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04030251 ( CITY OF CUPERTINO BUILDING DIVISION PERMIT � PAO OWN O � . „ . , BUILDING ADDRESS: PERM ND.04030251 OWNER'S NAME: PERMIT ISSUE DATE STTFAT-TTq NE:FF(CSANITARY OL NO. ARC rIENGINEER: BUILDING PERMIT TNM BLDG ELECT PLUMB MECH uoo LICENSED CONTRACTOtherebyR'S DECLARATION C��® �k t� �® F Ithereby.Thom Nat 1 am licensed under proviso...of Chapter 9(coen mmcing Job Description r ■ AL E4 with Section 7")of Division 3 of da:Business and Profession Cade,and my licmuc is '^ in full force and effete. .13333 I.I.m.Clue Cie.111 CHANGE SERVICE PANEL. (200A) JUL 7 2004 illY1- ARCHITECTS DECLARATION I mah mond my plans shell he uxtl m public records 3 Licensed Professional BUILDING OWNER-BUILDERemptfrom DECLARATION Y 1 hcrchy affirm on 1 am exempt from the Conine Co License Law for the oG which requires Permit 7(DL9.Business and Professions Code:motor yorcoumy K$m which mquMa a pewit re anew.,a@e improv.,demolish,ri repair any structure 1 171171171 "'y primmslieusedpuru requires thprovisions visio antsof fo suCh Contractor's Lice se Law(Chaned mem £FSG (commelicensedpurauammdse:ofDivisionrtheConwcmYaLimnseUon&Codrer9 Sq.F[.Floor Area Valuation y that he (commencingwithSections,and basis par ofdmBusiness mton.Ayviand,an or "ty Sen he is 31.5 b thenlrom antl the beau it the subjects cremation.Any violation of -akrH 3.r.�7v�..,4v Suction then J M any red dont fora pewit mbjecu de applicant m a civil penalty of 3 a3i 8 a I09Ccr0 0 Occupancy Type not more Nm five hundred dolls.($508). ❑1,u owner of the property.or my employees with wages an their sets compensation. will dodue work.and the swmurc is not intended or offend for sale(Sec.7044,Business Required Inspections ani d P afta .ns Cade:The Convectors Licums Law does not apply an an owner of q p pmpeny w ho builds c r i m proves thereon,and who does such work him.el f.r through his awn employees,provided thatsuch improvements am nm intended.offered for ads.If, however,Ne building or improvement is sold within one year of ermplction,the owner. builder will have the burden of proving the he did at build or improve for purpose of oleo) �'1.as owner of the pmpest,Me exclusively conuscdng with licensed contractors to construct the pmjecl(Sec.7044,Business and Professions Code:)The Contractors U. cane Law docs not apply to an owner of property who builds or improves theman,mtl, _ who contracts for such projects with aconumror(s)licensed pursuant to the Contractor. License Law. ❑lam men to Sec. B&PCf�o_th�is/n'ss�.n Owner V Data y/ / WOR S COMPENSATION DECLARATION/ I/ / 1 hereby afarne under penalty of perjury one of da following deelanlloodn I have and will maintain a Certificate of Consent to self-insure for Worker's C.mpen. Md.".u provided for by Section 37M of the Isbor Code,for the performance of the work for which this pewit is issued. ❑1 have and will maintain Worker's Compenadon Insurance,as required by Section 3708 of the Labor Code,for the performance of the work for which this pewit is Issued. My Workers Compensation Insurance carrier and Policy number aro: Carrier, Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu section.,tire,be complsad if the pewit Is return hu ndnd doll sus($10(h) or ass.) 1 certify that in the performance of the work for which Nis pewit is issued.I shall not employ any person in any manner an as to become subject to the WoM1cri Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:IL alter making this CmiOcaa of Exemption,you should become subject to the Worker's Compensation previsions of the Labor Code,you must .J Z forthwith comply with such provision or this permit shall W demand revoked. OCONSTRUCTION LENDING AGENCY (~ I herchyaRiw that Nem is a c.umetinn Imdingagenry far use Nor...of ai7 the work for which this permit is issued(Sec.3(197,Civ.C.) ILt. Under's Name - az Lenders Addrom U0 1 certify that I have mad this application srM shote that the above inro..lime is ITr Fcorrect.1 agree to comply with all city and county ordinances and state laws relating m C) building construction.and hereby ambarim reprosentmiwa of this city to enter upon the 4k7 aha.-nuo daned property for inspection purposes. d (We)agree to save,indemnify and keep humless the City of Cupertino against y liabilities,judgments,costs and expenses which may in my way accmc against mid City V 7 in consequence of use granting of this permit. A APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGUO�N/8f / >�O`/ Re-roofs Signetu�AppbcantlContmcmr �� Data [(HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne appricsnt or forum building acupem nom or handle hasardaus to m id as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety coda,pies 25532(a)7 � All roofs shall be inspected prior to any roofing material being installed. Will the applicants future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove F. hasmdnus air conhominants an defuned by the Bay Aro.Air Quality Management all new materials for Inspection. District? ❑Yes [D No 1 have mad the hmardous materials requirements underChad ar 6.95 of the Caliber- out"mid, ctyCode,SeNon25505.25533 and 8534.1 understood dual if to building docs not curenl�y,l(ma a anent,that it is my responsibility to nodly the accupmt of the myvire cele I mutbsmE1'.60missummof.Carifa:aeor a =r. 'Signature of Applicant Date o.� Owner or euthorisad Age. Data All roof coverings to be Class "B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 UPEkTINO Building Department JOB ADDRESS: PERMIT# /D 310 W,,,,d,,k4 lir C- 3 v 2 S- OWNER'S NAME: 34 a', T�. PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: 1 Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing 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 Owr( er/Contractor Signature Date (650 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO APN# —15- / � 00,5- 0, Date: 3/3 0A) 4 Building Address: /D 3 q U (/✓u ��C ti Z)r Mailing Address (if different from building address): Owner's Name: Fct t, Phone#: OCP17 6 Contractor: T License#: Contact: /j Phone: / Cupertino Business License#: 0 Fax: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential ❑ Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: '41o0 6 Occupancy Group: Type of Cot ction: . / zoDA Please check this box if the project is a C �v� � /' second-story addition: ❑ 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 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 BENERGYEner BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC- Comm. Housing Mit. Fee BUILDING LOU, -0-0 3 . 1 of o0, CITY OF CUPERTINO PERMIT APPLICATION FORM CUPEI,TINO Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCONEVIM 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING AWL BPWATER Install/Alter Water Pie PLUMBING go BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BRENLAMHAN 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 Fumace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance I 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 BRENMSAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 CITY OF CUPERTINO CUPEt�TiNO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct ' MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Seb 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 EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 Community Development 10300 Torre Avenue Cupertino CA 95014 AS A . Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPERTINO Building Department JOB ADDRESS: PERMIT # lv�9D G✓ �cC , , b t 3 2,S—r OWNER'S NAME: ti sw PHONE # yro S 99 6-13 t 6 GENERAL CONTRACTOR: FAX# I am not using any subcontractors: 5- Signature Date Please check applicable subcontractors and complete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood J Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile O er/Contractor Signature Date OWNER-BUILDER VERIFICATION 1. (Check one) I or my m ediate family (parent,spouse or child) will perform: l� A. — All the work authorized by this permit B. A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to • 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be performed I declare under penalty of perjury tha a above is true and correct. I have read and understand the Owner-Builder Informatio -(revers56ede . Property Owner's Signature_ Date: S/-nov Job Address: �k-,� 3 ?U �� rrf Permit# D q o 3o--S'/ Any changes to the information Rrovided on this form shall be submitted to the City of Cupertino Build Devartment. City of Cupertino Building Department CITY OF 10300 Torre Avenue C U p C kT I N O Phone: (408)777-322 ��! I , Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner-builder you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself,you may protect vourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work,with the exception of various trades that you plan to subcontract,you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as contractors or subcontractors,then you may be an employer. If you are an employer,you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding,federal social security taxes,workers compensation insurance,disability insurance costs,and unemployment compensation• contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers compensation insurance. For more specific information about your obligations under federal law,contact the Internal Revenue Service (and,if you wish, the U.S.Small Business Administration). For more specific information about your obligations under state law,contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale,property owners who are not licensed contractors are allowed to perform their work personally or through their own employees,without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder building permit,erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors'State License Board in your community or at 1020 N Street,Sacramento,California 95814. Please complete and return the enclosed owner-builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino Printed on Recycled Paper