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05080233 (2) ------------- CITY OF CUPER'fINO '"` BUILDING DIVISION PFRbTC C0NTRACTfIRINRMON FO �I ,,, � x_- BUILDING ADDRESS: PERMIT NO.0 5 0 8 0 2 3 3 OWNER'S NAME: PERMIT ISSUE DATE BARBARA ANDERSON _ 08Z25/2005 NE: SANITARY NO. CONTROL N0. ARCIIITFCTIENGINEEA: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH aoo LICENSEDCONTRACTOR'SDECLARATION lob Description U P 1 hereby affirm that 1 am liecnutl under provisions.f Chapter 9(commencing �a�s= m mu forested effect. REPLACE SLIDING on WS License Class Lic.N � V � I O DateContractor ARCHITECTS DECLARATION 4i e J I understand my plans shun IN,used as public rands fli 1 2005 DaU 1 J 3 y Licensed Professional l OWNER-BUILDER DECLARATION �I®� k+ � .'�a S 1 heron,affirm that I am cxcmpl from the Contmemr's Liansc Law lar ilio _ Try Or o following reason.(Section 7031.5.Business and Prore,minns Code:Any titter county `�'l,,,Jj $5795 K$ which requiresa permit to construct,alter,improve.demolish,lir repair'any slructum mom'^ PHe,wincOonce,itin.myuires lheapplicaut[.,such permil to flo.mr.eJ statement t�< RindheisliccnudumobamtothepmvimmbftheCammetor'sLlccnulow(Chapter9 Sq. Ft.Floor Area Valuation (commencing wi th Section 7001 of Division 3 of the B usincss and Professions Code)or i that he is exempt therefrom and the Nazis far the alleged exemption.Any violation of Section 7031.5 by any applicanl for a permil subjects the applicant to a civil Penalty of r Occupancy Type our more Than Five hundred dollars($AID). ❑L as owner orlhe property,or my employees with wages as their sole compensation, will do Ne work.and Ne swaore is not intended oroffered fm.,ole(Sec.]044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply m e ns an owner of 9 P property who builds or improves thereon,and who does such work himselfor through his own employees,provided ilial such improvements arc not intended or offered for sale.If, however,the building or improvement is sold within ane year of completion,the awner- builtler ill have the burden of proving that he did not build or improve for rumosc of I.as oW.Cr Of InC prOForly.am exclusively Contracting with licensed contractors 10 e nsormthe project(Sec.]044,Business and Professions Code:)The Cm owtor's Li. e ac law does net apply to an Owner of property who builds or improves thereon.and _ whoc.nlra forsuch projects idtacenlractor(s)licensedpursuatntothe Contractor's Lktnu L ❑lame em under See. .B&P C for this reason Owner AAVA. Date ZS- WORKERCOMPENSATION DECLARATION 1 hereby afford editor Penalty of perjury ane of the fallowing declarations: 1 have and will bodermn a Ccrtifiale or Consent w self-insure for Worker's Compen- sation,u provided for by Section 3700 or the labor Code,for the perfmmance of the work for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the perrormance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Cartier, Policy N., CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This sceti.n need not be completed if the permit is for one hundred dollars IS lad) lir less.) I cenifv that in the performance,or the work for which this permit is issued.I shall not cmployany perso any manners.as to become subject to the Wmkeri Compensation Laws of California!Date A,Ihm t NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject t.the Worker's Compensation provisions of the Labor Cods,you must �Z forthwith comply with Such Provisions othis permitshall the dccmcdrev.kcd. CONSTRUCTION LENDING AGENCY E-a tva-] I hereby affirm that there is a Construction lending agency for the performance of [4 > Ne work for which Jos pemt it is issued(Sun.3(19],Civ.C.) W — Lender,N. 0.. loud efs Address C.) p 1 certify that 1 have read this application and Etats that the above information is W f-' counter.I agree to comply with all city and county ordinances and mite laws relating to 0O building cousloction.and hereby aulhorise representatives of this city to enter upon the a shave-memmned property for inmpuetion purposes. F-t (We)agree to save m indenify and keep harmless the City of Cupertino against Ito D, liabilities,judgments,costs and erpcnxcs which may in any way accme against said City of the grano ng of this permit. C]Z APPLICANTsUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issuedby: Date SOURCE REGULATIONS. Re-roofs Signature of Applicnm/Cantraaor Dale HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant m future building.ecepant store or handle hsiarduus material u defined by Ibo Cupertino Municipal Code.Chapter 9.12,and the health and Sorely Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. p Yes 0y. Will the ag,1,,am or future building occupant use c,iipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit AOL hazardous air cmmminarks as defined by the Bay Area Air Quality Management all new materials for inspection. istda? byes .2, n I bavc read the havaNuos macrials requimmcn¢mdm Chapter 6.95 ams Carter nia H.1dr&SaOI,Cc&S255f5,25533.d25534.lundersmdlhalifthc building Jews n ncnJy M1ave a te dot a{nhal is my responsibility In nuuly the recurrent of the recut r entr\vn nmual ct)Sn'o toractmnalearaapanlIyyyyyy /- Signature of Applicant Date Owner a.moriv.eaagem y7 Dole All roof coverings to be Class "B" or better --------------- 7i ----------- C>I�r r rF k ..., ; KV MOW YY° Y .. -.v 4 / w"'•r ray' Ec ai y i - - RE�SI'DENTIAL P120�ECGOVER;SHEET ..w ;, xsP-. ' —c. yrs w.� `s'"c E� F ..r"" c u--cx IN OF '-+-�. CUP-RTINO Assessor's Parcel Number: /� Name of owner. a f �jcl rq 1 �IAC(Son Project address.. -Kiqz 1 nQ Wood Contact person. -pg Urex, p-tJdf Phone. ���' S ^� 2- Fax.Fax. Net square footage of lot. [ ` NExistin Proposed Square footage: First floor: Second floor: Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N ® Is privacy protection planting required for the project? Y N On what floor(s) is work being done? Brief description of work. ( &+f 7BpIGt2 S� io�inC �oo�' Code editions: 2001 CBC (Y -N)2001 CFC (Y -N)2001 CMC (Y-N) 2001 CPC (Y -N)2001 NEC (Y - N) Effective 11/1/02 Plan Review Process Work Book Page-8-Revised 4/28/04 _ - t CITY OF CUPERTIN# CITY OF PERMIT APPLICATION FORM CUPEkTINO APN # 30-- 1 ;7 a Date: Building Address: AA __ Mailing Address (if different from building address): I 2, Owner's Name: Phone##: br,rA soy Flo '�dS-8�28 Contractor: License#: -7 13tj LA s Contact: Phone: qvO 7atS {28 Cupertino Business License#: L�Crf'Grs AvkafSuh Fax: Building Permit Info: gerlgc(ng e widows + 1 Si,a GlAsr Dm,-- Bldg w�Bld Elect ❑ Plumb ❑ Mech ❑ Job Description: 0- &U01 nH- rX-41( + Z w,- 4o�/ 5 I Fra-,EJ Residential Rr: VmUO PIT LQ ndoAICommercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK 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 BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 ° � 3 � alO CITY OF CUPERTIN* PERMIT APPLICATION FORM CUPEkTINO 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 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 Repie 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 clin MECHANICAL BRENUHUiAN 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 > 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 IMF 2of3 ( tTY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl 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 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 PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3of3 CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOWINFORMATION `- BUILDING ADDRESS: PERMIT NO.0 5 0 8 0 2 3 3 914 BLAZI qWOOn AV OWNER'S NAME: PERMIT ISSUE DATE WJBARBARA ANDERSON 08/25/2005 E: SANITARY NO. CONTROL NO. a ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 °00 LICENSED CONTRACTOR'S DECLARATION u I hereby affirm tbar 1 am I"¢enud under provision of Chapter 9(commencing Job Description _ x withBeer7000)afDivision3af0¢BusincasandProfessionCode.andmylicenseis �^ - a�n in(ullfurecandcffecL REPLACE SLIDING DOOR &9 WINDOWS, .. i License Class LIC.N =p oath Convscmr p ARCHITECTS DECLARATION 4� I midersund my plans lreuudupuNic records ;LLu 1 Liccrtscd Professional `03 OWNER-BUILDER DECLARATION (� Z .�<I 1 hereby affirm Nal 1 am exempt from the Connanals License Law for the II�R(� fl q, k p o following reason.(Section 7131.5,Business and Profession Code:Any city or county IIL61'1 nU Ytl grYr:v B Lm which"mics a permit a construct,alum,improve.demolish,m rapair any gmctere S 7 9 S prior to its issuance.also requires the applicant for such Permit to rite a signed statement that W is licensed pursuant the pmvisimts of the Commcur's License law(Chapter9 Sq. Ft.Floor Area Valuation 'Fp (commencing with Section 7")of Division 3 of the Business and Procession Coded or y 5 that he is exempt therefrom and the bssu for the alleged exemption.Any violation of Section 7031.3 by any applicator for a permit subjects the applimmi to a Civil penalty of APNr Occupancy Type not marc than five hundred dollars(S5(10). ❑1,m owner of the property,in my employees with wages as their sole compensation. will do rte work,and the swpure is not intended or offend for sale(Sec.7041,Busiws and Profession Code:The Caavaztor'a License Law docs not apply in an owner of Required Inspections property who builds or improve thereon,end who doessuch work himself or through his own employees,provided mat such improvements art not intended ma0eeed for sale.If, however.the building or imprOmment is sold within oro year of oomplimmn.the owner. builder ill have the buNen of proving mm he did Tat build or improve for puryuse of talc . I.as owner of the property,am exclusively contracting win licensed contractors u c niouct the project(Sec.?D1d,Business and Profession Code:)The Conosemr's Li c law don not apply to an owner o(propery.who builds or improves themon,and who canna forsuch projects contractiong Iicemad pursuant use Connectors Licenee ❑Ione em under Sec. _ I1 � B At P CC for this ronin Owner (.a'� Date WORKER' COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declaration: 1 have and will maintain a Cenificmo of Convert o self-inure for Worker's Compcn- sxtion.as provided for by Section 3710 of the labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compcnation Insurance,n required by Section 37M of rte labor Codc,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number art: Carrier: Policy No.: _ CERTIFICATE OFF Ef ImONFROM WORKERS' COMPENSATION INSURANCE (ITu In.aced not be completed Base permit is forage hundred dollars(SIM) or[oil.) I mmfv that in the performance of to work for which this permit is issued,I shall not employ any person in any manner so as to become subject o the Workeri Compensation Laws of Ca omia.Date Applicam NOTICE TO APPLICANT:IL after making Tis Ccnificate of Exemption,you should become subject in the Worke(a ComPemaOon previsions of the Labor CCM,you mug 2, forthwith comply with such provision or Tis Permit shall be dcemcd reward. ZO CONSTRUCTION LENDING AGENCY 't•+ 4 I mushy affirm that there is a construction lending agency for the perfmmencc of !Yi > the work fur which this permit is issued(Sec.30D.Co.C.) W A Lioulm's Name 2 Lender's Address U 0 I certify mg I him read this application and sou that the above information is W F coreCL 1 agree to comply with all city and county ordinances and sure laws relating to DU building construction.and hereby aunama repmsenotivrs of this city to enter upon the �+a above-memioned property for impaction purposes. (We)agree to save,indemnify and keep harmless be City of Cupertino against F" to liabihOm.pointers,costs and expcnea which may in any way Carve against sod City U Z APPL CANT UNDERSTANDS ArND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature or ApplicaDate14AZARDO / 1A2ARDOUS MATERIALS a DISCLOSURE Type of Roof Will the applicant or Town buildingoccupantauraorand to ba�gusmaterial as defined by the Cupertino Municipal Code.Chafer 9.13,and the Health and Safety Code.Swtion 25532(ay? All roofs shall be inspected prior to an roofing material being installed.6. IL 4. Will me sufficing or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove Or harardnus air corium inions n defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Ycx 1291. 1 have read me hmarnmsmancriab myuimmuma under Chapter 6.95 of Oc Califor- his Heal"SafctyCodc,Sced 255(5.25533am1255NAtiodersondtherifthc building docs OgrFbqcntly have a IC L at u my reapomibility hogodly do occupant ar N v requi anti hrehmust met ri rbsaaneepfaCeNfnuo yapangy Signature of Applicant Date owner ar aamomi.ca.,FT 7 o„e All roof coverings to be Class "B"'or better