04020022 CITY OF CUPERTINO n��s,�� r v a.'�. d�a ' rs er x Com" '
BUILDING DIVISION PERMI'l� 'C�1VT,R2'�LC.� O7,2TNIIOMALe,T
BUILDING ADDRESS: J PERMIT NO.
04020022
R'S NAME: PERMIT ISSUE DATE
RONALD
PHONE: SANITARY OL N0,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
e I� 0
dOo LICENSED CONTRACTOR'S DECLARATION IobDescri tion
Ig I heechy afmm that 1 am Ilmosed under provision of Chapter Y(commencing P
wide Section]Q1M0)of Division 3 ofd.Sun.and Pro! Code,and my licrossc is
n umoseCl Lo..neanyrcegks 13 U, BATHROOM REMODEL
Lfellt
h Dam Contractor CONTRACTOR: KEAN CONSTRUCTION
ARCHITECTS DECLARA
S -a NA J jazy_sed u public s
+n S Licensed Professional
OWNER-BUILDER DECLARATION
j<x I hcmby.Rum Nm I am exempt from Ne Cmurmim's License Law for(be
0 0 following mason.(Section 7031,5,Business and Prefcssium Code:Any city or county
$ which requires a permit to mostme,site,improve,demnllsh,or repair any amount
F�< priorm its iuueece.elw mquimrlM applicant for ouch permism Rle.signed a.mmcm
0 deaheislingwit pSccdm7")of Dshm3 Ne Cousimurhndi'melaw(Croc)or Sq.Ft.Floor Area Valuat}(lp000
(commencing wit Semon 7000)of Division 3 oft o eSed exempt on.Any
vi Curie)ar h�b
$ Ws he is exempt temfmm and the buss for the alleged exemption.Any vieladon of
Section 7031.5 by any applicant for a permit Subjects dee applicant to a civil Penalty of APN Number Occupancy Type
not more than five hundred donor.($500). 35617030 . 00
❑1,M owner orim properly,car my employcea wit wags as then sole eompenmtion,
will dotework and theao Comae totinmMreas Law
does
not apply 7014,Business n Required Inspections
and ertywhobu Code:no Cethemofa ndwho Uw dao not apply if rt owner of �[tF,111 q P
pmpenyloycm ild.mimpmwmhImprandwho a n.uchended imselrartrough his I GALE '
owneer.the raping or I provemimprowmcntsarenosimendadorn@mil for sic.If, �':t9 �1
Wilder r.the building or Improvement u cold within one year of completion,purpose
of
. builder will Nw tint burden of proving that he did nos build or improve for puryox.r
sale.). W0111 0 J 2004
❑I,as owner of the property,am exclusively contracting with licensed conoectom m
construct the project(Sec.7044,Business and Professions Code:)The Contractors L. '
thus.Law cocanot apply can ownmofpmpersy whobuilds or.m ustinthereon,and p �
wbo cammcss ser such ply hea who aeomncmrty whoved pursuant b to Com en,a and.
Lkenm Law.
❑1 we exempt under Sec. ,B ds P C for this moron Lf NNW
e Dam
WORKER'S COMPENSATION DECLARATION
1 hereby in.under penalty of perjury one of dee following decimations:
I have and will maimain aCWRateofC.sounme.self-Imum for Worker'sCompen-
sidon,as provided Be by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is Issued.
❑1 haw and will maintain Workers Compensation Insurance,as sequined by Section
3700 of the labor Code,For dee pesfonnasmc of the work for which this permit is issued.
My Workers Compereation Wmanav artier aM Policy r
Cartier. PoBHGq)y'Ny.:
I' / CERTIFICATEOFEXEMPf10NN)ROM WORKERS'
`(/%q COMPENSATION aaSiSSURANCE
(Thusection need nmbecomplemd If she permit Is formm hundred deltas(51011)
or las.)
I certify that in the performance of the work for which this permit Is issued,I shill not
employ any person in any mannerm as he become subject in theworkcri Compensation
Laws of Cadifomla.Dam
APPlime,
-NOTICE TO APPLICANT:If,after making this Cenificnm of Exemption,you should
become subject to the Worker's Compcnsatlon provisions of the lahnr Code.you most
0z forthwith comply with such provisions w this permit shall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
'pa I hereby affirm that there is construction lending gency for the performance of
!Yi 7'the work for which this permit 1.issued(Sec.3097.Civ.C.)
GQ Landers Name
,7'z Landes Address
V 0 I coolly that 1 have mad this application and stoic that she sbow infor mil..is
Lea !+ COMM I agree to comply with all city and county oNinmms and sure laws misting m
0 SV" building construction,and hembyautodm¢pesentatives of this city memuupon Nc
g2t show-mentioned preperty for inspection Purposes
g), (We)agree m save,indemnify and kap harmless the City of Cupertino against
Tq
liabilities,judgments.costs and expeuses which may in any way memo against mid City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W1'�H ALL NON-POINT Issued by:
SOURC GUL aTION . __s e
3 Re-roofs
nature of Applicam/Conwctor Dim HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ed by t1 applicant or(Muni building e.Chaptimm er handle h Health
a material
m defined by to Cupertino Municipal Cada Chapter 9,12,roil she Halt and Safety
de,Section 25532(.)' All roofs shall be inspected nor to an roofing material being Installed.
❑N. etre P P Y g g
Will he it'lmam or future building=upon,oro equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
..It hamrdour air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
DirOiclT
O Yea
I have mad on,bvardte smaterials mquimments under Chapter 6.95 of Inc Califor.
nix Health A Safety Code,Sadao 25505,25533 and 25534.I on art ft building
doer n cunentiy hewn a moans thus it is my responsihilily m netil a oecupans of the
mgamhi most be 't P. imamm on ceAa Occupancy,/6 Signature of Applicant Date
f 1..�.i.
Owner....thorinedagcnt Dam All roof coverings to be Class "B"or better
�EQ��4� CASEHfi� (
Poo
j hl��roo+J App Gf
{ �APPROv .
10 AvZORDANCE W' THE dIY,00
g1PExUINo A
OA'6E_{
specifications MUS.
aIzt p, ob at all times and it is urtI
®e UelA on -.. 1 changes or, alterations
fawiu`'to make any ermlasion from
salms w Deut written
%eaf Cupertino.
The roping of this Ptan and apeciflcetiong COPY
A L NOT ba held to permit or tr j�c�PP•
pp�eval of the violation of any or, �dro�f
0 ,v Ciro Ordinonce nr Mato haw. i.c�t off ILI
Kati
2004
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1' FEB 0 2004
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C1C� WITY OF CUPERTINOO
CITY OF PERMIT APPLICATION FORM r
CUPEkTINO
�
APN# 3 5 ` I c)30
Date:
Building Address:
Owner's Name: e / / Phone #:
Ve /1 /rPS SG�G r'� �1�lG 650
Contractor: — / License#:
Contact: Cupertino Business License#:
Building Permit Info:
*❑. Elezi� P] b Mech
Jb escription:/�
Residential ❑(/ ` /�d� �Q� 'r 1 Commercial ❑
Sq.Ft. Floor Area: V S/Sq.Ft.:
Cost of Pro)t�V/ Occupancy Group:
/
Type of Const tion:
916
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
� o —t z
�D� of3
CITY OF CUPERTINO
BUILDINGDIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
04020022
R'S NAME: PERMIT ISSUE DAM
vNE:
RONALD
SANITARY OL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 a 0
u Q LICENSEDCONTRACTORSIOUDe5Cr1 Description F ��LED
uu`$sF 1 barely affirm NS I em ONTRA TO S DECLARATION
of Chapter 9(commencing p
with Smc00n7 f0ivitlon30f du:Buainesaand Profc s Co de,end my them is
"n4 "funeOfed"�"Wu� fCJ {� BATHROOM REMODEL
jnZ License Clef" u Lic.N _` �.l�v '
z Dam Contract? CONTRACTOR: KEAN CONSTRUCTION NOV q 2004✓� ARCHIIEC tial a u ss T*SDEC pts RA
Uy Vn•{lans ehe/VCprCcu'J public mobfik
3 G LicerauI herebyprofesmol BUILDING p ■G
OWNER-BUILDER DECLARATION L N
1 hereby affirm o n 1 am exempt from ren Contractors Co License Lew for Ity
O D fallowing reason.(Suction 710 LA Business and Improve,
demolish.
Code:Any city or county
$ which its issuance.
a permit re coves de, alka imprnvm,dmm111 it t m repair ed strucstatement prior oslissuance,alsontmi theappncanff Conpermittofileasignedvammcm
FFZ< tat he islianud pursuant ate provisions of dfccBusines and Poef Law(Chaptm9 Sq.Ft.Floor Area Valuat�op9000
eoIcommencingwithherefrom and of D;vis;on3 of thealed exempt Pm An vi lahConn)of
tet he is exempt therefrom and the basis for the alleged exemption.Any violation of
Suction 7airy•applicantfor•permit subjects the applicantoacivil penalty of APN Number Occupancy Type
not more M.Nen five hundred dollen(5300).
❑hes owner of the properly,or my employcca wire wagau Heir sole compewdon, 35617030 . 00
will do On work and me swctum isnot intended or armed foraelc(Sec.7044,Business
and Professions Cade:The Contractors License Law does not apply In an Owner of Required Inspections
properly who builds or improves Marcos,and wha does such work himself or lluough his
own employees,provided tnsuch improsemene arc mainlended oroRemd for sale.If.
however.the building or improvement is sold within one year of completion.the Owner-
builder will have the harden of proving that he did not build or improve for purpose of
sale.),
1,as Owner of the property,em exclusively contracting with licensed conlnemn tm
mnstmet the project(Sec.7044,Business and Professions Code:)The Conmeter's L;-
range Law doer not apply an an Owner of property who Wilda or improv Ihemon,and
who contracts for such projects wit a cunlractOgs)licensed pursuant in the Comommes
Llcenu Law.
❑1 am exempt under Sec. .B&P C for this mason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of to following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sal;On.as provided for by Section 3700 of me Labor Code.far the performance of to
work far which this permit is inued. 1
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Codle,for On performance O(me work for which this permit is heated.
My Wmkere Compensation Insurance artier and Policy n r
Carries: COMPENSATION URANC6 '
{'
CERTIFICATE OF EXEM DO OM WORKERS
y(Thls section need not W comPtmred irthe permit is foranc hundred dollars($100) '
or less.)
I certify that in to performance of the work for which this permit is!wood.l shall not
employ,any person in any moneran as t become subject m die Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Ceninare of Exemption,you should
become subject m the Workers Compensation provisions of me Labor Cede,you must
O forthwith comply with such previsions or this permit shall W deemed revoked.
„z„ r~NnCONSTRUCTION LENDING AGENCY
'N Ihemhy affirm mat there is a construction lending agency for the Performance of
W the work fur which this permit Is issued(Sec.3097.Civ,C.)
W Q Under'a Nemo
z Lender's Address
U I certify that 1 have mad this application and sum tat to above inrormniun is
W correct,l agar to comply with all city and county ardinances and state lava minting to
C U Wilding construction,and hereby authorise repventativ of this city to enter upon On
W above-men0oned pmpeny for inspection purposes.
(Wc)agree m ave,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,ensu and expenses which may in any way accrue against said City
U7 in consequence of the granting of this permit.
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WL'tH ALL NON-POINT Issued by: e
SOURCG�U�LAT`ION�. J rs -
Conu of Re-roofs
nuum of ApPliceHAZARactar D m
HAZARDppUS MATERIALS DISCLOSURE Type of Roof
Will tc applicant m fula re building Occup tasman or handle haandous mamnal
u defined by dm Cupertino Municipal Code.Chapter 9.12•and the Health and Safety
Section25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea 13x40
wm the applicant or
fu
building ap<apam age equipment or aevima whish If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air antaminamts ea defined by due Bay Area Air Quality Management all new materials for inspection.
inrict?
[D Yes telNu
I have mad the hamrdoue materials requirements under Chapter 6.95 of the Califor.
nia Hcalt&SafciyCodc,Smc ons25505.25533md25534.to ti(Ihc Wilding
daeslu merely have a mnent,that it is my mspo undliry o nodi mcupent of the
rcyulmmu hr not be elpnory��ssumcmof.cerdca Occupancy Signature of Applicant Date
o f bf�i. has
Owner ger authorized agent Darn All roof coverings to be Class"B"or better