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03110073CITY OF CUPERTINO -'.' �>�� •w"' .,, ',• ' BUILDING DIVISION PERMIT yCONTRACTORINFORMATIONt;:. BUILDING ADDRESS: CUPERTINO KITCHEN DESIGNS PERMITNO.03110073 7491 TIPTOE LN NER'S NAME: - 10562 S DE ANZA BLV PERMfTISEUEDATE MARK SHELLIE PEERCY 11/14/2003 one: (408) 257-4900 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BGS ELO PLUMB MECH O LICENSED CONTRACT'OR'S DECLARATION 1 hereby affirm Thal I are licencem Bernard under provisions of Chapter 9 (comencing Job Description p with Scion MBof Division Softhe Bua .sand Professions Code, and my licenseis m mnrnaerfem. 3 BATHROOM REMODEL Liana Cl: s ¢.N�4n� Data antibdpr LP�FraNN IFINI4LE® ARCHITECTS DEQWA ION1 DEL/ prN 1stand plans shall bcu public re ds. """`� �"p ` . JAN 2 6 2004 a Licensed Pmu fcmne OWNER -BUILDER DECLARATION 1 hereby MTrm that 1 am exempt from Ne Contractor's License Law far the following mason. (Section 703 L5, Business and PmEssam Code: Any city or county which requires a permit re Carol eller, improve, demolish, or repair any structure BUILDI 0 0 0 ! poor n its issuance, also requires the applicant for such permit to li It a signed statement that he is licensed pursuant in the provisions of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7")of Division 3 of the B usincss and Profession. Cal or ! that he is exempt therefrom and dm basis for the alleged exemption. Any violation of 35928007.00 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of All APN Number O Type not more than five hundred dollars (S500), GGU anC y ❑ Les owner of the property, or my employees with wages as their our compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cede: The Comracmra License Law does not apply to an owner of Required Inspections properly who builds orimprovcs thereon, and who does such work himself orthrough his own employees, provided thatsuch improvements are unintended or offered forule. If, however. Ne building or improvement Ia sold within one year of completion, the owner - builder will have Ne burden of proving Nal he did not Wild or improve for purpose of sale.). ❑ 1, as owner of the properly, am exclusively moral with licensed contractors to construct the project (Sec. 7044, Business and Professions Cade:3 The Conuamar's Li. cense law does not apply to an owner of property who Wiids or improves thel and, who contracts for such projects with a Coastal licensed pursuant to the Contractor's Lieenrs Law. ❑ 1 am exempt under Sec. B & P C for this moon at Data WORKER'S COMPENSATION DECLARATION ' 1 hereby affirm under penalty of pedury one of the following decimations: I have and will s sum for Worker's Compene a Certificateio7 as provided for by theLaCreel r for by 3]00 of the labor Code, for the performance of the ode, a iensue weakf work for which this permit is issued. El 1 have and will maintain Worker's Compensation Insurance, as required by Section ., ' 37W of the Labor Code, for the performance or the work for which this peal is issued. My Workers Critics a0on Insurance carrierands Policy number am: r:.Cilh�'E FUND xiRllcyNo.; CERTIFICATE GP EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not Wedunpleted if 1be permit is ro one hundred dollars ($1110) Icss.) I ecnify that in the Performance of the work ror which this permit is issued. 1 shall not employ any person in any manner an as m become subject o the Workers Compensation Laws of California. Dale ' Applicant NOTICE TO APPLICANT: If, .flet making this Cmurmale of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm Nat there is conalmotion lending agency for the performance of the work fur which this permit is issued (See. 3097, Cl, C.) Lender's Name Lender's Address 1 cattily Nat 1 have read this application and mote that the above information is cored 1 agree to comply with all city and county ordinances and sate laws relating to building construction, and hereby authmim mirrommatives or this city to enter upon the above-mentioned d propc for inspection purposes. (We) agree to save, indcmmfy and keep harmlass the City of Cupertino against st es inecamaxpeudgmenhC gnats iand of this ea which may in any way acerve against said City m conseyucnro of the granting of this permit / 1 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOUR EREGULATI p� � � UC.t-� 11 1+ 03 Re -roofs Type of Roof Signature of ApplicanVC,amoselm -'am HAZARDOUS MATERIALS DISCLOSURE Will the applicant m town building eve cupant nmc or handle havarduus material as defined by the Curial Municipal, Code, Chapter 9.12, and the Health and Safety de. Section 25532(.)] ❑Yes XNo All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or deices which If a roof is installed without first obtaining an inspection, I agree to remove mit ha...dous air contaminants. Carl by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes No _ 1 have read the henmous materials requirements under -Chapter 6.95 of the Califor. iia Health & Sarety Code, Secuons25505, 25533 and 25534.1 understand thdif the holding ties not currently have a Brady, Nat it is my retina ih oy to imply the acupant of the �re its winch most at pool mi uancc fa Carl or acup�ne' Signature of Applicant Date \ I !q All roof coverings to be Class "B" or better Owner or authorized agent Date BUILDING DIVISION PERM BUILDING ADDRESS: OWNER'S NAME: MARK SHELLIE PEERCY PHONE: ARCH ITECTIENGINEER: i p LICENSED CONTRACTOR'S DECLARATION F 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing • U with se tion 7000) of Division 3 of the Bus . s and Professions Codc, and my license is r ° in full for .L�nd effect. ,w�__`` 7� ? Liccnsc Cl ic. N ❑ Dam ContrTto r ARCHITECT'S A lON a 1 a�andmpg plans shall he u f public rcnds H Licensed Professional OWNER -BUILDER DECLARATION _ 1 hereby affirm that 1 am exempt from the Contractor's License Law for the o 0 following reason. (Section 7031.5, Business and Professions Code: Any city nr county which requires a permit to construct, alter, improve, demolish, or repair any structure —'" prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chaprcr9 $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or i that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500)_ ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion. the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ 1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li- cense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. , B & P C for this reason z 0 CUPERTINO KITCHEN DESIGNS IPERMIT NO.03110073 10562 S DE ANZA BLV 408)257-4900 BATHROOM REMODEL Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker'sCompen- sation, as provided for by Section 3700 of the Labor Codc, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Codc, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am: r Sf`h� FUNb , No.: CC' d I,<j'1 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE CTTis section need not be completed if the permit is for one hundred dollars (S100) or less.) I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensalion Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compenuation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency [or the performance of the work for which this permit is issued (Sec, 3097, Civ. C.) Lender's Name Lender's Address 1 certify that I have read this application and stale that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the ahove-mentioned properly for inspection purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities.judgmcnts, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: )I f I+/* Signature of Applicant/Contrzetor ../ Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant ur future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the HCalth and Safety Codc, Section 25532(a)? F1 Yes KNu Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Arca Air Quality Management District? 171 Yes {Q No I have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building docs not currently have a tenant that itis no rc IN ity to notify the occupant of the pAuirc*nts which mustjri met prior to gfuanec,pf a ficate of Occup"cy. . Owner or authorimd agent Date Sq. Ft. Floor Area 35928007.00 APN Number Re -roofs Type of Roof PERMIT ISSUE DATE 11/14/2003 SANITARY NO. CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB Job Description Required Inspections o Valuation Occupancy Type Date 0/ I / All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better �,, CITY OF CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM ? APN # -3 5 q - 2-0, - 007 Date: ll// *-/0 3 Building Address: •7"1, 'r1P t,F- LA11,9 fup, 1-:pepNGA - q:5 o I �-- i Owner's Name: Mr. , M,n.� . IYl aY k �� S b ,, !l," Phone #: BBLDGFEE Bldg Permits . foot Contractor: G uPF-FR71ti o k.;Te y F -NAG si c-7,� License #: Contact: A} ,,4 u Cupertino Business License#: Building Permit Info: Bldg [Q- Elect ®` Plumb Q" Mech ❑ Job Description: Residential D � OC''r`' �r�`M04e_l. Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: BBOILER4 Boiler> 1M to 1.75 M Btu Cost of Project: Occupancy Group: Boiler > 1.75M Btu r BCONSTAX Construction Tax Type of Construction: BCONSTAX 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 1 of 3 [TY OF CUPERTINO CITY of PERMIT APPLICATION FORM CUPEVINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMLTLTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMIVIM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNLTMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTEVIE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLLTM SING l 1 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 Sprinkler/Backflo PLLTM SING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLLTM SING 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 cfrn MECHANICAL BREMA]RHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFLTRNOV 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 2 of 3 %2ITY OF CUPERTINO CITY of PERMIT APPLICATION FORM CUPEVINO 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 Appliance ELECTRICAL 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 BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp 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 Change BUILDING 3 of 3