03090126 CITY OF CUPERTINO
BUILDING DIVISION PRR14 „CONTRACTOR+INFORMA
BUILDING ADDRESS: PERMIT N%3 0 9 012 6
OWNER'S NAME: PERMR L%UE DATE
3
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L� t� (�
Zoe, LICENSED CONTRACTOR'S DECLARATION
�u❑ 1 hamthy affirm that I am lianmd under provisions of Chapter 9(commencing Job Description �'��res■F�®
ZW with Section 7000)of Division 3 ofthe Business and Professions Code,and my license is
<e. in fail Bermand affect. S7 S KITCHEN REMODEL
Licca.Cl Liv.N
Dam Contractor CONTRACTOR: KEN POLK GEN. CONT. NOV 1 8 2003
ARCHITECTS DECLARATION
I w u 1 understand my plans Nall M used ss public reemda
X01 Licensed Pmfcuinnel BUILDING
g OWNER-BUILDER DECLARATION
ecc 1 hereby of tan that 1 am exempt from the Contractors License Law for the
O b following reason.(Section 703 1.5,Business and Professions Code:Any city or county'
<m which requires a permit as construct,elteq improve,demolish,or repair any structure
priono its issuance,also requires the applicant for such permit to 0lcasigneJ stammcal
e�ct that he is Recused pursuant o the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Val u$tI4000
2 (commencing wi On Section 7000)of Division 3 of the B usincts and Professions Cod.)u,
that he is exempt shereftum and the basis for the elici ed exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant tlr to a civil Penalty of 3 5)9`N3 ber0 0 Occupancy Type
not more man five hundred delta.(Ss00). - - - - - - P Y YP --- -
D h a owner of the property,or my employees with wages as their solo ComPearcahn,
will do the work.and theswcture is net mutated or offered Tamale(See.7041.Business RR
and Professima Code:The Conaceme,License se Law donot apply to an owner of 101 — FOUNDAT`MYd Inspections
properly who builds or improves thereon,and who doessuch work himself or through his
ownemployces.provided that such improvements aremt intended oroRered formic.if, 102 — PIERS
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 Wild or improve for putpoae of 103 — UFER
.1,)
le') 104 — REBAR
D 1,as owner of me propeny,am exclusively contracting with licensed contractors to
Construct he p,.jctt(St .70b1,Business and Professions Code:)no Contractor's U. 105 — ANCHOR BOLTS
cen3c Law does,not apply to an owner of property who brei Ids or improves themon,antl, lO6 — SEWER & WATER
who contracts for such projects with a conuetorrs)licensed pursuant to me Contractors License Law, 202 — UNDERFLOOR PLUMBING
D l am exempt under Sec. .B is P C for this reason 203 — UNDERFLOOR MECHANICAL
Owner Data—WORKER'S COMPENSATION DECLARATION 204 — UNDERFLOOR FRAME
I hereby of em ander Penalty of perjury one of the following declaration: 205 — UNDERFLOOR INSULATION .
ave and will maintain a certificate ulf
te ofConseno -asure forworker's Compen. 301 — ROUGH PLUMBING
n,u provided for by Section 3700 of the labor Code,for the of the .. 302 - TUB & OR SHOWER
wn,kmrwhich this unfit is he p303 — ROUGH MECHANICAL
I have and will maintain Worker's Compensation Insurance,as required by Section
3700 oftho labor Code,for the performance of the work for which this Permit is issued. 304 — ROUGH ELECTRICAL
My Worker's Cnmpeasalinn Insurance carrier and Policy number am: � 3 0 5 — FRAME
Carver: S� ,0 T GGa/aaa� Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKER ' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 — INSULATION
mmsectumaneed notleccompleud ifthe Permit is foronehunbcd dollars(SIp) 308 — SHEETROCK
nr leas.)
I certify Out in the Peru Ice of the wort for vection trya permi h lamed,I shah nut 309 — EXTERIOR LATH
employ any Nuarn in any annerso"m becomes c(m a It ion 310 — INTERIOR LATH
Lawsaf Celi(mnia a
Applicant Hca_ 311 — SCRATCH COAT
• NOTICE TO AP LI ANT:If.aftKr making this Cannata of Exemption,you should 313 — ROOF NAIL
ImmunesubjectComply the Workers Compeom us permit
.(,he edemedLabor Code,you mull 501 — FINAL ELECTRICAL ENERGY
z forthwith Comply with orkprovisionsorthis permitshall hedeemedrevoked.
z C
CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY
Y Ihereby atloon 'd
Bacmisaconatractinnleading agency far the perfmorenccof 503 FINAL MECHANICAL ENERGY
the work fur which Ihia permil is issued(Sec.BIN7,Civ,C.)
1 q Under.Name 504 — FINAL BUILDING ENERGY
ndcr'sA Jress
z 505 — FINAL ELECTRICAL
J C) 1 comfy that I have read this application and sats that the above information is 506 — GAS TEST
y correct,1 agree to comply with all city and county ordinances and sum laws relating to
DU building convection.and hereby authorirerepresematisesofthisCity toComo uponthe FIN PLUMB G
N WW ahave.menamed property for inspection tortures OS FI L
(We)agree ro rave,indemnify and keep harmless the City of Cupenino against
fA li.1,11Aia,judg L, al capcnxs which may in any way accoC aga,n last City 5
J z inconsequence fthc gaming of this permit.
jsPP (CANT NOERSTA ND WILL COMPLY WIT ALL ONPOINT Issued by:5 ING Date
E ULATION
Id I ameam
Re-roofs
Signature APNIcxH HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant or future building OCCupant Store or handle hazardous mau ial
as defined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safely
Code.Section zss3z(an
[:]YC, �Nu All roofs shall be inspected prior to any roofing material being installed.
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
ham dour air conmminanu as defined by the Bay Area Air Quality Management all nWmaterala for insp Ion.
loll❑Yes (�NoI have rtaJ the haaaNnusmaurialsrequiremcnu under Chapur h95o(thc Califond.netcu etyhave dons zssos.zss33 amlzsssa.lundc6 1moi this lvilaing ('..
docs not cu Ily hosts n4 un it my reapum.1.1.1 to 'ly do upant of the
reyui me hichma t dortuissuan¢ofami' ,(rt cc an Signat eofApplicant Da[
Ow rurawhorindagent d Duo All roof coverings to be Class "B"or better
ITY OF CUPERTINOR 2
aCIRF PERMIT APPLICATION FORM
CUPE TINO
Dater / 7
0
3
Building Address:
Xaa rl of E v
Owner's Name: Pone#:
3d( 45/�Y-&e, T
Contractor: License #: _
Contact: Cupertino Business License#:
Building Permit Info:
Bldg �Z. Elect ®, Plumb Me
Job Description: 2EPLAc.E 'lL�, cF1er� C�bt
Residential ® A� kj—S Uc. to LCommercial ❑
Sq.Ft. Floor Are : $/Sq.Ft.:
Cost of Pr Iect �� Occupancy Grou
Type of Co
uanti Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 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> 1,75MBtu MECHANICAL
BCONSTAX Construction Tax. BUILDING
BCONSTAX Ind/OfFComm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V > IOOOA 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
Iof3 _r- / 3�� 3 (g
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IWITY OF CUPERTINOO
CITYOF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily 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 Repipe Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo 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 cfin MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfin MECHANICAL
BREMAPPLI Appliance 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 Lkp2liance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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a OITY OE CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
/�Ouantitv Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rept], 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 Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEN2 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
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3 of 3
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T Da kepi on the jot at e;l times and it is un' J
hl lawful fill ) make ant changes or CO alterations
on sum without mitten permission from.
p C the buil ling Dept., City of Cupertino.
i�rC?`J The ata ping o(in ; plan and specifications;g Q 7G
SHALL JOT be hel to permit or to be or, CA
approve of the viol tion of any provisions =0 (P
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