04100128 .CITY OF CUPERTINO g �a ,z
BUILDINGDrvlslory PERMIT GCINTRAGTORINFOI.2MATION:
BUILDINGADDRESS: SEY _ PERMITN
Q34100128
10125 N WOLFE RD
OWNER'S NAME: PERMIT ISSUE DATE
MIKE DEMPSEY 10/19/2004
ONE: _ SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
40, LICENSED CONTRACTOR'S DECLARATION Job Description
L� O O O
i Ua u 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p
.a,a withScorce ndeffefDivisionSofineBusinessandProfcssinnsCnJc.antlmyliccnuis TEMP POWER
_ or in mu force and arcen.
License Class Lied
nt O Dolc Contractor
pp� ARCHITECPS DECLARATION
C 1 understand my plans shall he used as public records
JyU
3 o G License)Professional
,5 OWNER-BUILDER DECLARATION
+ 'a q 1 hereby error that I am exempt from Ne Cnmmelm-A License Law In,the
a
00 following reason.(Section 71131.5,Business and Professions Code:Any city or county
Km� which requires a permit o construct,alter,improve,demolish,or repair any structure h 200
__y prior to its ismane,.rdsu requires the applicant forsuch Permit o filen signed statement '7
a that he is pursuant provisions S Ft.Floor Area
fxo p p v (Chapter q. Valuation
eat- (commencing wi th Section 7070)of Division 3 of the Business and Professions Code)or
y r3 Nat he is exempt therefrom and On 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(2500). e Occupancy Type
❑L as owner of the properly,or my employees with wages as their sole compensation, -
will do the work,and the structure is net intended coffered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to 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 far sale.If,
however,me building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving mat he did not Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed convectors to
consumer the project(Sec.7044,Business and Professions Cade:)The Contractor's U. -�f
cense law does not apply to an owner of property who builds or improves maroon.and. 41
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
yiiennae L.W.
I am exempt under Sec. ,B&P C for this reason
Dale a
WORK 'SCO PE ION DECLARATION
1 hereby affirm under penally o do,one of the(all w' g declarations:
❑I have and will maintain a Certificate of Convent to self-insure for Workcre ComKn. -
sarion,as provided for by Section 3700 of the Labor Code,for the performance of the
weak for which this permit is issued.
D 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 or the labor Code,for the performance of the work for which this permit is issued. '
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is for one hundred dollars(:100)
or less.
I certify mm in h arta rice of the work for which this Permit is issued,1 shall not
employ anypeom er^ azobecome subject to the Workcmr Compensation
Laws of Cal i a
ApPlica t - _
NOTIC TL NT.1, or taking this Cerilicare of Exemption,you should
becomo jcct to the Work Compensation provisions of the Labor Code,you must
� 'Z forthh comply with such provisions of this permi"mall W deemed revoked.
LZ.t O CONSTRUCTION LENDING AGENCY
I hereby affirm mat inert is a construction lending agency lot he Performance of
!Yi the work for which[his permit is issued(Sec.3097,Civ.C.)
�W Q Lender's Name
z Lender's Address
U I certify mal l have read this application and sale that the above information is
ar F C ffmcl.I agree to comply with all city and county ordinances and state laws relating to
C V of
lding conswction,and hereby authorim representatives of mis city to enter upon the
ahovome judgments,
dProperty for inspection pm,mwhich ms.
H y (We)agree to save,indcmni fy and keep harmless the Ci ry of Cupenlno against
yr beriricifoome cthe ostsand expenses which may in any way accmc against said City /
C) APPLICANT UNDEgxTANG A WILL COMPLY WITH ALL NON-POINT Issued by: Date//
s0 CE FG A NS. f
Re-roofs
Si ore o ApPlicanUCon facmr
HAZARDOU MATE S DISCLOSURE a Type of Roof
Will the applicant or futu buildim cripant Aoinarrhandlc hararduus material
As defined by the Cupertino Municipal C e.Chapter 9.12,and the Health and Safety '
Code,sc❑c Yea 255320.)1. All roofs shall be inspected prior to any roofing material being installed.
es
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
coir hazardous air contaminants as defned by the Bay Area Air Quality Management all new materials for Inspection.
District?
❑Yes
1 have real Nc hezaNnus materials requirements under Chapter 6.95 of the Califnry
nia Health&Safety Code,See' 255f15,2553Jand 25534.1 undersmnd thmifthe building
does not cure ly ve atedant Out it is my fes Wm l ily at noufy the Occupant of the
IrAVion c s hi- must hem Priormissuanc Camficate of Occupancy.
Signature of Applicant Date
D e amhorized WK Abe, All roof coverings to be Class "B"or better
.. ,.i T.^!h i;r u.F AFlm "Nr-.. ,n•..,Ma.0 r..vn 4'e.. � .i*,.v'i r. .�.,., y
`CPCLARA cpOy FIRE DEPARTMENT .;
FIRE 'r° SANTA CLAM COUNTY CONTROL NUMBER
14700 Winchester Blvd., Los Gatos, CA 95030-1818 a n
(408)378-4010 (phone) • (408) 378-9342 (fax) PERMIT NUM E
PLAN CHECK No.
PLAN,REVIEW COMMENTS
CODE/SEG SHEET NO. /� 6
Ro.& ,tar o� �- a c- rs2 c cd:m ar t 3a z'Gie»4 s f
a,p
Ma Two
83l - 320 — 3 -7547 cc-«
JURIS �i PLANS SPECS NEW REMODEL AS CONST.DESCRIP. BY Jj DATE PAGE
GU 1 C 1:1 ❑ 01 )O- lg•O`� SOF
SEC./FLOOR OCC OCC.LOAD AREA ARCH/L G/CONTRACTOR/OWNER
M 10 "L
NAME OF FACILITY LOCATION
A California Fire Protection District serving Santa Clara County and the communities of
Campbell, Cupertino,Los Altos, Los Altos Hills, Los Gatos, Monte Serena, Morgan Hill, and Saratoga
FIRE DEPARTMENT
CpL
jA, FIRE �a� SANTA CLARA COUNTY
14700 Winchester Blvd., Los Gatos, CA 95032-1818
(408) 378-4010 • (408) 378-9342 (fax)• w .sccfd.org
SPECIAL EVENTS INFORMATION SHEET
The following information shall be provided in order to process the special events permit:
Address of event: � � /r
Contact Personl/ 2:_ c Phone No.:
Address: S���/� �/ /2� 1�itp ^
Iriz2—/cPg/ 2op
1. Date of event: Hourf Operation:
2. Type of event: O
3. Number of people anticipated: 5;
4. Size of tent or canopies: K\0 Q f
5 Number of booths: Food/Coo
king: Vendor/Artist: 0fF
6. Tent/Booth Supplier(s):
Date tent/canopy being erected: N lq� Date down: n�it
• Entertainment - what type: l�o
Stages/Platform(s): N e N e
Carnival Rides: ^ �-
Cooking (how prepared): Kho-
Will there be deep-frying?
Will there be BBQs, open flames, or candles?.----'
14. Special Effects: 3 e g"
15. Source of power: Generator: �� Electrical:_j 2-0
16. Source of heat:
17. Access Closure: N
18. A Plot plan showing the tents, canopies and/or booths dimensions, and distances from
other tents, canopies, booths,buildings,vehicle parking areas and roadways shall be provided.
19. A seating/table arrangement plan, if applicable, indicating the number of seats, seat
• spacing, aisle locations and widths, exit widths/locations and exit sign locations shall be
provided on a floor plan. (For tents and canopies only).
Organized as the Santa Clara County Central Fire Protection District
Serving Santa Clara County and the communities of Campbell, Cupertino,Los Altos,
Los Altos Hills,Los Gatos,Monte Sereno,Morgan Hill,and Saratoga
i
' i
CITY OF CUPERTINO
CUPEI�TINO PERMIT APPLICATION FORM j `� is 1 z�
N
31 66
-Ba�Address: P,0R t%,-5 Le- 1 Mailing Addre (if Xfferdht from building address):
Owner's Name: Phone#:
-, SIU - d /
Contractor:
- `i � License#:
Contact: Phone:�3/ 3 o-39 Cupertino Business License#:
�� r i Fax: Yt 9 — 2—
Building Permit fo:
Bldg ❑ Elect P] ❑ Mech ❑
Job Description:
Residential Elcommercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Gr
Type_of Constructs _ _ Please chec this bo if-the r ' ct is a
second-§to" a —
'IFPrWect Size: .Standard ❑ _Lare ❑ Ma'or ❑
Quantity Fee ID Fee Description . Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERl 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/ uasi BUILDING
_ BCONSTAXBQ . - Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax-Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICALRI
BELEC1001 Elec 600V> 1000A ELECTCAL _-
BELEC200 Elec Svcs 600V<==200A ELECTRICAL
BENERGY Ener BUILDING
BENERGYADD Ener Add Multi BUILDING
BINVESTIGA Invests ation fee BUILDING
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l�tiy
CITY OF CUPERTINO
PERMIT F APPLICATION
CUPRTINO O ORM
fiV-Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCONR M 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
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 Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Ston-n/Rain Water __ __ PLUMBING
Aft 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
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BRENHNHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platfonn 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
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CITY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID =eatn
Description Fee Group
BREMSIGNAD dd Branch ELECTRICAL
BREMSIGNS s, Mar uee ELECTRICAL
BREMTHEATR tin Fix ELECTRICAL
BREMVENFAN in le Duct MECHANICAL
BREMVENSYS S stems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSVdIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary BldgPermit BUILDING.
BTEMPSVCS Tem Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electricals foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
No EE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPE FEE Plumbin2 Permit Issue PLUMBING
- PPLBG - — --Plumbing Fee sq foot - - .. PLUMBING
ZADDCHG Address Chane BUILDING
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