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04100144 CITY OF CUPEWrINO BUILDING DIVISION PERMIT ,CONTRACTOR INFORMATION BUILDING ADDRESS: PERMIT N®41.00144 0441 TULA LA E OWNER'S NAME: PERMIT ISSUE DATE JANET BERTAINA KENNEDY 10/21/2004 ONE: SANITARY NO. CONTROL NO, ARCHITECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 M 00 LICENSED CONTRACTOR'S DECLARATION- Job Description U I I hereby affirm that I am licaned under provisions of Chapter 9(commencing P with Section 7010)of Division 3 ofthe Business and Professions Code,and my license is o Fom)force andeffect. ELECTRICAL PANEL UPGRADE jLjz License class Lla.« 200 AMPS v,'O Dam to Contracr t,J ARCHITECTS DECLARATION aa 1undernJ my plans shall Mdied as DECLARATION u.G Licensed Professional / ` S OWNER-BUILDER DECLARATION Contractor's ON j mil a 0 1 hereby.(Ere that 1, exempt from Ne Coxions C's e:Any Law fur the M followingrears etabun 7 cont, Businessand mprve,deinns Code:Any city or roomy I $ wnirM1 requires Issuance,permit re cores the alter,improve,demolish,nr repair any structure Fra nediticament that heor to slcenedpuruntto the thovisiosof for Compactor Liens aw(Chapon9 Es0 2p, mourningwdpurstion7 epmvivision3oftheBumnessan ProesaonsCodmr9 Sq.Ft.Floor Area CP _#ValUa$ftSr000 ��$ (co,he is exempthherefrom and of basis An nr the aged Casand Profession Code)or Natio is exempt any applicant p li and the baso far the alleged Gumption.Any violation of not mom thann 703 n any dollafor a rs(SS Permit subjects the applicant ecivil penalty of APN Number80 . Occupancy T e n.tmoremanRvonaaamJdmiaraasW). 35913080 . 00 p y YP ❑I,as owner of the property,or my employees with wages u their sole compensation, will do fee work,and the structum is not intended or offered for sale(Sec.70,94,Business and Professions Code:The Contractor's License Law does not apply in an owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his own employees,pmvided that such improvements are not intended or offered for sale.If, however,Ne building or improvement is sold within one year of completion,the owner- builder will ban the burden of proving Nat he did not build or improve for purpose of sale.). L as Owner of the property,am exclusively connecting with licensed contractors to construct the project(Sec.7044,Business and Professions Code)The Contractor's Li. cense law does not apply to an owner of property who builds or improves thereon,and. who connotes for such pmje er wi Ch a eomractor(s)licensed pursuant to the Contractor's License law, ❑I am escrept under Sec. B&P C for this reason �Q.�. 7 c . lo- i4 0 / WORKER' COMPENSATION OPLLAROION hereby air,.under penahy of perjury m¢of the following declarations: ❑l have and will maintain a Certificate of Consent to self-insure for Workers Compcm ration,as pmvided for by Section 37W of the Imre,Code,for Inc performance of the work for which this ermit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 37W of the Labor Code,for the performance Of the work far which this permit is issued. My Worker's Compensation Insurance Cartier and Policy number am: Canner: Policy No.: , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if the permit is Toro is hundred dollars($IN)) on less) I cenify that in the performance of the work for which this permit is issued.I shall not employ any person in any manners.as to hecum.subject to the Wmkcrs'Compensation Laws of California.Did Applicant NOTICE TO APPLICANT:If,after making this Credited.of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you most .J O forthwith comply with such provisions or this permit shall he deemed mvokcd. '� CONSTRUCTION LENDING AGENCY [-v I hereby affirm that there is a constriction lending agency fonhe performance of Ca Nc work fur which this permit is issued(Sec.3N7,Civ,C.) 6iQ Lender's Name z Lender's Address U Q I certify that I have read this application and into that the above information is C4 F COReel.I agree to comply with all city and county ordinances and state laws relating to pU building construction,and hereby antnnre representatives Of this city to enter upon the G shovomentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,Pogroms,costs and expenses which may in any way accrue against mid City U in consequence of the granting of this permit. y' APPLICANT UNDERSTANDS AND WILL OMPLY WITH ALL NON-POINT Issued by: Date O SO CE REGULATIONS. ;O / s ofApplicanUnt Coracmn "��L' >�f/ e Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety ,jdftCmie,SectYcNu ia,25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑ Will the applicant or furore building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit ha...does air cnnumirom,as defined by the Bay Arca Air Quality Management all new materials for inspection. District? C Yest 1 have read the hazaNnus materials reyviremen¢under Chapter 6.95 of the Calif., nia Health&Safety Cnde,Secdons 255)5.25533 and255J4.1 unJcrsmntl that if IM huilJing does net Connolly have a tenunt,that it is my resp.nsi cloy to nnuly the oecupam.1 do, requimme iso,C mast me poormis meeof thrQeorotap ty. Signature of Applicant Date i ,?� OrF ow .r Ion s hmieed agent o e All roof coverings to be Class "B" or better Community Development d ' 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY F Fax(408)777-3333 fUPEkTINO Building Department JOB ADDRESS: PERMIT# 6o(-Iyl vy/eoiy� OWNER'S N QKe_ gn i w PHO '!os -7-sr -8 375' GENERAL CONTRACTOR . 7-�, FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing b Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile er/ or Signature Date � h • CITY OF CUPERTINO COPE TINO PERMIT APPLICATION FORM qpkPN# 66 Date: r1 .� -- V GT '-f Building Address: Mailing Address (if different from building address): Owner's Name: n #: Ja-,G4 /telI/ • 8,rTJ�a (rYL� a� � �fqg- 2Sr7 - qZ97� Contractor: . L' ense #: P1./k� . /C. . Contac--- - hone: •2 (4 N _ V�L.2gupertino Business License#: ,1Z. .K. i—q� Fax: Building Permit Info: Bl Elect Plumb ❑ Mech ❑ Job Des ription: Residential µCommercial ❑ _ Sq.Ft. Floor Area: $/Sq.Ft.: ' Cost of Project: p Occupancy j Type of Construction: , . Please check this box if the project is Ad Nk second-story addition:, ❑ U Pro'ect Size. . Standard ❑ Laze ❑ Ma-or ❑ 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 BBOILER5Boiler> 1.75M Btu MECHANICAL' BCONSTAX Construction Tax BUILDING BCONSTAX hid/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 BELE 1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<-200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 CITY OF CUPERTINO CUPEIi;TINO 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 BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING MIXTURE 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 rinUer/Backflo PLUMBING BPSTORM Stomn/Rain Water PLUMBING doll 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 BREMAlRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFD{T _ Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Fumace > 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 BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM uanti Fee ID Fee Descri tion Fee Group BREMSIGNAD Rmdl Si s Add Branch ELECTRICAL BREMSIGNS Remodel Si s, Maz uee ELECTRICAL BREMTHEATR Theatrical Li tin Fix ELECTRICAL BREMVENFAN Vent Fan Sin le Duct MECHANICAL BREMVENSYS Ventilation S stems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BS' Swimmin Pool BUILDING BTEMP Tem ora Power ELECTRICAL BTEMPPERM Temporary Bldg PermitFELECTRICAL ING BTEMPSVCS Tem Dist Svcs BUSLIC Business LicenseING ELECTRIC Electricals footRICAL EPERMITFEE Elec Permit IssuanceRICAL MPBRMFEE Mechanicals . footNICAL MPERMITFEE Meeh Permit IssuanceNICAL PPERMITFEE ' . plumbing Permit Issue PLUMBING PPLBG Plumbing Fee Qn foot PLUMBING ZADDCFIG - Address Chan e.._ _ BUILDING 3 of 3