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04100182CITY OF CUPERTINO� 7 z U y o y < omommencingwith s> s� LL IA IGQ)?i'TRAT!QK 1Gl k'URMA.'�1' - - auaDlNc D3vlsrory PERMIT -�• BUILDING ADDRESS: C BROOK CONSTRUCTION PERMIT NO. 04100182 OWNER'S NAME: PERMIT ISSUE DATE iiaaasss�B'� NE: SANITARY ROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSEDCONTRACTOR'S DECLARATION JobDescri Description - - - p I hereby affirm. that 1 am limnsed under provisions a( Chapser 9 (commencing .. with Section trashier Division 3.f Nc Business and Proposed... Codo,and my fears. is Lifen mica and erten. REVISION - - LANDS CAPE / ARBOR / ENTRY Li cense Class U'. It Date Connector NO NEW ISSUED/ ORIG. #$04030136 ARCHITECTS DECLARATION I undersand my plans shell W used m public Boards ,PERMIT Licensed Professional OWNER -BUILDER DECLARATION 1 booby exempt from she Contractor's License Law for the (Scu the 1 following reason. (Secdo1 ](131.5,t, Business and i.m Cuor: Any city or county . 1. - - improve. d i which requires a pesmil to cnnsaucL alter, improve, demolish, or repair any structure pooh. its ismance. also requires the applicant formals permit to rile a signedsatement License law(Chapter9 Sq. PI. Floor Area Valuati Q[1115 that he is licensed pursuant to 00 provision or the Contractor'. Section 70010) of Division 3 of the Brsommand Professions Cade)sa '7 Net he Is accept therefrom and the basis far she alleged m reption. Any violation of APN Number Occupancy Type Section ]031.5 by any applicant for a permit subjects she applicant to a civil penalty of not mare Nan five hundred dollars (5500). C] 1, as owner of the popeny, or my employee¢ with wages u their sole compensation, 37514031.00 Required Inspections p will do Nc work end the structure leant intended aroffeed forsala(See.7W.Business and Professions Code: The Conuacmrb License rs Law donot apply to an owner of q property who builds or improves thereon, and who does such work himselfor though his own employees, provided than such improvements ere not intended oraRered formic. If. however, the building or improvement is sold within one yev of completion. Ne Owner. builder will have Ne burden of proving Nal he did not Wild or improve for purpose Of ssaE] ❑as owner of the property, , B exclusively contractingfesss with licensed canleetora to U con¢IBet the project (Sec. Business and Professions The COnmcor's Li. v ds or.) came Law data not apply ja an owner of properly who Wilda improves muton, and o an who acafor such prokca with aamanuensis) licenud purterauammde, ConaactoYa - \, - - -- License Law, ❑ lamm mem under Sec. . e &PC Imi¢ /\�� Qration he 0 or WORKER'SCOMPE ATIONDECLARATION I hereby affmn under penalty of perjury one of Ne f IIO1Y declarations: I have and will maintain aCenifncem of Consent th self -insure for Worker's Compcm unto., m provided for by Section 3]00 of the lobar Code. for Be performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as eyvimd by Section 3]00 of Ne Labor Codc, for the performance or Ne work for which Nis permit is issued. My Worker's Cmnp reartmn Inseenea carrier and Policy number are: Cartier. Policy No.: - CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This .,if.. need mt be completed B the permit is future hundred d.11. (gID0) M It,.) 1 sanity that in the Performance of the work for which this permit is issued. I shall not - employ any perms in any mmnersa as to become subject to the Workcri Compensation Laws of California. Dace Applicant NOTICE TO APPLICANT: IL after making this Ceri foam of Exemption, you should become subject to the Worker's Compensation provisions of the labor Code, you must Z forthwith comply wish such provisions or this permit shell he deemed evoked. CONSTRUCTION LENDING AGENCY that there issued(Sec.30 lending agency for performance of -r I herebywhich R. work fur which this permit is issued (See. 3097, Civ. C.) QLenders Nam. Leaders Adtlrau z 0 I certify has 1 have mad this application and sate that On, above information is Fcareer. I agree to comply with all city and county urdiumms and suis laws elating to Ubuilding construction, and hereby uniform, representatives of Nis city to enter upon me U ah ova+mentioned property for inspection promote. (WO) agree to save, indemnify and keep harmless the City of Cupcnino against f liabilities, judgments. costs and expenses which may in any way same against uid City / — Z in APPLICANT UNDERSTANDSor the granfing tAND me Permit, ILL. COMPLY WITH ALL NON -POINT Issued by: Date SOUH6 REGULATIONS. .- to -M-04 Re -roofs Type of Roof wof Ari icanVCmnmem oto B HAZARD S MATERIALS DISCLOSURE' Will Ne applicant Lir future building occupant store or handle hamidous material az defined by the Cupertino Manic' sl Cada, Chapter 9.12, and the Health and Safety Code. Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Ye Na If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which mil ha'ardous air conmminanH as ncd by the Bay Area Air Quality Management all new materials for inspection. District? a ❑ Ycs 1 have mad the histamine materials requirements under Chapar6.95 of she Califor- nia HcalN & Safety Codc, Sectiau 25505,25533 andZ534, I undersand straddle building docs no currently have a marmf that it is my responsibility m unify me cceupanwf the m c whic muslasmctprinr ismmmara,paNReaaOrOccupamey. - Signature of Applicant Date All roof coverings to be Class "B" or better nerorauthorindagcon f Da��ta{y! LOtCZCt11 'S= +aC FZC F f U, CITY OF CUPERTINO- ` t3UILDIN6;DIVISION PERAN �.LCQR,�%O,RMQN BUILDING ADDRESS: C BROOK CONSTRUCTION PERMIT NO. 04100182 OWNER'S NAME: PERM117MUEDATE NE: SANITARY OL NO. ARCHITEMENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description -.- - I hereby affirm that 1 am licensed under provAims, of Chapter 9 (commencing with Section 7000) of Division Sof the Business and Prefershms Code, end my license is in full tam and effect. REVISION--LANDSCAPE/ARBOR/ENTRY License Clan Lic.p Data Contractor NO NEW PERMIT ISSUED ORIG. 404030136 ARCHITECTS DECLARATION _ 1 understand my plans shall be used as public records . Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that Iam exempt Joint the Character's License law for the following muhn. (Section 7031.5, Business and Profcaaions Code: Any Cly or county - which mquln:s a permit to construct, slut. Improve, dcmnllsh, or repair any stmctum 'do, m is issuance. abh requhu lM applicant furnace Permit m file. lgmJ.lmorld Llmnm Law 9 Sq. Ft. Floor Area VaUatl lat he is licenmd[moment to the psionmf am Customer' mmvi (commencing with Section 7M) of Division 3 of the Businrasand Profusions Cade) or , 115 that ha 4 exempt dhemfram and the bub for the alleged exemption. Any violation or SeNon 7031.5 by any applicant for s Permit subjects the applicant m a civil penalty of APN Number Occupancy Type not mom than five hundred dollars (650)). ❑1,u Owmrarthepmluny.mmyemployceswiNwrAutlubwlecompemlim- 37514031.00 Required Inspections P will do the work. and the structureb noUnundeador offered inteds(So,.0044. Business and Prefeemrs de: CoThe Contncmfs Liana cs Law donot apply to an Owner of q proMny w ho Wilds or improves dmmon, a nd wha does such work himself or mtough his own employees, provided Net such improvements au nhtinunded mot forule IL however. the building Or improvement is cold within am year of completion. the owner. _ builder will have We burdm of proving Wad M did not build Or improve for purpose of \ ❑ h as Owner of We progeny, am exclusively contracting with licensed convectors m commuct the Project (Sec. 7044, Boamm and Poodess ms Code) To, Conascm/e Li. mese law does not apply so an owner of property who builds or Improves Bremen, and, _- _ - - -- _ - who conuacsfor such gropes wlNvcomncmr(s)Ilanutl pursuant We COntnctots' - — Licenm law. ❑ I am Caere under Sec . 0 & P/C�for �Wis�reason m� V WORKER'SCOMPE ATIONDECLARATION v I hereby d .. under Penahy of perjury ane of Ne l 110 ' deductions: I love and will maintain ACenirieare of Consent to mtr-insure for Worker's Compo n- samm, As provided for by Stttinn 3700 of the labor Code, far the performance of be - work for which this pmmR is lured. . ❑ 1 have antl will maintain Worker's Compensation Insurance, u required by Section 3700.f to Labor Code, for We performance of be weak for which this Fermin is Issued. My WeakaJs Compensation 1. comer cod Policy number am: ' Cartier. Policy No.: , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ' mal section coed non be completed if the Permit Is far ane hundred doll. (510(y or ansa) - 1 canifv Wal In the performance or the .,it for which this Permit is lured. l shall not ' employ any person in any manner so As In become subject to the Workers'Compensmlon Laws of California. Dam - - Applicant NOTICETO APPLICANT: Jr. spur making this Conificsu of Exemption. you should became subject in the WorknYs Campostaion pmvisihns of me labor Cod., you must [ forthwith comply with such provisions or this permit shall de deemed raveled. CONSTRUCTION LENDING AGENCY 1 herby affirm that mem is consauc30 lending agency for the perfurtname of web far which this permit Is issued (See 109], Civ. C.) Leader's Name Le ...� � Lender's Address I certify that I have read this application and sou that be abuva Information is cartett 1 agree to comply with all city and county ordinances and sou laws relating to building eonsouelian. and hereby saturation mpreemtadves of this city to tour upon be above+mentioned property for lnspcNon purposes (We) agree m save, indemnify and kap hornless the City of Cupertino against / liabilities. Judgments, costs and expenses which may In any way some against said City Z In conuymnec of the greening of this permit. APPLIC NT UNDERSTANDS AND ILL COMPLY WITH ALL NON -POINT Issued by: Date ' SOUHa REGULATIONS. �O Q , Re -roofs Type of Roof . sec of ApplicanVConveno em HAZARD S MATERIALS DISCLOSURE WIII the applicant or forum building Occupant croft or handle hn4rdous material As defined by the Cupem e. Manic el Code, Chapter 9.11, and the Health and Safety Cale, Section 23532(eI, All roofs shall be inspected prior to any roofing material being installed. [:3 Yes No If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant sex equipment or dcvias which emit hazardous air content! s u ncd by the, Bay Arco Air Quality Management all new materials for inspection. District? ❑ Yes 1 have mail the hasoubms materials requirements under Chapter 6.95 a(b, Califon .is Healb&Safety Code, SeNhns 23505,15533 and 25534.1 unkri rend mal lime building Jcost no ,mmatly Avva a tenant, man in is my mspansihility in nilly the Occupant nr the mqu' c whie mustbcmct 'Dr ivawmofaj;mircamartxcupamyy. Signature of Applicant Date All roof coverings to be Class "B" or better mer ur authorized agent -1-one CITY OF CUPERTINO I61 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 4 Sec: Twp: Rng: Sub: Blk: Lot: APN ........:.37514031.00 DATE ISSUED.......: 10/28/2004 RECEIPT #.........: 27581 REFERENCE ID # ...: 04100182 SITE ADDRESS .....: 10330 STERN AVE SUBDIVISION ...... CITY .............: IMPACT AREA ......: OWNER ............: BARBARA BEANIE ADDRESS ..........: 10330 STERN AVE CITY/STATE/ZIP ...: , RECEIVED FROM ....: BARBARA BERNIE CONTRACTOR .......: CARL DAUGHTON LIC # 22392 COMPANY ..........: C BROOK CONSTRUCTION ADDRESS 189 BERNARDO CITY/STATE/ZIP ...: SUNNYVALE, CA 94086 TELEPHONE ........: (650)965-8972 FEE ID UNIT QUANTITY AMOUNT ------------------------------------------- BPLANCKREP HOURS 4.00 348.56 TOTAL PERMIT 348.56 METHOD OF PAYMENT ----------------- OTHER TOTAL RECEIPT : • AMOUNT ------------ 348.56 348.56 PD -TO -DT THIS REC NEW BAL ------------------------- ----- 0.00 348.56 0.00 ---------- ---------- ---------- 0.00 348.56 0.00 NUMBER ------------------ M/C 1 CI CUPEkTINO 4 4 c) 3 U1-30 ITY OF CUPERTINO PERMIT APPLICATION FORM v '� ( a --o / g Z APN # ( (� / Fee Description Fee Group Date: l 0 Building Address: O -6 --50 _ Mailing Address (if iffer t fro building address): �E�l IUO 0l Ft T'YI' P#16"v Owner's Name: Boiler <= 100,000 Btu MECHANICAL Pone #: 79 h LOS Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu Contractor: BBOILER4 Boiler> 1M to 1.75 M Btu icens G- 4!4- T Boiler > 1.75M Btu MECHANICAL BCONSTAX C,qntact: Phone. 4M BCONSTAX Cupertino Business License#: fle4x-m- Fax: 1'S—S Con. Tax for BQ Zone BUILDING Building Permit Info: Hotel and Motel BUILDING B14 A Elect ❑ Plumb ❑ ech ❑ Job Description: /�� BELEC1000 1 Residential ❑ BELEC1001 Co ercial Sq.Ft. Floor Area: BELEC200 Elec Svcs 600V <= 200A Cost of Project: BENERGY 0yupancy Group: r15 Type of Construction: BENERGYADD . Please check this box if ro' s a .. BUILDING BINVESTIGA second -story addition: ❑ Project Size: Standard ❑ Large ❑ 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 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 7 1 of3 3 CUPEkTINO WITY OF CUPERTINOO PERMIT APPLICATION FORM 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 BOVERTRAE 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 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 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFIJRN Relocation of Fumace MECHANICAL BREMFURNOV Relo Fumace > 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 BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Ap Hance ELECTRICAL C. ` IT&I aluo CUPEI,TINO WITY OF CUPERTINOO 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 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 MPERNIFEE 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 LA •