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05120101 CITY OF CUPERTINO � BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ��: BUILDING ADDRESS: CUPERTINO PLUMBING PERMIT N0.05120101 22678 SILVER OAK CT OWNER'S NAME: PERMIT ISSUE DATE ROSE OMEGA HARRISON 1300 DELL AVE T -----22/16/2005 NE: SANITARY N0. CONTROL N0. (408) 253-0618 ARCHITECrIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH (� 0 °00 LICENSEDCONTRACTOR'S DECLARATION lobDescri tion uC 1 hereby sf ion Nal I em licensed under providom of Chapter 9(commcneing P �W wish Section?UfU)of DiviLon Sof dm Bush...and professions Code.and mylicense is off in fullfo¢eendeffea O REPIPE & WATER HEATER License Claza Lie. z F p Date_(2—rL canuano��r nS 7W ARCHITECTS DECLARATION C 1 undersand my plans shall be used as public records JOU o Licensed Profesamul J S OWNER-BUILDER DECLARATION y/ f I herchy affirm that I am exempt from Ne Contractors License law for the isiO following reason.Permit 11131.5,Business and improve, de nm Code:My city of county B which requires;issuance,permit re enwruct,elms,improve,deermii t or mash and swoon•. $6000 poor to quires the appliciint forsuch o file asigned moment fiQ (mom incingsedpursuant tion7 N)prevision Sq.Ft.Floor Area Valuation y H$ (cat he is (commencing wiNS«bona and the Divisionr of Wicgednruend Profeson.Any Code)or .- that he u 3rempt Nemfrom and die baso far be alleged cxucant in Any violation of Section mo 7031.5 by any applicant for a permit subjects the applicant to a civil pemltY of not more than five hundred dollars(5500). p Occupancy Type ❑1,ma own.of the,property,or my employee wish wage as chair vele compewdon, will do the work end the immure is not intended or offered for sale(SCc.?OW,Business and Professions Codc:The Comractor's Licerae Law does not apply to an owner of Required Inspections pmpcity wine builds or improve thereon.and wh.docasuch wurkleimwlfor through his own employcn.Provided that such improvements are not intended oroRered imitate.If. however.the building or improvement is writ within one year of eompleuon,lie owner. builder will have the burdrn of Proving shat he did out build or improve for Purpose of sale.). El I,as owner of the propenY,am reclusively convecting with licensed mnvutors to construct de project(Sec.7W.Bminess end Prof.sions Code:)Ta,Cancacum's Li. cense Law docs not apply to an owner of propeny.who builds or improves shemon,and who conusca for such projects with a convacmrfs)licensed pursuant in the Convectors License Law. Iamexcmptunder See ,B&PCforthismaon Owner Dem 13071WORKERS COMPENSATION DECLARATION I hereby affirm under penahy of perjury,one of the rellowing declarations: 1 ham and will maintain is CmuBam of Ouni to wlf-imum for WacmrsCompen- W ion,as provided for by Section 3?00 of Ne labor Code,for the performmce of Ne rt for which this permit is issued. 1 have and will maintain Workers Compensation Insurance,as required by Section of the labor Cade,f«Ne performance of dm work for which Nu permit is issued. Workers mpcnsarion Insurance carrier and Policy nuusmberr�am-rtier. A��//IBf P01mI,Na.: A6Z!?&j4 CERTIRCRIT OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thies CImoneedno14mmpined iHhepermitisfmonehund dMllm(s100) or less.) I arufy that In the pen1memnm of the.,it for whim this permit is issued,I shar nor employ any person in any manner so as to become subject to Ne Workers Compcmation Laws of California.Dam Applicant NOTICE TO APPLICANT:If.After making Nis Ccnificam of Exemption,you should become subject m she Warkel a Compemadan provisions of the labor Cade.you muse 0 z forthwith comply with such provisions or this Permit shall be deemed rooked. z CONSTRUCTION LENDING AGENCY (•-h 4 I hereby affirm that there is a coram«tion lending agency for Ne performance of C'h7 the work for which this permit is issued(Sts.3091,Civ.C.) Qlenders Nene U z Lcnderi Address U Q I Certify Nat 1 have raid Nis aPpli.li.o and stem thm rhe above infommiun is FCorrect.l ego«to comply with all city and county ordinances and sum laws relating to O U building cansvuction,and hereby memoeae eprexnedives of this city to enter upon the W alhovcmcnummd property for impeeuon purposes. rCL (We)agree to save,indemnify and keep harmless the City or Cupertino against N liabilities.judgments,Cosa and exp.vm which may in any way Aman,against aid City U,Z in consequence of she granting of this permit. ^ APPLICANT UNDERSTAN AND W L COMPLY WITH ALL NON-POINT Issued by: Date ��G t- URCEREGUyA Re-roofs azure of App JGonUACtm Dale HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant mom or handle hvudoes material ,mdefined by dhc Cupertino Municipal Code.Chapter 9.13,and due Health and Sarety Code.Section zssu(')? All roofs shall be inspected prior to an roofing material being❑Yea ❑Na P P Y g g installed. Will thea timate or fume building occupant ase a If a roof is installed without firs[obtainingan inspection,I agree to remove applicant Bquipment or devices which P it haaNnus air conaminana a defined by me Bay Area Air Quality Management all new materials for inspec District? ❑Yes 0 N — 1 have mad the WIsidommamrials equimmena underchapter6.95 critic Califor- niaHesWr&SafetyCodc,Seclimmin 5,2.5533 and 25530.1 umk:rsmnd dim ifthe building Ones not curmmly haat a mount,that it is my mspomihility to noury the occupmt of the requirement,whit s at Ourtoissuancc ofa Cerouir: of Occupanry. SlgnatUre pplican Date �2 r� o .oriato .edasmIt Dam All roof coverings to be Class"B" or better Community Development y, 10300 Torre Avenue ' y Cupertino CA 95014 Telephone(408)777-3228 # CITY OF Fax(408)777-3333 UPE�TINO Buildin De artment JOB ADDRESS: PERMIT # 7 O TI 2- l�7 OWNER'S NAME: e a — l PHONE # —p / GENERAL CONTRACTOR: Ph,..b) _ FAX # _�K"-7 I am not using any subcontractors: /Z—/(—e)� Si �e Date Please check applicable subcontractors and com Tete the followin information: MGGIazing ONTRACTOR BUSINESS NAME BUSINESS LICENSE # s &Millwork Finishing l on : Carpeting / Wood Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor ignature Date Pig CITY OF CUPERTINO o o CITY OF PERMIT APPLICATION FORM CUPEkTINO ' r APN# 2L4 L4C, ' b ��L 0 Date: Building Address- Mailing Address (if different from building address): O ner's Name: Phone#: Drn a-I-&r 1So �s � 4t �y Ctractor: J License#: r)C - C�"-L ctor Cont ct: Ph ne: 253 OC.ei � Cupertino Business License#: C6,aG C�, Fax: 2S3Cr, Z3, La Building Permit Info: Bldg ❑ Elect PlumbN Mech Er Job Description: �,- Residential Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group UCS Type of Construction: v� Please check this box if the project is a 'AILsecond-story addition: ❑ Pro'ect Size: StandardLar e ❑ Ma'or ❑ —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 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 W3z (P 1 of3 4�/ 7° ' 3 1 , CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC 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 MIXTURE 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 Dis osal 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 cfn MECHANICAL BREMAIRHAN A/C Units <=btuMECHANICAL MECHANICAL BREMAPPLI ApplianceMECHANICAL BREMBUSWAY RemodelELECTRICAL BREMFIXT Lighting ELECTRICAL BREMFURN RelocationMECHANICAL BREMFURNOV Relo FurnacMECHANICAL 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/A aratus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT R air/Alter Heating MECHANICAL BREMRESAPP Remodel Res A liance ELECTRICAL 2 of 3 d CITY OF CUPERTINO CUPETyo f�TINO PERMIT APPLICATION FORM Quantity Fee 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 BSWIIv1 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 Change BUILDING 3 of 3