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04030030
CITY OF CUPERTINO • BUILDING DIVISION PERMIT CON FT OR INP© tMATIQN� BU ILDING ADDRESS: PERMITNO. 04030030 OW NET'S NAME: PERMIT WITE DATE JOSHUA FREnRRTrYR 0 4,12 NE: SANITARY 0 TROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGELECT PLUMB MECH p 0 E 0 0 Lp Zp LICENSED CONTRACTOR'S DECLARATION C I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job DOSCfIptlOn with Section 7")of Division 3af tW Businu�,and�Prrofqessions Code,and my license i, o LIe. JAS 3z �l03 ELECT SERVICE UPGRADE ^14 License _ FINALE® I Contractor I�e ARCHf1ELTSO IcrtcuOdi 1 understand my plans shall W used ss .'��O� Licensed Professional MAR 1 0 2004 OWNER-BUILDER DECLARATION 0 2 1 mesio .(firm that 1 1. exempt from the Gamna Co e:esseAny c Law for me O Oy- which reason.(Section aD 1.5,Business and tie. item Calc:Any city or county BUILD X$Y. poor oor t ituiress ism n e,mitalso re CMNnhe al0n Imptrsu,hPermit demolish.W repair ed ,Wuant f>:e prianaiu issumce,ahum,to dares thovisiocl of forthe sucCarmermipL file ces Law(taement NO the( menccenudpursuantInOeofDivision3deCo usinessLk<muesto(Chapter Sq.Ft. Floor Area ValuatiING on (commencing with Section rt W0)th Division 3 of the aged msand Professions Code)or �.. Nat io Is campy meefrom and the bears for the alleged cxemptim.Any violation of Section than ] by very applicant far a permit subjects the applicant in a civil penalty of not mom thann five ve hundred dollars(5300). 3 7&N8`NM0gr0 0 Occupancy Type I,ss..a,of the property,or my employees with wages"disbands compensation, willdo the work end the structure v not intended croQered forsam(Sec.7044,Business and Raressions cam:The Convector,Lir...Law does let apply to an owner of Required Inspections propeny who builds or improves thereon.and who dao such work himul f ver through his own employers,provided that such anprovementsau notimmnded reoffered fat ale.It, however.the building or improvement is sold within can year orcompleme.the owner Wilder will have the burden of proving that he did not Wild or improve for purpose of sale.). 0 1.as owner of the property.am exclusively convecting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Convectors Li- coese law door not apply in in owner of property who Wilds or improves demon,and who contracts for such pmjecu with a conromm s)licensed puissant in the Convutora {' an La 1 ran exempt under Sec. .B k P C far this resson Owner Dau WORKER'S COMPENSATION DECLARATION I hereby affirm under penally of perjury ore of the following declarations: 1 how and will maintain a CeNfinu ofConum m self-inseam for Warkcr'a Compcn- Miian,as provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. 1-11 have and will maintain Worker's Compensation Insurance.ss required by Section 3700 of the Labor Cade,for the performance of the work for which this permit is Issued. My Workers Cnmpensavon Insurance carrier and Policy number am: Cartier. Policy No.: _ CERTIFICATE OF EXEMPT ON FROM WORKERS' COMPENSATION INSURANCE (This union teed notWcompleted ifthe permit mforonc hundred chili a(SIM) or less.) 1 certify that in c Performance of the work for which this Permit is issued.l shall not employ any pcna nye mer ssm Wco eabject tothe Wormus Comjunsation Laws of Calif _ Nm7�rrTq APPLICANT:If,after making this Cenifism,of Exemption,you should been Sect a the Work.'.Compensation previsions of the Labor Code,you must OZ forthwith comply with such provisions or this p mrsit small W deemed revoked. 'yQ CONSTRUCTION LENDING AGENCY [-n Ihereby affirm that more is a construction lending agency for the performance or tYi 7 de work for which this permit is issued(Sec,3097,Civ.C.) ' ALender's Name D z Lender's Address V Q 1 comfy that 1 have read this application and sate that me about information is F torten.1 agree to comply with all city and county on irmom and sum laws minting to O U building construction.and hereby auboriu representatives of this city to enter upon the Lkl show-mcnf rood property for inspection purposes. Ly,, LL (We)agree Io saw,iodemn and keep harmless the City of Cupertino against (.y y Iiarfi0ea,judgments.costa and ea "am which may in any way memo against mid City U`z in consequence of the gaming a( is permit. ^' APPLICANT UNDER TAN ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date s U TlosWConmear Re-roofs 'natureIt,/ Ap ¢HAZARDOUS MA RIALS DISCLOSURE Dau Type of Roof will the applicat or for..W Ildi g occupenlalom or handle herallous materiel m defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and safety rare,accyes 25532(a)? All roofs shall be inspected prior to an roofing material beim ❑Yes �Na P P Y g g installed. 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 it hazardous air contaminants as defined by me Bay Arca Air Quality Management all new materials for inspection. District? D Yes Iffi No I hew mad me hvsrdnm materialsm immenuunder .Chopur6.95ofthe Califon ms HcalmkSafcty Ccm,Sccdom75505,25 Sand 25534.1 urdcrsund that ifum Wilding docs not comedy ha lenant.that it' y responsibility a notify me acural of the requircme tswhich at Wm -prior syatkc ofa Ccmfich ver Occupaay. . Signature of Applicant Date �'— All roof coverings to be Class"B"or better wncr or au o ,cd a,car pati Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OP Fax(408)777-3333 UPEI�TINO Building De artment JOB ADDRES§, / / PERMIT # OWNER'S NAME: Vops PHONE &,5 I 3 GENERAL CONTRACTOR: :r -P N-,-� A FAX # L—Fa C.r7l.e t,4 %�e 9-,S �/f LC.i4 rgt�/J 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 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 % j t y er/Contrctor gnature Date ,a OF CITY OF CUPERTINO J C `4 ITYOF PERMIT APPLICATION FORM 3 c, 3 o APN# 3 Date: 63 - I o Building Address: Mailing Addr5's•(if different rTom building address): 1 03 4 5 LJ Lx�D&-LL,I cl�, /Z / I hone Owner's::Ic)S at}�j(L<-LG + (�'� P�Xptiu_ �PUtq --2,5 0,+1d Contrao � 4� License#: ',3 2 �p3 Contac Phone:6Y,, 391-. 6 192 Cupertino Business License#: t 9q-V1&j �n N Fax: 6s-b �4-I 1 F Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential $0- erc al ❑ Sq.Ft. Floor Area: $/Sq.Ft.: D Cost ofProjec Occupancy Group: [ P00 Type of Construction: rPlease check this box1f4he4w6ject is a v��C�vN� tE e�l� Zale� second-story addition: ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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 Incl/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 Z- t of 3 * 307, 27 tamsCITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group 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 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 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 cfrn MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> 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 BREMSIGNAD Rmd] Sips Add Branch ELECTRICAL BREMSIGNS Remodel Si s, Marquee ELECTRICAL 2-of 3 CITY OF CUPERTINO cuP TYOF o PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS 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 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