04100052CITY OF CUPERTINO
1 .
BUILDING DIVISION MIMI`
;CONTRACTORAN.E,0RMATI�O,
-BUILDING ADDRESS:
PERMIT NO04100052 4 1 0 0 0 5 2
OWNER'S NAME:
PERMIT ISSUE DATE
NE:
SANITARYO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
op
I hereby affirm Net I sm licensed under provisions of Chapter 9 (commencing
-
with Section 7") of Division 3Of the Business aged Protessiuns Code, and my It.. is
irfull force and errect
NEW WINDOW (GARAGE)
License Clsu Lk,a
Date Contractor
ARCHITECT'S DECLARATION
I undcrstsnJ my plans shell W mad ss public rtcnrds
Licensed Prefessinnu
OWNER-BUILDER DECLARATION
1 hereby olfir , het 1 em exempt from ae Ci nuaeurr's License Law for the
fallowing reaann. (Section 70313, Business and Protrusions Code: Any city or county
which no,ims a pemgi, m cnnswes, alar, improve, demolish, or repur any suucum
prior m its issuance, esu features the applicant for such Permit to file a signed auu ocrt
Sq. FL Floor
Valuati
het he is licensed punvan to the Provisions of fee Conmsm"sLicenew Law (chapter 9
on
(commencing with Sudan 7000) of Division 3 of fee Businessand Profeed mm Code) or
that he u eumpl therefrom and the btu for was uleged exemption. Any violadon of
3 9'�1$'111�Gr�l lV Occupancy Type
hl' 1 9
Schon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
Out more than five hundred Miami ($500).
❑ 1, in owner of the pmpeny, or my employing with wages in Bair sets compensation,
�r� ��.,,dls T
eeSypnS
will dO the work, and the structure is not intended or offered forale(Sec. 7044, Business
data not
and Code: The ConuumEuros Law data not apply m an owner of
andns Cow: The Co unesendwho
TRQ(tt{jrGd
any who theme. dao himself oanOwne his
who
I LL UV
own employees, provided nn such Improvements arc notinanded oroRerrA forsee, If.
II l/��J_g
however, he building or improvement is old within one year of completion. We owner.
Wilder will have he buNen of proving hal M did not Mid or improve for purpose of
aaleJ.
1, in owner of the property, am exclusively contracting with licensed conuumn m
nstruct the project (Sec, 7044, Business and Professions Cade:) Ths Cmuetwe', Li•
cense law data not apply to an Owrecr of property who builds or improves wanton, and
who contacts for such projec0 with a communist) licensed pursuant to the On uactoe.
License Law.
❑lam exempt er Sec Bk PCf.,srr,fl/g).reamn
Owner Oeu ✓✓S
WC 'R'S CO 5PE! SATION DECLA TION I
1 entry affum under putty of perjury one of fee following dulvations:
hero and will -m inaCeNfimmof Comuntaulr-insurefor Worker'.Comped
ren, in provided for by Section 3700 of ns labor Code. for the performance of the
work for which this permit is issued.
I have and will mounted Worker', Component.. hLnlMa. as aatintd by Soctinn
3700 clubs Tabor Code, for the performance of the wart for which this permit is issued.
My Worker's configuration Insurance carrier and Policy number aa:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
r
(Diesection need nobecomplead Uted permit la forge hundred dollars (klfar)
often)
1 certify Not in the performance of the work for which this Permit u issued. 1 shall not
employ any peramn in any manneru in to become subjul in the Workers Compensadon
Laws of California Date
Applicant
NOTICE TO APPLICANT: If, after making this Ccni0cew of Exemption. you should
became subject to the Worker's Compensation provisions of We Tabor Code, you mum
forthwith comply with such provisions in nus permit hall re domed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for ate performance or
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Name
-
Limda's Add.
I ceniry that I have sad this application and sum Net ate above information Is
correct I agree to comply with all city and county ordinances and ata laws relating to
Wilding construction, and hereby aumorix repmunutives of this city to enter upon the
above-mentioned property for inspection pugroua
(We) agree to aa. indemnity and keep harmless da City of Cupertino against
liabilities, judgments. ensu and expansion which may in any way active against said City
in consequence of the granting crusts permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURC GULATI S.
Re-roofs
Type of Roof
e Appl nUCanuector Dai MATERIALS DISCLOS
Will the applicant or future building Occupant store or handle tremendous material
in dcflned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 255324)7
Yin
All roofs shall be inspected prior to any roofing material being installed.
❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant um equipment or devices which
t humdnw air conuminanu in defined by we Bay Area Air Quality Management
all new materials for inspection.
ail
❑Yes IgNu
1 have mad the hisardtws materiauaquirements under Chapwrr.95 critic Califon
nia Hcahb&SafetyCotic, Sections 25515,25533 and Z5534. 1 understand thatifthe building
duce not currently In a cargo, that It is my femarshility in merry the occupmt of one
requitementswhie metallic apdoruissunsceofaCeeifieatoofOccupency
Signature of Applicant Date
DkD
All roof coverings to be Class "B" or better
0 or au 'id agl6t lifte,
CITY OF CUPERTINO
BUILDING DIVISION PER"��41.As[�4..�RN071.Y.�1`f
BUILDING ADDRESS:
1 14 'VQRKqTTTPT7. DR
ERMIT N00 4 1 0 0 0 5 2
"'"""04100052
OWNER'S NAME:
PERMIT ISSUE DATE
DTFP MASER
08/2
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 1�
LICENSED CONTRACTOR'S DECLARATION
lob Description
P
I hereby affirm :hat l am licensed under provisions of Chapter 9 (commencing
with Dlvision3ofBec Business WPro(cameo Code, and myliccnm is
^ rx
llto=adefef
in full fmee and effect.
NEW WINDOW (GARAGE)
��
License ala. ue.g
�®
Dam Contractor
f/rY(�r"'gpael f11n11`L
ARCHITECTS DECLARATION
I understand my phos shell he used as public rma,&
NOV0 �/
OO V 2004 '
Lemont Professional
OWNER-BUILDER DECLARATION
License Law for the
1 hereby affirm that 11. exempt from Ne Comas;
sr
Code: Any city or county
Co
fallmy
]ruamoet,amasand
nw, dcihn
which rtyuire a perit ns cnmtrucL eller, impmw, Jcmolhh, or repair any annum
whicwingmoon. Permit
t(1t
prior to its issuance, also requites the applicant for uch Permit a rile a signed statement
Nal he u licensed punuantm Ne pmvisionof the Comracmri Licnvc Lew (Chapur9
Sq. FL Floor Area
v
7u tion
(commencing with Section TWO)of Division 3 of the Business and Professions Code)or
that he u exempt Ncrefrom and the basis far Ne Alcgcd cam ptim. Any vuludon of
39VV9tjD14er00
Occupancy Type
Section 7031S by any applicant for permit subjects the applicant o a civil penalty of
not mom Nan five hundred dollars (SSW).
❑ Las ownvof(he property, ormycmplaycm with wagesa their.mleeompcnation,
Required Inspections
will do the work, and One sWCmm is not intended or offered formic fSee. 711 Business
and Profusions Code: The Character's Liana Law data not apply m an owner of
property who buildaorimpowas therma.mdwho dom mehavork himselfor through his
own employee, provided Bass such improvements are not mounded or offered forsale. If.
however, Ne building or improvement is mid within one year of completion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1, awt the property. am cluaiwly contracting with licensed contractors to
oar of ce
anuuct the projen (Sec. ]OCG. Business and Profession Cade:) The Contractor's Lt.
came law does not apply to an owner of property who Wilds or improve themon, and
who contracts for such projects with a comenclor(s) licensed pursuant o the Contractors
License Law.
of eaemptu aSee B k P C far rtuaa
lth,
Owner � �rl{(�,
Deu �5
TJ
WO 3.:R'S CO 3PEI SATION DECLARf�TI_ Doth
1 ereby e f on under penally of perjury ane of she following declaration:
❑ I haw and will maintain aCenlfeue of Conenuo self-insum for Workers Compcm
section, as provided far by Section 3700 of the Labor Code. far Ne perfom swo or Ne
work far which his permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, a requited by Section
37W of be, labor Code, far the perfonnmce of Ne work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if tiro permit is foromhundmddollars (SIM)
nr les.)
1 certify Not in the performmee of the work for which this Permit Is issued, l shall not
employ any paten in any manner an as m become subject to the WorkeW Compensation
Laws of ca iftand . Doc
Applicant
NOTICE TO APPLICANT. IL after making his Ceniacam of Biennium, you should
Mame Subject m the Worker's Compensation previsions of One labor Code, you most
foMwith comply with such pmvisinn or Nis peril shall be deemed rewked.
CONSTRUCTION LENDING AGENCY
I hereby union that them is a construction lending agency for the performance of
the work for which this peril is issued (Sec. 3097, Civ. C.)
Undoes Namc
Lcndeh Address
I certify Net 1 have mad his application end Soon Beal the be. information is
correct. I agree IO comply with all City and county ardluaaa and sum laws misting to
building convection, and hereby aumor m repmmns timr of this city to carte upon be
ahoomm mmncd property for inpeeuhn purposes.
(We) agree no save, indemnify and kap harlea the City of Cupenim again)
liabilities, judgmcnu, costs and expenses which may in any way accmc against mid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date '
SOURC RLeCULATI NS.
Re-roofs
Type of Roof
G
q AppI nUContractor Del
HAZARDOUS MATERIALS DISCLOSU
Will the epplicam or future building occupant store or handle Musudous meurial
U defined by the Cupertino Municipal Code. Chapter 9.12, and the Both and Safely
Code, Se 25532(a)T
❑ym �Nu
Yes
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or future building occupant use equipment or devices which
emir haven a air continent nanu as dcfned by the Bay Ara Air Qmlity Management
all new materials for inspection.
Diuric@
0y AN.
I have mail Ne lanterns mamrialsmquircmenu under Chapur6.95 of tee Califor-
ata Health & Safmy Code. Sections 25585,25533 and25534.1 untlersund thetifthe building
dna nal curr any h s tenant Nat it is my responsibility to may tM occupant of the
mgammcnowhic mastW et prioruisshanceofaccniriemofOceaayo
Sign atureofApplicant Date
(0,471
All roof coverings to be Class "B" or better
o
or oulthbt eg n, q.ta
I
t
fl,
APPROVED
IN ACCORDANr� f1TH THE MY 09
Cc k r : jcb at a'1 calGations MOW
times and it is un
!, to r::ata any
Iz c' a^B`s or atterabov
le
W' 'j
w': '� "ion irongn =
the buila;'g DeSt.,
The st'_'rcmg of
t'
3H;. -L Nnbe he'" tC '.r —'t '3rtc be ar
Ap(rrGF21 of t�P \-C''` -'j a. -y prOVISIen°
L,w
-- blttthlG�
SC077 MASt:-M�S
113} YoFiKSHIFiE bl2% P%"'fl �40 • G�..
U�FlcE C071
AL -10.01
OWER -BUILDER VERIFICATW
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
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 3 below.
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
' vc cu vtacacu
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
erformed
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Information (reverse side).
Property Owner's Signature: Date:
Job Address: I I S t ��tW li i t� Vg::: D- Permit # OLL 1 0 D O5-2 .
eup�iz1in�n CffF qSDIC. - - -
Dear Property Owner:
City of Cupertino Building Department
10300 Torre Avenue,
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 yourself 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
Pnnted on R=Ycted Paper
CUPERTINO
WITY OF CUPERTIN60 b -y
PERMIT APPLICATION FORM
N#
V U
Fee Description
Date:
Building Addlr
MECHANICAL
Mailing Address (if different from building address):
Boiler <= 100,000 Btu
MECHANICAL
— /'
Owner's Nam
MECHANICAL
BBOILER3
Phone #:
I
BBOILER4
Boiler> IM to 1.75 M Btu
11 - 2
Contractor;
Boiler > 1.75M Btu
MECHANICAL
License #:
—
BUILDING
P.
Ind/Off/Comm/Quasi
Contact:
Phone-
JZS3 -$
Cupertino Business License#:
Q K ,E� iL Fax: "
Hotel and Motel
BUILDING
Building Permit Info:
Constax — Resi/Mobile
BUILDING
BELEC1000
Elec 600V <= 1000A
ELECTRICAL
Bldg Elect ❑
Plumb ❑ Wch ❑
Job Description:
�^��
BELEC200
Elec Svcs 600V <= 200A
Residential ❑
BENERGY
Coer
Sq.Ft. Floor Area:
BENERGYADD
Energy Add Multi
$/Sq.Ft.:
Cost of Project:
Investigation fee
BUILDING
Occupancy Group:
Type of Construction:
Please check this bo ' ' t oject is a
second -story addition:.
ro•ect Size: Standard ❑
Laze ❑
Major ❑
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> IM 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
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
CUPERTINO
WITY OF CUPERTINO
PERMIT APPLICATION FORM
Quantity Fee ID
Fee Description
Fee Group
BMISCELL
Miscellaneous Fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUILDING
BNUCOMME
New Comm Electric
ELECTRICAL
BNUCOMMM
New Comm Mechanical
MECHANICAL
BNUCOMMP
New Comm Plumb
PLUMBING
BOVERTWE
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
Storm/Rain Water
PLUMBING
BPTRAP
Kitchen Trap
PLUMBING - -
BPVENT
Alt of Drain & Vent
PLUNMING
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
BRENMIXT
Lighting Fixtures
ELECTRICAL
BREMFURN
Relocation of Furnace
MECHANICAL
BREMFURNOV
Relo Furnace >'1 OK btu
MECHANICAL
BREWMAT
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
�J
2 of 3
OITY OF CUPERTINO+
CUPEi�TINO PERMIT APPLICATION FORM
QuantityFee ID
Fee Description
Fee Group
BREMSIGNAD
Rmdi Signs Add Branch
ELECTRICAL
BREMSIGNS
Remodel Signs, Marquee
ELECTRICAL
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 Insection
BUILDING
BSWIIv1
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