05070102 (2) E.
OF CUPERTINO
BUILDING DIVISION PERMIT p�C�NTRACTORINF,ORMATIQN
B U I LDING ADDRESS: PERMIT ND05070102
192 RTTTP.P 0Aj< 2T
.R'S NAME: PERMIT MUE DATE
TRUEBLOOD NICHOT,AR R
NE: SANITARY NO. CONTROL NO.
ARCH IIECTIENGINEER: + BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
°00 LICENSED CONTRACTOR'S DECLARATION
F❑ I hereby affirm Out l am licensed under provisions of chapter 9(commencing Job Description
ZW wish Seclion 70,M)of DiviIs�ion Sar Ne Businesamd Pmlessian+Codc.mil myliccnse is
nMd infvllforce andeffect. _ 7 35736 A _ 2 BATHROOM REMODELS / n
�i License Class 1Lea
\ h.
�� Dam coati ter 2/18/05 WARREN HILL CONST PD FOR BUS LIC
R ARCHITECTS DECLARATION rte. ,. r ear
'a56U - Ivnterim /«I�n' n spublic meords
o Liced nseProf s eI /� V
3 OWNER-BUILDER DECLARATION !!! n
y 1 hereby affirm that I am exempt from the Contractors License Law far the ` 7CIo(v
0 0 following moon.(section 7031.5.Business and Professions Code:Any city or county A�n c`I ✓✓
K m which requires a permit to construct.alter.Improve,demolish,lir repair any strvcmm
J2) prior to ILL Issuance,also requires the applicant for such Permit to file a Signed statement y
< that heuncenemthions
licensed orwisathc
TC.ounkir',LiceneLaw(Chapter9 Sq.Ft. Floor Area Lb Val U$t(41000
s�0 (commencing wi th Scaion 7")of Division 7 of the Business and Professions Citric)or f�
that he it exempt therefrom and the basis for dre alleged exemption.My violation of C�
Section 7071.5 by my applicant for a permit subjects the applicant o a civil penalty of APN Number A44Occupancy Type
not more Nm five hundred dollars(5500).
01,az owner ofthe pmpeny,or my mployces with wages as their sole empenvuon, 32651046 . 00
will do the work and 0mmocture is not immndcd or offered for sale(Sce.7W.Business Required Inspections
and Professions Code:The Contracmrs License law docs not apply to an owner of q P
prope ny who builds or improves thereon.and who dhes.such work himself or through his
own employees,provided that such improvements..or intended muttered for sale.If,
however,Ne building or improvement is roll within one year of completion.Ne owner.
builder will ban Inc Wrden of proving that he did ret build or improve for purpose of
sale.).
❑1.as owner of the prepare,am exclusively contracting with licensed contractors to
construct Ne project(Sec.7614.Business and Professions Code:)The Contractors Li.
cense law docs net apply to an owner or property who builds a,improve theteon,and
who convects for such projects with a contractor(s)licensed pursuant to Ne Contractor's
License law.
❑lam exempt under See. ,B&PC roe this reason -
F Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
1 ham and will maimain a Cenifieato of Co..,to elf-moxa,for WorkeesCompcn-
smion,az provided for by Section 7700 of the labor Code,for the Performance of the
work for which Nis permit is issued.
�I have and will maintain Worker's Compcnsntion handsome.u retained by Secuon
37W of the labor Guide,for the Kdormanee 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
(Thu section recd not M completed if the Permit is for enc hundred dollars(SIM)
lir less.)
1 certify that in the wifronomcc of the week for which this permit is issued.10.11 nto
employ any Person in any m�q;!; rty,Tcomesubjauo the Workers'Ohn crismion
laws of CaI fomp DJm Vr C S
Applicant [�` ---v�� 1
NOTICE TO APPLICANT:If,after making this Ccnificam of Excmpion,you should
become subject to the Worker's Compcnvtion previsions of the labor Code,you most
.J.z forthwith comply with such provisions or this Permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-+ I hereby alRrm that there is s consuuctinn lending agercy for the Pc,(..an.of
!X the work fur which this permit is issued(Sec.3097,Civ.C.)
fa7 0 Landers Name
= z I<nder's Address
V Q 1 certify Nu I Nvc sad this application and sum that thc bow,information is
f-+ correct.1 agree to comply with all city and county ordinances and shite laws relating to
0U building construction,and hereby authorise mpresenmti+us of this city to enter upon the
r W abuvamentioned pmPeny for inspection purposes.
F" G. (We)agree to have.indemnify reit keep toothless de City of Cupertino against
to liabilities,Judgments,costs and expenses which may in my way see=against said City
U in coneipamee of the granting of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
�� 7 - 1 oS' Re-roofs
Signature of AppganlC.a..trr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hevaNuus material
u defined by the Cupertino Municipal Code.Chapter 9.11.and d¢Health and Safety
.seamen zss3z(a)7 A All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
-
Will the applicant or future building occupant use equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
it hanmlous air conmmimnu as defined by the Bay Area Air Quality Management all new materials for inspection.
ixvict7 /
C]Yea lIB4Nu
1 have mad the hazardous materials requirements under Chapter 6.95 of tim Califor,
nia Health&SafciyCole.Seeumns 15505,25533 and 255N.1 understand dam if the building
dos not currently hoax a¢liana that it is my rtsponsihility b notify ve occupant of Nc
rcgaimnm ts wnicn muu be mm oe to issuance or a RNOcam of Occupancy. Signature of Applicant Date
�`�'—��'' ! ' All roof coverings to be Class"B"or better
Owner or authorized agent - Date
CITY OF CUPEIMNO '3'�a'`•�'
BUILDING DIVISION PER CONTRAGTQR4NFORM ON•
BUILDING ADDRESS: 11111 1,110 5070102
TTvP OAK ST
ER'S NAME: PERMITISSUEDATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLODGIt PLO ME�CH
uo0 LICENSED CONTRACTOR'S DECLARATION IOI7 Description
w❑ I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing I p
iW with Section P)Nd.fDivision Sof NCBleinessand Pforcssiuns Code.and my license is
Lifull eClaand effect. 7 35 36 2 BATHROOM REMODELS
p,aaz
License Clue cmap�
—c Dam TS DE or 2/18/05 WARREN HILL CONST PD FOR BUS LIC
ARCHITECTS DECLARATION
5 i 1 undersea d my plan I
public records
G Licensed Pm aMfi I '
g OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt[rum the Commcmrs License Law for the
a 0 following reason.(Section 7031.5.Business and Prorecsions Code:Any<iay of county
Q f which requires a pcirmi to consbuca,alter.improve,demolish.or repair any structure
._ ce
iprior to its issuance.also roquire the applicant for such Permit to file a signed statement +
that he is licensed pursuant to u la
the provisions of the Contractor's Licenw(Chapter 9 Sq. Ft. Floor Area Val u$t1QP000
as (commencing with Section 7000)of Division 3 of the Business and Professions Code)of Y
'y $-Nat he us tempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects to applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollar(S500).
❑huownerof the propenY•or my cmploycv with waguasteir sole cpmPewtlon 32651046 . 00
will do the work.and the structure is not intended of offered tarsal.(Sec.1044,Business
and Professions Cade:The Contractor's License Law dors not apply to an owner of q peCt10HS
propenywho builds or improves thereon,and who does such work himself or through his �' �
tun employees,provided Nat such improvements are not intended proffered for sale.If.
howevey,the building or improvement issold withmone yeuofeOmpledon.theowner-
builder will ban the burden Of proving Nat he did not Wild m improve for purpose of -
sale.). AUGO 1,as owner of the propcny,am exclusively contracting wit licensed Contractors to 6 7 2005
conswet the project(See.1044,Business and Professions Code:)The Contractors U.
cove law docs rnot such ply je an owner of property who aerids or improves themon,and. p �Is
whom Law
forsuchply to a witherof contractor(s)licensed pursuanttotoContractor's tRtlq�.gJ6i71 IgNg9ZY1JH�p
ts w.
am tempt under Sec. .B h P C for this reason
ner Dat
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury orae of the following declamations:
❑I have and will maimed n a Cenlficato of Consent o salf-insumfor Worker's Corinna.
astion,u provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as sequined by Section
3700 of the Labor Code,An the performance of the work for which this permit is issued.
My Worker's Compensation Insurance Cartier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION 114SURANCE
ruts,section need rmbs romplemd if ft permit isfmonc hundred dollars(SIM)
or less.)
1 ceniry that in the performance of the work for which this Permit is issued.I shall net
employ any person' any ma rsa aassAdyy becu C )cn to the Worom'Cnmpensation
Lawn of Calif nrn td
IT;r
Applicata_( 9
NOTICE TO APPLICANT:Jr.iifer making this Cenificete of Exemption,you should
tjecome subject to the Worker's Compensation provisions of the Labor Code,you mum
,J z forthwith comply with such Provisions nr ria permit shall W dcemcd revoked.
z O^ CONSTRUCTION LENDING AGENCY
Ihemby affirm that them is a construction lending agency for to performance of
a 7 Jm work fur which his permit is issued(Sec.309"!,Civ.C.)
W Q Lcndcr's N.
4' lender's Address
U C I certify that 1 have read this application and Sudan that to about information is
F-' correct.I agree to comply with all city and county ordinances and sum laws relating to -
QU building communion,and hereby aaahorim mponsentalives or this city as enter upon the
Y'tf3 above-mentioned pmpeny for inspection purpo^es.
(We)agree to save,indemnify and keep hurt to City of Cupertino against
H� liabilities,judgments.costs and expenses which may in any way acerae against saidCity
U z APPCANTCUNDERSTANDSAND
of dhe grantial,of this permit.
APPLICANT COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.�c
fir'--~sig 7 Re-roofs
Signature of AplarcaHAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant or future building occupant store or handle havardous matonal
,T fand by to Cupertino Municipal Cod,Chapter 9.12.and to Health and Safety
Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
C]yea
Will to applicant or future building peculiars um cquipmcnt or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
L]yes ,$No
I have mad to hzvardaus materials requirements under Chapter 6.95 of to Califor.
nia Heal"Safety Cook,Steam 25505.25533 and 25534.1 um1crsmnd aha if the Wilding
does not cumendy have a tenant,on,it is my meso,hit ity to nudl'y the acupant of to
requirements t ortoissaancea(acemre7teoraeapancy. Signature of Applicant Date
��'°—^=""'r' / �r���� All roof coverings to be Class "B" or better
Owner or authorized age rat' Daae
CITY OF CUPERTINA
•CUPEiZTINO PERMIT APPLICATION FORM So 70102--�
APN# 3 0 ` 5/ Date:
Building Address(: }`/(O Mailing Address (if different from building address):
Owner's Name: Phone #:
IAJ t C. 61 STY, v OQfl . q 15y- 3
Contractor: License #:
bt)r+rrr_ 3s- (! a
Contact: Phone: 3 jp-_L( Cupertino Business License#:
(A)cz V Fax: 5,2,T
Building Permit Info:
Bldg ❑ �1 tt Elect n nn Plumb, / 1 Mech ❑
Job Description-.,Zf3,,+l.
Residential t& Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
-70
Cost of Project: �/G� _ Occupancy Group:
ype of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard Z Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
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 Flee 600V > 1000A . ELECTRICAL
BELEC200 Elee Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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