or better 4worCITY OF CUPERTINO or CARTING — -- - - PERMIT APPLICATION FORMaS�a is APN# O / Date: r Building Address: ( Gi ,C S44 FUVAIJ L Mailing Address (if different from building address): Owner's Name: /) n, I r �M1 Phone#: (4zd) 7 q- 343 Contractor: &ULicense#: 2J c�pRlL Contact: Phone: Cupertino Business License#: Fax: Building Permit hifo: Single Story ❑ Two-Story ❑ Three-Story ❑ Basement ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: p > � Type of Constr-uctio 2 e(ec rtrcaJ AJ I OsSL (�1A 'J,) roject Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V <= IOOOA ELECTRICAL. BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BOVERTIME Inspection Overtime BUILDING BPBACULOW 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 /L 1 of � U� •p��JJ�� I v' CITY OF CUPERTINO CUPE(�TINO NEW SINGLE FAMILY DWELLING PERMIT APPLICATION FORM lqp�uantity Fee ID Fee Description Fee Group 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 cfin MECHANICAL BREMAiRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL 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 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 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 2 of 3 CITY OF CUPERTINO CUPEI�TINO NEW SINGLE FAMILY DWELLING PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group 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 3 of 3