05090003 CITY OF CUPERTINO �aik5� x;#'� '' �` '
BUILDING DIVISION PERMIT W—, - GT R INFO,RMATIO
BUILDING ADDRESS: THE WINDOW BROKER PERMIT NO.O 5090003
1612 VITIA MARTA rT
OWNER'S NAME: PERMIT ISSUE DATE
LOU & ALLISON PRUSA 2385 LINCOLN AVE 09/01/2005
ONE: SANITARY NO. CONTROL NO.
(800) 639-4527
ARCHITECT/ENGINEER: BUILDING PERMITINFO
eLDG� ELECT t� PLUMB MECH
O l�
LooLICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
nt! with Section 70Bo)of Division 3odtha Business ad Professions Cude,end my he...is
u in full fame and )� ��2 REPLACE WIN ~ L ALATION W/STUCCO
j Llcmn. Lk.as ,s
H Da n 'i CO .
' � FINISHING
ARCHITECTS DECLARATION
1 understood my photo W11 W used as public ranrts
OCT.0 Licensed Porfessi.nat Q ZU�
OWNER-BUILDER DECLARATION
EQ 2 I hereby.(sere on I ore exempt from the Cortins Co License Law for the
i c O following rcuoa Permian 703 nsu r,Business and Professions Calc:Any City or county
u�^ which requires a permit to cannraL eller.Impmw,demnlisM1,or repot,any structure
R1 III nim
,ZS pow to its issuance,aim requite the applicant for such permit to rile a signed statement Valuat Cp 80
<
that he is Reamed pursuant to the provisions of the Cantrabri Licence faw(Chapter 9 Sq.Ft. r e
ll s€m (eammencingwith Scction7000)o(Divuion3ofthe Businmad Prormiam Code)ur
NF F Net W Is emmpt therefrom and the basis for the alleged exemption.My violauon of
Section 7031.5 by airy applicant for a permit subjects the applicator On a civil penalty of APN Number Occupancy Type
not mom Om It hundred damn($51)B). 36638020 . 00
❑1,as Owner of the property,or my employees with wages as their who compensation,
will do the work and the structure is not intended or offered for aate(Sec.7W ,Business Required Inspections
,and Professions Code:The Common's License Lew does not apply to an owner of q P
property who bulldsmimprovea thereon,and whodnesmch wad himself.,through his
Own employees,provided thosuch Improvements rte not Intended or offered torture.If,
however,the building or Improvement is mid within one year of compholan,Ne owner- -
builder will have the burden of proving that he did not Wild or Improve for purpose of
sal..).
❑1,as owner of the propeny.am"elusively contracting with licensed coouanmn m
consumer the project(Sec.7044,Business end Pte fesioes Code:)M Cootranafa Li-
ceme Law does not apply In an owner of property who Wilds or improve thereon,and
who contracts for such prokets with a commou t(s)licensed pursuant to the Conuxrofs
Lkenee Law.
❑I4m exempt under set .B As P C for this on
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby.115a under penally of perjury,era of the following declarmanue
I hsw p o will maintain eCW Bab of Consent r Code.
a Wodefa ce of ft
earn,a provided far by Section 37000,the IaWr Code.for the performance Of tW
ward for which this permit is Issued. '
❑I haw and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for On,performance of the work for which this permit is heard.
My Worker's ComPenetian Imunnce re ice and Policy number em:
Cartier. `'�v a •-.'7, Policy No.: I_�,I6330
CERTIFlCATE FE%EMMUN FROM WORKERS'
COMPENSATION INSURANCE
(Thissada need at W catnplcbd if the permit Isf.ronc hundred dolia(n1a) _
nr lea)
1 certify that In the performance of dtc work for which this Permit is issued.l shall not
employ any person in any manncran u in become subject o lW Workeri Compemarlon
Laws of Calif nuia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenifrek of Exemplion,you should
Wcome subject to the Worker's Compmuaiion provisions of the Labor Code.you must
,JO forthwith comply with such prouina vor thio permit shall W revoked.
oked.
z'-• CONSTRUCTION LENDING AGENCY
rN r�-i I hereby Orion that Nen isaeonsuuctina kedinggcney for the performoux of
CYithe work for which this permit b Wood(Sec.3097,Ci,C.)
D.1 Q
Under'.Name
az Lendeft Address
U O 1 cenify that 1 haw read this application and some that the show information is
nrT". enamel.1 egra to comply with all city and county ordinances and atom laws relating to
rV^ building construction.and hercby cmnify dlrcpmsenutiwte Nis city martin ager upon Nc
W ahove-mentioned property for Inspection purpose&
LL (We)agrees,cave,indemnify ad tech hannm the City of Cupertino d City
fg Iiacoitlgjude of do Standing
this carnit. may in aY way scam against and City
UZ mconseANT of DERSTing of this per mit.
w< APPLICANT UNDERSTANDSAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL�['p�ONS. //
/�nrnYso.�//c.0 Q'?- rJ" I `JS . Re-roofs
Sigm4d.of ApplicanUConuacmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at future building Occupant store or handle hev4Nous material
as&flood by the Cupeno.Municipal Code.Chapter 9.12.and the Health and Safely
Cade.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea koro
Will the applicator or future Wildingazupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hannous air conmminants ss cfncd by the Bay Area Air Quality Managcmcm all new materials for inspection.
Disuict7
❑Yes u
I how read the havardnus macrials requirements under Chapkr6.95 or Nc Califon-
ria Health Ar Safety Cade,Sections 25505,25533 a[25534,I underswnJ Ihml(Ne Wilding
does not currently haw a Rrant,that It Is my responsibility to nodfy tW occupant or the
r,cyNrcma}a+�'�hm.t/gqWmetpoorinismaaaraCemfcatea(acupancy. Signature of Applicant Date
a'M_i Ca.�%x .\9' o1 '-0 All roof coverings to be Class"B"or better
Owner reauthadved agent Dam
CITY OF CUPERTINO
C1 0 CUPEkTINO
PERMIT APPLICATION FORM `S �3
APN# X66 Date: 09 - 01 — os-
Building,
9 _ 0 1 — oS
3 �o2D
Buildin Address: 'n Mailing Address (if different from building address):
2-IG 12 Villa PIBv�Q ct. CR 95014
Owner's Name: hong#:
Low R 11 i sow rasa (409 973 $058
Contractor: License#:
;.4 oma, Sr4e✓ 7193$2
Contact: Phone: ] wO)b39-4S27 Cupertino Business License#:
Av,A Fax: 10 3 23 -S S
Building P rmit Info:
'Bldg EI Elect ❑ Plumb ❑ Mech ❑
, s v«o +;o; ti;Job Description: 1I(aM -
Residential Lr 4, mew
Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
S, ROD- .00 —
Type of Construction: Please check this box if the project is a
second-story addition:} El
ro'ect 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 EnergyAddMulti BUILDING
BINVESTIGA Investigation fee BUILDING
I of 3,
2162 Villa
PLAN �.
•
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CITY OF CUPERTINO �vh�•Tr'•�.ve e r (`{{p ` s 'z
BUILDING DIVISION PERMIT V iV 7. ��0A ZNF6RMATf0 ,''
BUILDING ADDRESS: THE WINDOW BROKER PERMITNO.05090003
21612 VTT.T.A MARTA CT
OWNER'S NAME: PERMIT ISSUE DATE
LOU & ALLISON PRUSA 2385 LINCOLN AVE 09/01/2005
SANITARY NO. CONTROL NO.
(800) 639-4527
ARCHITECTIENGINEER: BUILDING PERMR INFO
BLDGO PLUMB
MECHO
�Oo LICENSED CONTRACTOR'S DECLARATION Job Description
r� 1 hereby affirm that 1 un Rumored under provisions of Chapter 9(commencing p
with Section]070)of Division 3 of the Business atm Profesdom Code.and my license is
in full ro=and enem. C 3$2 REPLACE WINDOWS (6) -NF INSTALATION W/STUCCO
i,N? License Clw 1 .e
Dam AOS C IY
chairman a -,i FINISHING
ARCHITECTS DECLARATION
I understand my plana shall W used as public secnWs
Da!
G Licensed Protests enal
OWNER-BUILDER DECLARATION
I hereby an.that I not exempt from the Coommu's LIeenso Law for the
i e fallowing mason.(Section RD IS,Business and Protections Code:Any city or county
+�m which requires a permit to construct.alter,narrow.demnlW,or repair any uructum
fZ> prior to its issuance.alto mquWs the applicant for such pcmtit to etc a signed statement
xx<
that he is licensed Protestant to the provisions of cite Connector's Limasse Law(Chapter 9 Sq.Ft. Floor Area Valuat CPB
pFtF$ (commentln{with Secucn]000)nf Divuicnlnf Ne Butines and Fvrwlou Code)or
'� .. Nu M Is exempt Nuefrom and the basis for me alleged exemption.My violation of
Section 7031.5by,try applicant for a permit subjects the applicant to.oNII penalty of APN Number Occupancy Type
not more than five hundred dollars 6500). 36638020 . 00
❑1.u owner of tie pmpmy,err my employes with wgea u thetr wle canpenntlon,
will do Bre work,and thes"cmrt un or Intended or offered for win(S".ION.Business rf6 f.
and Pm(wiow Code:The Consomme,Licemen law does not apply m an Owner of Required InspeL'tlofis
pmpmywW build,O improves titemon,andwho deesauchwork himselforthrou{h his /�
own employees,provided Natwch Improo manu tie unintended or offered for able.If. (rr
however,the Wilding or improvement 1.sold within one year of completion.the owner. tT
builder will haw the burden of proving that he did not Wild or Improve for purpose of /✓ I�
sale.), OS
❑1,as owner of the property,am exclusively contracting with licensed contractor,to
construct the project(Sec.]OOA,Business and Professions Cede:)The Contractors U.
ecus Lew docs not apply to an owner of property who Wilds or Improves themon,and fTY7t/W(/n
who contracts far ouch pmjecm with a wnmcuu(s)licensed pursuant to the Consadoes ayF>;9y,
License Law, tj,\r\7Al+Y�
❑1 an exempt under Sec. ,B@PC for this moan
Owner Dem
WORKER'S COMPENSATION DECLARATION
1 hereby aBLsn under penalty of perjury one of me following decimations:
I how and will Consentcelb
eimeln•Certificate of Consent m inwm for WorberaCompen-
'gon,u provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u required by Section
3700 of Ne labor Code,for the performance of me work for which this permit is issued.
My Werkeea Compensation Insurance ca 'mend Policy number ma:
Carrier: a�a G Polley No.: t S 163 30
CERTIFICATE F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
frhhace0on need not W completed if Ne lu rnil B foronc hundred dollen(g100
lir lass.)
1 coni(y that in Ne performance of No work for which this permit is issued.I shall not
employ anyperwn in soy manncrso as to become subject to the Workcri Cempewdon
laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this CcniRnm of Exemption,you should
became subject m me Workers Con pcwmpn provinces of the Labor Code.you most
•JO forthwith comply with such provisions;or thio permit Nall dW mmrewled.
,z.t CONSTRUCTION LENDING AGENCY
rev Ihereb alum that there I. construction landin a for Nc
F' r g {encY performanceuf
a> Ne wok for whish N4 permit h istied(Sec.3097.Civ.CJ
0
Lerbees Name
r7 z LenLamder,Andreas
V O 1 certify mat I haw read Nia application and mm that the show Informadun is
Iy tonne,1 a{rem 0 comply wire all city sod courtly ordinances and tum laws missing to
O rV^ Wilding construction.and hereby wNonm mPreanmiw,of this city to enter upon Ne
W ,bow-menudgm judgments.
cut for inspection es puryoses
S (We)agree to sons,indemnify and lump harmless me City of Cupertino against
fn inconseque consequence
th.cuuand expenses which may in anY way wmw against old City
V 2 in consequence of UNDERSTANDS
of thispermit.mit.
r" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE RECOONS,
x(117 t3 tc?w ILe 09—01 - JS Re-roofs
Sigwuie of ApplicsuWConMctor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Bre applicant or future Wilding occupanutore or handle haardous material
an defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safely
tOde
,section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes FsnU
Will the applicant or future Wilding occupant taw equipment or dcvmra which -If a roof is installed without first obtaining an inspection,I agree to remove
t hanrdeus at,contaminum u coned by the Bay Area Air Quality Management all new materials for inspection.
Diauict7
0 Yes u
I haw reW the hezardus memrials requirements underChapwr6.95 of the Celifor.
tie Health@ SefctyCodc,SoWN25505.25533 and 25534.1 undcumnd thalif he Wilding
Jou not currently have a tenant.that It h my mspouihllhy to nodly the ucupant of the
my Oen IMT met pnu,m instance lira Cemec.w of occupancy. Signature of Applicant Date
5P� TGs rl e .9 9- OI —0
.� All roof coverings to be Class"B"or better
Owncr or authorized agent Dom