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03100116 CPfY OF CUPERTINO '�twwAr aero S`Ta s *" BUILDING DIVISION PSR � CONRACTQRINFORM„AWN BUILDING ADDRESS: PERMIT NO.03100116 3100116 ln9c)r VIRGINIA 2WAN 121 OWNER'S NAME: PERMIT ISSUE DATE MORRIS F, qT­rF.RRY T.TN INE: SANITARY N0. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0, LICENSED CONTRACTOR'S DECLARATION I F 1 hereby affirm Nm 1 am licensed under provisions of Chapter 9(commencing Job Description ,�W with Section lOq))nf Division 3 of be Business and Professions Code.and my license is ! in full forte IT �L' Data 1= _ Chromatinic WINDOW & PATIO DR. REPLACEMENT (13 WINDOWS) ¢�¢ f aacHrrEcrs DECiiiniziqCONTRACTOR: THE WINDOW BROKER #24873 W ^:1 understand my plaaz shall be used u public records LLo Licensed Pmfcssimal OWNER-BUILDER DECLARATION i<E I hereby ntTrm that 1 am exempt frum the Contractors License Law for the a O followi.g reason.(Sccdim 113 L5,Business and Prefemions Code:Any city mommy 12 which rctlaims a permit to cnnswm,alter,improve,demaliih,or repair any.xtmetim :y< prior to its issuance,also requires the applicant for such permit to file a signed statement last he is licensed pursuant lot the previsions of the Contractor's Liccnsc Uw(Chapter 9 Sq.Ft. Floor Area Valua[ 79276' 2 S u(commencing with Section 7”)of Division 3 of the Business and Professions Code)or that lop is exempt therefrom end Ne basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a pemtirsubjodx the applicant to a civil penalty of 3 ,$I�`rOICI 7 0 0 Occupancyy31 e not more than Eve hundred dollars D50). '7P El 1,as invade of the pro,porty.or my employees with wages as their sole compensation, will do Newark and the atmctete is not intended or ofesa l for sale(Sec.7W.Business and Profcssiens Code:Trip,Committees Liceme Law does not apply to an owner of Required Inspections property who builds or improves diamond.and who des meh work himself or Nmugh his - own employees,provided that uch impmwmentt are not intended oroRered for ale IL however,the building or improvement is said within one year orcompletion,Ne owner- ` builder will have Bar burden of proving that he did not Wild or improve for purpose of ae) 1,as owner of ct property,,B ex imses and contracting with licensed convectors i. centum the project(Sec.n a x,Business and Rofeasions or The Cs Jachdon.Li whoa Law docs Bol apply m an owner of property who Wildspor improves Comon,and, who contmcu for such projects with a conlnahr(q licenced pursuant m the Convector's Liana Lew. ❑taro exempt under See. ,B 6PCfor thlsrcazon Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury arc of Ne following declarations: haw and will maintain a Certificate of Consent to self-haute for WorkeM1 Compen- on,u provided for by Section 37W of the Labor Code,for tbe perfornantt of Ne work for which this permit is issued. ❑1 hoc and will maintain Workers Compensation Insurance,az required by Section 3700 of NC Ube,Code.(a,the performance of the work for which this permit is issued. My Workeds Compensation Insurance carrier al PP No.s number am: .y_��� .rYLRLeUYCERTIFICATE OF EXEMPI'IONpIapM W R�o O� COMPENSATION INS61fANCE (This section need not be completed if the permll Is I'monc hundred dollars($100) ar less.) 1 eenify,that in the performance of the work(or which this permit is issued,1 shall not employ any penton in any manner a az to become subject to the Workers''Compensation Laws of California.Data Applicant NOTICE TO APPLICANT.If.after making Nis Certificate of Exemption,you should become`iubjecl m the Worker's Compensation previsions of the Labor Code,you most D O forthwith comply with such previsions or this permit shall W dermad revaked. ��y CONSTRUCTION LENDING AGENCY 1 hereby affirm that them is a convection lending agency for the performarme of :1ti thc work far which this permit is issued(Set.3097,Civ.C.) ge Lender's Name 5 z Under'Address Q 1 eenify that I have read this application and ante that me above information is y F correct.I agree to comply with all city and county ordinances and spite laws relating to D V building convection,and hereby solarium representatives of his city to enter upon the G above-mentioned property for inspection purposes. - (we)agree to ave,indemnify and keep husnle s the City of Cupertino against rn liabilities,judgments,costs and expenses which may in any way accrue against aid City JZ in consequence of Ne grand ng of his permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date r fli�lz,' SOURCE EGULATIO SnprCmd. 3 Re-roofs iLnemm afApplicaHAZARDOUS MATERIALS DISCLOSURE Date Type of Roof Will the applicant ar furore building..part stem nr handle havuduus material as def tied by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes 1�1Nu 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 1 hazardous air conamitsnu as defined by the Bay Area Air Quality Management all new materials for Inspection. .vitt? ``// ❑Yes ACINI 1 have rad the hvardem,materiels requisemcnu under Chapter 6.95 of the Calirm, riaH-,d,&Safcay Codc,Secdmu255D5,25533 and25534.1underspind Narifthe Wilding does not currently have a tenant,that it is my respectability In airy dte occupsnt of Ne m4uimmcn bleb uuhmelpnart ssuenceof.cerifcatcor ver. Signature of Applicant Date + `(�� All roof coverings to be Class "Bt'or better nc Owauthariscd a gent �—D g t Su ME�� RF, APPROVED M OCT 15 200 1N ACTIN CO CODE TCRD►% %CES �11P� TIN DATE SIGNED „of°Latif s MUS' Thi et Paas and .P- ; . ti all times ar d it is un ton the jG-a. r itFratiens cr;" charges o• vaful to maks ' �mV'on irom pn same without written Ce', ar ino. xD the building Dept., City of G r an and sp,citications f rato Jha stamping of this P`� to faa ar. SHALL NDT be held to permit r' aclo<< sPPTOW of tha vioiaton of am. Gre" , ni enY City Ordinance pr Sta1e �w' X� Xe bij *CITY OF CUPERTINOO v 3 p CUP TY01' O PERMIT APPLICATION FORM qWPN# l �� Date: io /,S— 03 Building Address: 102,46v Rt Owner's Name: Phone#: L,;ta Contractor: fj " Q r License#: Contact: DYY/NPIr Cupertino Business LLicense#: � goo 6;q y Bu� it Info: 7 Bldg Elect ❑ Plumb ❑ Mech ❑ Job D ription: PA {,m C,&t�&4f pL I a4� Kdential 92 'e Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: �Z / 00 Occupancy Gro Type of Construction: 10 • 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 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 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 2�5�, �J/ • v 3✓'.•� (ZITY OF CUPERTINO* °TM°r PERMIT APPLICATION FORM CUP'ETIN0 Quantity Fee ED 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 ection 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 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 clin MECHANICAL AL A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY Remodel Busways ELECTRICAL WBRENMqH00D YT Lighting Fixtures ELECTRICAL RN Relocation of Furnace MECHANICAL NOV Relo Fumace > l OK btu MECHANICAL AT Heater Installation MECHANICAL Installation of Hood MECHANICAL C Misc A aratus ELECTRICAL PP Rem Non-Res A liance ELECTRICAL LE Pole/Platform Fixture ELECTRICAL • 2of3 `CITY OF CUPERTINO CITY Of PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ED Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREN=CEPT 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 13REM-VENSYS 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 Electrical sq foot ELECTRICAL EPERMTTFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMTTFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING • 3 of 3 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRA,CTORINFORMATION BUILDING ADDRESS: PERMIT NO.03100116 3100116 .R'S NAME: PERMIT ISSUE DATE NE: SANITARY NO. CONTROL N0. ARCHITECfIENGINEER: ; BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 all, LICENSED CONTRACT'OR'S DECLARATION 1 hereby from that I am licensed under provisions of Chapter 9(commencing Job Description mm with Section 00(oof Division S of the Boniness and Professions Code,and my license is =N in full forcif ,t� Lice n lu Lie.M_ WINDOW & PATIO DR. REPLACEMENT (13 WINDOWS) o Date cpntr ARCHITECT'S .A CONTRACTOR: THE WINDOW BROKER #24873 a u /til under¢IanJ my plans shall he tema pued as public rccnNs a ocn � Licaed Professional S OWNER-BUILDER DECLARATION )<y I hereby affirm that I am exempt from Ne Contractor's License Law for the :,10 following reason.(Section 7031.5,Business and Professions Code:Any city or county m which mquires a permit to construct,alter,improve,demolish,or repair any 4ruqum Seri pd.,to its issuoncc.alsurequires the applicant for such permit ut filcaxigned statement that he is licensed pursuant to the provisions(if the Contractors License Law(Chapter 9 Sq.Ft.Floor Area 1 2 $ (commencing with Section 700E of Division 3 or the Business and Professions Code)or 6 thm he is exempt therefrom and Ne basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a Penult subjects the applicant o a civil penalty of 3 y,87.7,Tya.�ker 0 O not more than five hundred dollars(S50B.' M14®lY 9` O c ype ❑I,u Owner of the property,or my employees with wages a a their sole compensation, will do the work,and the awcture is not intended or offered for sale(Sec.7044,Business t and Professions Code:The Contractor's License Law does not apply to an..at of Required Inspectio gUILUING— property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended OroRered for sale.If, however,Ne building or Improvement issold within one yesr ofcomphdion,theowner- builder will have the burden of proving Wat he did not build or improve for purpose of sale.). El 1,as owner of to property,am exclusively connecting with licensed comforters to construct the project(Sec.7044,Business and Professions Codi The Contractor's Li- . cense Law docs not apply to or owner of proper,who builds or improves nhemon,end who contracts for such projects with a edntractods)licensed pursuant to the Contractor's License Law. ❑I ons exempt under Sec. ,B&P C for this rcsson 1371Mr Data WORKER'S COMPENSATION DECLARATION (hereby affirm under penalty of perjury one of the following declarations: e c and will maintain a Cenificme of Consent O self-Irma for Worker's Compote ,as provided for by Section 3700 of the Labor Code,for the performance of the for which this permit is issued. ave and will maintain Worker's Compensation Insurance,as required by Section . of Ne Labor Code,for the performance of the work for which this permit is issued. orkre/ycs C.�"penetion Insurance carrier and Policy number are: br.YG L1l� Polio�NOy4'glh 3; —2� CERTIFICATE OF EXEMPTIONPI1yM W RO IFR$:p O� COMPENSATION INBUORRANCE Y Cnesection need not becomplcled Rube permit is for one hundred d.R.(SIRE or less.) 1 certify that in the perfndromem of the work In,which this permit is issued.1 shall at employ any Person in any manner se as to became subject to the Workers Compensation Laws of California.Dane Applicant NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should become subject to the Worker a Compensation provisions of the Labor Cotle,you must �Z forthwith comply with such provisions or this permit shall he deemed revoked. r O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of x.fir One Work for which this pcsmit is issued(Sit.3097,Co,C.) Q Lenders Name 5 Z Lender's Address Q 1 certify that 1 have read this application and SILO that the above information is y carted.T agree to comply with all city and county ordinances and state laws relating to V building construction,and hereby adhorim mpresemadws or this city to enter upon the �(A shove-mentioned property for inspection purposes. (We)agree to save,indemnify and keep ha erieas the City of Cupertino against ~D,I Eabllltice,judgments,coats and expenses which may In any way accrue against said City JZ in consequence of the granting of this permit r " APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE EGULATIO S. / - 3 Re-roofs ignawrc of ApplicaH ContraclahHAZARDOUS MATERIALS DISCLOSURE Danc Type of Roof Will Ne applicant or future building Occupant stem or handle hmarJous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety le,Ballon 255J2(a)? All roofs shall be inspected prior to any roofing material being installed. ' ❑Yon �No 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 in hazardous air contaminants as defined by the Bay Area Air Quality Management all new maICC1a15 f07 inspection. utrie, `/ 1­1 yes AC1No T have mad the havaN"uuss materials mquimoncn6 under Chapter 6.95 of the Califor- nia Health&Safety COM,Seeuons 255(15,25533 and25534.1 undo .d then if the budding does not currently have a mount,that it is my responsibility in nodl'y the Occupant of the requimmennh ustbemenpnorl/y,�wxnceareCenlOeamof <r. Signature of Applicant Date 'C2- 7—n e All roof coverings to be Class 'B"or better Owne iuhoriezd agent g