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03120062r 0C zC W r UC �E a U2 0 CITY OF CUPERTINO T'"�`,^, La,�""`"`Y"a �'" ONM T WTNFURMWril� BUILDING DIVISION PERMIT 4.i'^-sS3d.. . �",� �3s2e?+.. g BUILDING ADDRESS: - PERMIT NO03120062 OWNER'S NAME: PERMIT ISSUE DATE ANN SHIRKEY 12 44:OL ONE: SANITARY NO. ARCHITECrfENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description Job 1 hereby "An thin am licensed under provisions of Chepmr 9 (commenting whh Section 70010) or0MAW 3 ardor Business said profcasiom Code.and my [let.IA L ,�c REPLACE TILE & VALVE' AT SHOWERFIN,�LED License Class Lk. g License Class Dam Comramar ARCHITECT'S DECLARATION IundersundmyplansshallcuseduPuhlicrecords - JAN 2 8 2004 . Licensed Professional OWNER -BUILDER DECLARATION 1 hereby afrm that I am exempt from the ConinctaYs License Law for the BUILDING following reason. (Sudan 703 L5, Business and Prefesslom Cade: Any city of county which ant.h. A Permit In craswc4 alma improve, demolish, or repair any annum prior In its issuame, also reclaims the applicant for such permit to Ne a sigud mumem Committal" home law(Chapur9 Sq. Ft. Floor Area Valuat on visheas of dM at M is licensed puuenl m Ore pmmio Nn (commencing wide Section 7000) or Division 3 of the B..[. and Profeufom Caen) in that he B exempt Nertfmm and the buss for the alleged mempdom My violation of 3 5VWJ4t43d)gr0 0 Occupancy 'type Section 7031.5 by Any applicant for a peamit subjects the applicator m A Civil penalty of nor mom dun Bw hundred dollars (11500). Ni, u owner cribs property, or my employees with wages u their role compensation, Required Inspections o,athework. and Nestmcwu iamimencied OraRertd foraam (Sec. 7044, Business and Profeasions Cade: The Conunmfs Liam Law dos not apply to an owner of property who builds or im proves themon, and who does such work himself cur through his own employees. provided that such improvements Am notlnMMed or offered for sale. if, however, lie building or improvement is sold within one year of completion, It mwmr- bulkim will haw the Wrdcn of pmving this, he did not build in impmw for purpose of sale.), ❑ h As Owner of dM limitary am esslusively contracting with licensed canu¢torS to comtmct the pmjee (Sec. 7014, Business and Profession Cade:) Tim Conlnmof's U. cense Law doe at apply in A. owner of property who Wilds or improves thereon, and who contracts for such projects with a conwcur(s) licensed puravant to die Conuxmta L Anse Law. I Am exempt under sea. / B & P C far thl. �_�-C%3h (0////0 3 Owner R'S�C COMPENSATION DECLARATION I lumby affum under penalty of perjury arc of th fallowing duleruiam: I have and will maintain a Certificate ofCament to self-imum for Worke sCompen- satim, As provided for by Section 3700 of the labor Cade. for the performance of the work for which this permit is issued. ❑ 1 have and will maintain Worker's CDmpensadOn Imuran, As myuimd by Section 3700 of Ne Labor Coda for dm petformmee of In work for which this permit h Want. My workefs Compensation LnSmemoe carrier and Polity number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This seeim need no, W completed if the pcmit Is fora.. hu.drrddallm ($100) or lase.) 1 cenify that in dic perfamance of the .,it for which this permit Is Immd, l shall not employ any person in any manner an a m become subject in the Workers' Compensation Laws of California. Dau Applicant NOTICE TO APPLICANT: If, Aller making this Cenifrcam of Exemption. you should ECcome Subject m the Wader" Commtmuon Provisions Of TIM Labor Cade, you mum ' ' faMwith comply with Such providnm cur Its Permit shall be domed mated. CONSTRUCTION LENDING AGENCY I hereby aRim that Nemm is is a • construction lending agency for 0M Performance of ' the work fur which this permit is isamd (Sec. 3097, Co. C.) Leader's Nmc Leadee's Addteas I certify that I have read this application and sum that the Above informed. I. ' comet. I Agree ta comply with all city and county ordinances and stale laws mhting 10 building constmetion, and hereby Audition mpmsenutivea or this city to once upon the aMve-mcntiomd property for immcuon purposes (We) agree in saw, indemnify And keep haulms TIM City of Cupertino against I liabilities, judgments, cam and expenses which may in any way acme Against said City / // in eonSa9mnee of the granting of Its permit. ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date / SOURGQRE ATLONS. Re -roofs Type of Roof §ignmbre of Apidi erUCOA.Ior Dau HAZARDOUS MATERIALS DISCLOSURE Will die Applicant or future Wilding mcupam mart or handle hnordaus material u defined by the Cupertino Municipal Cade. Chapter 9.12. and the Health and Safety Cade. Section 25532(a)? All roofs shall be inspected to any roofing material being installed. ❑Yes u prior If a roof is installed without first obtaining an inspection, I agree to remove Will me applicant or mum banding Occupant use equipment or devices which not l nardous air con emu as defined by The Bay Area Air Quality Management all new materials for inspection. Dimria7 ❑Yesu 1 havereal dM bnurdous mutuals mquimments under Chapw6.95of theCaliror- niaRutN&Safety Code,Secuas25505.25533 uvd25534.1 undentsM iMlifdM Wilding does trot eurmmly have a WmAL the ibis my responsibility in notify dM areupsnt of dM reyuircmcnu which mum beena Prio.m issuance cur. - am or Occupancy. Signature of Applicant Date �J All roof coverings to be Class "B" or better mace or .a Onrmda ant Dam AS CITY OF CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 3 ( 2-0 � 6 Z W Quantity Fee ID N # 332 ^ D Date: 2-003 BAPPLOTHER Building Address: p / MECHANICAL Owner's Name: Ant-) sk,-Ie Phone #: aS'7•ozyy3 BUILDING Contractor: License #: MECHANICAL Contact: � Cupertino Business License#: MECHANICAL Building Permit Info: Bld Elect ❑ Plumb ❑ Mech Boiler> 500K to 1M Btu Job Description: J4_ % T ar u' /7T h O Residential ❑ i6 -?60X4!' S/�b/ �t dC ✓/i'GdG" Commercial ❑ BBOILER4 Sq.Ft. Floor Area: $/Sq.Ft.: BBOILER5 Cost of Project: /-3 Occupancy Group: AIL Type of Construction: BUILDING W 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 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 4 2�� 1of3 gym._, CUPER INO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMITIGATR Res. HousingMit Fee BUILDING BMNEWMULTI New Multi-FamilyRes MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamil 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 BUILDING 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 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 HeaterNent 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 BREVE URN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > I 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 L 2 of 3 �(�� CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM Quantity Fee 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 A liance ELECTRICAL BREMSIGNAD Rmdl Sips 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'S ecific Plan BUILDING BSEISMICOM Seismic Commercial 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 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 r 0