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04050142 TY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: JOHN ROWE PERMIT NO 04050142 CITY TILSON AVE E ' NA IT PERMISSUEDATE JOHN ROWE 18860 TILSON AVE ____. QS/21 /2004 NE: SANITARY NO. CONTROL NO. ARCHITECT(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTORS DECLARATION I Wrathy arrion that I.licensed under previsions of Chapter 9(commencing Job Description with Section 7")of Division 3 of the Business add Professions Code.and my license is I.fall fifloce and offact. CONVER CLOSET TO LUNDRY RM License Class-LLk.is , Dam-Ccumuscur, UPGRADE ELECT. SEWER ep ARCH TECTS DECLARATION I understand my plans sha:l Im used as public records I flemby arrom OWNER-BUILDER DECLARATION that I am exempt from the Contractors License Law for the is Licensed Professional O following much.(Section]BI LS,Business and ProaSsimas Co Any city or county which requires a permit to cnnaflflfl4 attar.improve,demolish,or repair any Structure �jto pd., its issuance,also requires the applicant for such permit to File a signed sunciflunt Bad he is licensed pursuant to the previsions or die Contractors Uccom Law(chapter 9 Sq.Ft. Floor Area Valuo�p0000 (commander,with Section 7000)of Division]of She Business and Prefessions Cods)or Nat he is attempt dardefieflon Said the basis for thic alleged caumnlith..My Aided.of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Family of APN Number Occupancy Type not more than five hundred dollars(M). 1.a Moor aides property,or my employees with wages in their sale compensation, 37516045 . 00 will do the work,Said thestructure is not intended oroffeend formic(Sm.7044,Business and Professions Code:The Chairman's Licamse Law it=not apply in an owner of Required Inspections property who builds orimproves thereon.and who does awliwork hinflulfor through his own employees,provided that Such improvements andothruended wGffemd for Side.It, however,the building or iMPMWMCnL issald within one year ofcompledon,the mine- Wilder will have the burden of proving that he did not Wild or improve for purpose of Sid..). E]1,in owner of the property,am exclusively contracting with licensed common to SOMMUCt the project(Sec.7044.Business and Preficassons Code)To Contractor's Li cone Law does not apply in an owner of property who Wilds or traprown;thereon,and, who contracts for such projects with a commatods)licensed pursuant in the Conflactoes L se Law. ❑I B&P 9 forNis dions Lm' WORKERS g Xi 4LI!- NSATION DECLARATION perjury ors,of the following destinations: I I ofCdamd So ulf-Insure for Winters C..pc.. am an provided for by Section 37M of the Latic,Code,for the peffrounflass of the 'For which this permit is issued. work'have and will maintain Woelor's Compensation firmuranci,as required by Smdon C]11 37 '�l of labor for the performancoof the work for which this permit is issued. St My Worker's Compensation Insurance carrier and Policy number am: Carrier.-Policy Na.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Disseetime naml accomplescal Irma Permit is for muchundroxidallies(IU00) or loss.) I minify that in the Performance of Bra work for which this Permit is Issued,I shill not employ any Nixon in any marencr an In in become subject to the Worken'Conmensation Laws of Calikennia.Dam Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject in the WaAms CourNeradon provisions of the Labor Code,you must 0 z forthwith comply with such provisions or this permit shall Is,deemed revoked. z"" E7 CONSTRUCTION LENDING AGENCY I harmy.M.Shut there I..c...tracda.lomfirt,,fl.,c�"Iflxtflc,flurtmaerormf the aflda far which this permit I.issued(See 3M.Co.C.) Lender's Name P6 .7 z Lender's Add. U 0 1 canify that I have mad ild,application and swat that the above information is "It. IT, F correct.I agree to comply with all city and county ordinances and sale laws mlating to 0 Ubuilding construction,and hereby aunhorin mparfleflunflifloa or this city to enter upon the UJ above-mcationtul property for Inspection purposes. CL. (We)agree in save,indemnify and laacp harmless the City of Cupertino against C11 liabilities jisignonts,con ' fliscus which may in my way accrue against said City yq4r n's 3 in con f1he 'In - this '"d 0 'a ANO by: Date - �PAD AND V'LL COMPLY WITH ALL NON-POINT Issued R EGULATIO Re-roofs natureofApplicantoZontriafor Data 7 HAZARDOUS MATERIALS DISCLOSURI Type of Roof Will the applicant or future building occupant Siam or handle hvallous materiel fined by the Cupcedno Municipal Code,Chapter 9.12.and the Health end Safety Section 25532(.)' All roofs shall be inspected prior to any roofing material being installed. rl Yes 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 hicoinhois womunflinams as defined by the Bay Area Air Quality Management all new materials for inspection. District? C'e. -, , I have mad the he. I us fieya at,oxittinflummus order Capper,6.95 of the Califun netI th&Saf,1yqt%&In III.25533and25534.1underfluaddiatifthe Imiding no "umand as. ofita it a my floproubility,to nobly the occupant of the I. rats,4wratualWax, a uruuancc .aCc'M'.""'P?7 I Signatu re of Applicant Date 061, Own r ortahoozed.grol Data All roof coverings to be Class "B"or better p CITY OF CUPERTINO BUILDING DIVISION PERM BUILDING ADDRESS: JOHN ROWE PERMITNO04050 14 2 18860 TILSON AVE NER'S NAME: PERMIT ISSUE DATE JOHN ROWE 18860 TILS PHONE: SANITARY NO. CONTROL NO. ARCHITECGENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Bopp LICENSED CONTRACTOR'S DECLARATIONO e UF�{ I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing Job Description E with Section 7000)of Division 3 of NC Business and Profusions Cock,and my license is �yr,� o infmlmraandeffen. CONVER CLOSET TO LQNDRY RM Z Licence Claw Lie,g r Dam amracmr UPGRADE ELECT. /SEWER :OCT 952004 ARCHITECTS DECLARATION �v I understand my plans sh.il W recd a publie no,inda BUILDING Licensed Pmfmahm.l Oat I am exempt from DECLARATION �0 0 I hemhy affinte that 11. exempt(rum Nc Canmcmfa Any C law for the 00 which urce,a Permit Ro sr.BusinessandProfession Curb:Any city structure K$V which require n permit re construct alcor,improv,demolish,nr repair any tatu<mm uZm pdoemits censedr ommquires tWasions o far mehpermiuocencele a Law statement < that he is licensed pSection emenuo Nc of Division of the Contractor's Licenselaw(Chapter Code) Sq.F[. Floor Area ValUpflpg OOO z�D 'hat(cohe 4 exempt with Sec ftmen and the basis for of the Business pt Proon.Any Cnde)car y'd$ Nei he ts eacmpt tnertfrom and the baso for the alleged exemption.My vlolafion of Section 7031.5 by any applicant for a Permit subjects Ne applicant m a civil penalty of APN Number Occupancy e not more then five hundred dollars($500). P y TyP ❑Lanowner ofthe propeny,or my cmploycawlN wgeass their sole compensatloq 37516045 . 00 will do the work,and the structure is not intended or offered for sale(See.7044,Business and Professions Codc:The Committees License law docs not apply in an owner of Required Inspections propeny who builds or improves themon,and who does such work himselror through his . awn employees,provided that such improvements arc not Intended mofferad Rnsale.If, h�, ever,the building or improvement is mid within one year of rompledon,the owner. builder will have Ne burden of previa,Nat he did on build or improve for purpom of vla). ❑1,as owner of the propeny,am uohnively contracting with licensed rontnctora to construct the project(Sec.7044,Business and Ptofusiom Code:)The Contrecmis U. ave law does not apply b an owner of pmperty who Wilds or improv themon,and who contracts for such projects with a contractor(s)licensed pursuant to the Commeclora Liean Law. ❑I exemp tler Sec. .B&P C far this reason .or :;AJ11-41L617-1 w (; WORKER'S COW ENSATION DEC' RATION I It rtby`(funs antler penalty of perjury,ane of the following declantiov: ❑Lha and will maintain a CertlOcate of Coven to self-insure for Worker's Compton. amion.as provided far by Seeriun 37M of the Labor Code,for the performance of the work far which this permit is issued ❑1 have and will maintain Workers Compensation Insurance.as required by Section 37W of tlec lsWr Codc.for the performance of Ne work for which this permit is issued. My Worker's Compenmuon Insurance carrier and Policy number am: Cartier. Polity No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not W completed lfthe permit is for one hundred dollars($IW) nrlGa.) 1 eternity Net In Ne performance of the work for which this permit is issued,l shall not employ any person in any muncrm as in become subject to Bc Workere''Compensauon Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption.you should become subject in We Workers Compensation provisions of the Labor Code.you must 0 Z. forthwith comply with such provisions at this permit shall be deemed rmmkcd. z CONSTRUCTION LENDING AGENCY 'r^t rte. I hereby alarm that there is a construction lending agency for the performance of Cthe work for which this permit Is issued(Sec.3097,Civ,CA WQ Isnticr's Name 0.. z Undoes Address J Q I ardfy that I have rtad this application and stste Nat Ree above information is D. E• arrect.1 Agra to comply with all city and county ordinances and sum laws relating to DU building covtmctian,and hereby authorim repvenutiv of this city to enter upon Bic >4ts3 shave (WC)nW property for inspectionnifkeep es (WC)agree rosaw,orandurpoharmless the City or Cupertino against / fq liabiliuu,judgmcnts,costs peva which may in any way c.against said City U Z tnPPLleq ceUND ERI'm AND AtND WILL COMPLY WITH ALL NON-POINT Issued by: Date R EGULATIO Re-roofs namrc of ApplicmVConl ter Datc HAZARDOUS MATERIAL,DISCLOSURt Type of Roof Will the applicant m,rMuniipal C,ecChapter or anntlh Health althamaterial fined by Ne Cupenina Municipal Code.Chapter 9.17.and the Hca1N anal Safety ode.S.ccdan 15533(.)7 All roofs shall be inspected prior to any roofing material being installed. Yes Po Will the applicant or future Wilding occupant use equipment or devicns which If a roof is installed without first obtaining an inspection,I agree to remove emit haaardous it contaminants as defired by the Bay Arta Air Quality Management all new materials for inspection. Dlstrict7 ❑Yes I have real the hvaNnus m9W als recut mon entsundcr Chapter6.95cr Bm Caliror- niaH hit, Safety Cede,Section 4551,15533 and 25534.1 codeuund that if the Wilding ora tcuneml watenan that itsmyrvaponslAilirymnoul'ytnemcumm.rthc Lhccnlaw out be me 'or a iammaoacer� /�orampane. I Signature Of Applicant Date own rar Amari.<da,ent 1'• J Date All roof coverings to be Class "B"or better 01iER-BUILDER VERIFICATON 1. (Check one) Ioar my�immediate family (parent,spouse or child) will perform • A. All the work authorized by this permit B. _ A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to b�-=-fV.11. • 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed ..................................................................................................................................................................................... I declare under penalty of . ' that the above is a an correct. I have read and understand the Owner-Builder Information(ree ,arse sid I�� Property Owner's Signature:/ �✓ " Dat /" a Job Address:. ) ��6 ': �+n Permit# � 0 Any changes to the information provided on this form shall be submitted to, City of Cupertino Build • Department. ItITY OF CUPERTINO o a CITY OF PERMIT APPLICATION FORM • CUPEkTINO APN #37f— � 6 Building Address: Mailing Address (if d' ren fro wilding a dress): I 'F6d `rl d A �� I Ownae: Phone #: { Contractor: License #: Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect ❑ elumb ❑ Mech ❑ JobDescrip ' Con%/ rr oFx � d D✓� olvn rr roon _ Residential 1 v d(w l— is a I �� Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Projec . 1 G Occupancy Gro p: f r� Type of Cons ction: Please check i box if a project is a second-story a ❑ Project Size: Standard ❑ Large ❑ Major ❑ 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 7 BUILDING 1 of 3 7 �� ' 17 i OTY OF CUPERTINO CUPEIi°TINO PERMIT APPLICATION FORM 7Quant!ityFee 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 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 Stonn/Rain Water PLUMBING RW BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER InstaWAlter 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 <= 10,000 cfm MECHANICAL BREMAPPLI Lk2pliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL 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 2 of 3 b *CITY OF CUPERTINCS CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantio Fee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance 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 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 Electricals foot ELECTRICAL EPEIUTFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPI.BG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 Ic IV) � +n CL.eAWO yr A-10 i yNI Alr-.Al coMiee 5 Qs avr� wuTe�' Sr Dr�i4G COWL11j ►i �i'�dt/ �� CY �„`�3 � vs 1 CA , ' e —T�D-p r.OR RECORD C py OR lid tPiG �avP._r cas Ms SIGSiED r end speer t and itis on R Ltd L_ loe ` on the lob at ail hie? atteratlon` ne Y.eFt maY.e any Chang ar yi aiya iaert. �cM OV Z Gj1? L 1`G71t9Gf 1 lavafuf to without viritt€n F 'I Oft same i,,, t city of C. ,�p ., steotitcadons i udding t,n a( ba at i the b . .Z.31 g of thw F u i tom- ii % l MnW : etnl;t at to f; 1 Ttte .. V7efd to F ttiJVsi€tn" / i ; 3NA1t MOT to viofatton of an'y G / / �✓�lj �G re 2� the -- ` -- -----.. .._ o, r, u;d,eance or *ate Liar, / AY 21 00$ 1 d g6 d Is CITY F � 1 / C� 4-,- P LDI G DO ."MENT , �a�� C-onc�✓ � � i I � Fav Pim ! Ivs i i t , I I NCw �3n�' pis I � ir�c�oyvl � i CITY F INO 1 ROV �mpe SUILDI. � iiylPJh p ` N��wpN_DU D1NAN�FS Dp ! MUS, Dons i Sl ssko= e� IM yatspe , ° 1Vf C ee vollJ�er Eve chanA S w ?Y o�writte of lava tion- papt., ��—anditpeaf�ca ar she bmlds of tip s plan aem a t0� n �� ( p pip�ss° ZIA NO - �,l vie, _ 1