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04040079 (2) P5 CITY OF CUPEICHNO `"n>slyar "� �+ n �' ' BUILDING DIVISION PERMIT - CONTI2ACT�OR INFORMATION BWLDING ADDRESS; DON WADE ELECTRIC CO PERMIT NOU4040079 5855 BOLLINGER RD OW NERS NAME: PERMIT ISSUE DATE GARY WORKMAN 16320 HARWOOD n4 /14 /2004 )NE: SANITARY NO. CONTROL NO. (408) 377-2323 ARCHIT-CT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MMI 0 0 0 0 1.00 LICENSED CONTRACTOR'S DECLARATION I hap [ C 1 nanny affirm that 1.m Bmnaa u pm ons nr Chapter Y(cnmmcncing lob Description n.0 with Sc n po vuion3ofine Busincs fcuinnC tle,andmylicenm is _ infwrn tide c 125 AMP SERVICE Z License az` Lic.Nsa ^ Dat Cern r _ g~g an CHnECI'S DECL ION J C u 0,00 1 understand my plans anal)k used azryYl c rcmNs /�j eon Licensed Professional a OWNER-BUILDER DECLARATION O 'yy a S I hereby afford that I em exempt from me Contractors Licenm Law for the no following Orion,(Section 7031.5.Business and Profession Cute:Any city or county K m which requires a permit Int construct,eller,improve,demolish,or repair any structure °_y poorIn its issuance.also requires the applicant for such Permit Els a signed statement E¢G that ncislicensed Pursuant lothe provisions ofthe CoroactimiLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation m� (commencing with Section 7")of Division 3 of the Business and Pro(cssimns Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a parody subjects me applicant to a civil penalty of 3; ?N3aRnUcr00 ane Occu not mutt man live hundred dollars(SSW). Occupancy Type ❑I.az owner of the property,or my employees with wages u theirsole compensation. will du the work,and the structure is not intended or offered for sale(Sec.7W,Business and Profcubns Code:The Conuaztm's License law docs nor apply Io an owner of Required Inspections property who builds m improves memon,and who duessuch work himself or through his own employees,provided that such improvement arc not ia¢nded proffered formic.It, however.the Wilding or improvement is sold within one year of completion.the owner. builder will hate me burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of me property,em exclusively contracting with licensed contractors to construct the project(Sec.7144,Business and Professions Code:)The Contractor's Li- cense law docs not apply to an owner or property who Wilds or improve Ihekon.and who contracts for such projects with a contrenor(e)licensed pursuant to me Contractor's License law. ❑I am exempt under Sec, ,B&PCray this rceon OElf y Date VWORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of me following declarations: . 1 have and will maintain a Cenifcae of consent to self-insum for worker's Compere sidon,az provided for by Section 37W of the,labor Cud,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as required by Section 37W of me labor Code.for the performance of me work for which this permit is issued. My Worker;{Compensation toxo caniere Poli monk,art: arn /gi I�e, r� 92P CE TIFI ATE OF EKEMI'rZfli FROM WORK S' COMPENSATION INSURANCE Met section need not k completed if the Permit is for one hundred dollars(51 001 s' or less] 1 eenify that in the performance of the work for which this permit is issued,1 shall not employ any iteration in any manner set az to hceumc su bjeel to the Workeri Cnmpcnsatidn Laws of California.Date Applicant NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should become subject to the Worker's Compensation previsions of the lannr Cody,you must �O forthwith comply with such provisions or this permit shall W deemed revoked. 'zy CONSTRUCTION LENDING AGENCY [-+ I hereby affirm that mere is a construction lending agency for the prrurmaneb of - '3S me work for which this permit is issued(Sec.3(197,Civ.C.) D] A Lender's Name L4 J Z Lenders Address O Q I ccnify mat 1 have real this city and c un'y o sok Net me above information statin is Ls�0 F building I agree to comply with all city and county oNinemacs and sole laws elating to pU above construction,pro,and hcmnyectiofim'mpreununiws of this city to sober upon the abovementionedpmpc costs for ins pection which may . F y (tub)agree m save,indemnify and keep harmless the City of Cupertino against Tq incoises encs of ts,the erase end of this esmit. they in anyway accrue against soil City CJ z APPLICANTc NDER TANof this permit. .^ APPLICANT UNDERSTANDS AND WILL LY WITH ALL NON-POINT Issued by: Date rSccu�25532(a)? ,s5 ApplicanUCont cmr `/ DakV Re-roofs HAZARDOUS MATERIALS DISCLO R Type of Roof hezpplicant or future building Occupant store he Icha rovssominai the Cupeninn Municipal Code,Chapter 9.12, d the Health and Safety 25532(a)? yyJJa I�h1Nm All roofs shall be inspected prior to any roofing material being installed. ea licant or f�uture buildin occn ant use a If a roof is installed without first obtainin an ins ection,I agree to remove pp 6 p o Air Qu or device which g pur air contamin—amu/u defined by the Bay Arca Air Quality Managbmcnl all new materials for inspection. ❑Yes No havesadthehadai ma krialswquiremcnuun@rCNpkr6.95oftheCalifor- ma Health&Safety Code,Sect un 25505.25533 and 25534.1'ndersund that if elk holding dos not currently have a knant.Nal' y reaponsihility notify the a<upanl of the rcu' non enpri mi aanreOf.Ceml r0¢upanbyy Signature ofApplicant Date //f-'O Owner or aothmnmd agent Dim 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 ADDRt SS: ' O � H g 0 IT #t0zhD OWNER'S N PHO —Z Z-75 GENERAL CONTRACTOR: FAX # 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 r 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 Oval /Contractor Signature � Date �U am CITY OF CUPERTINO CUP TY OF O PERMIT APPLICATION FORM Lf APN# Date: Building Address: S S &III' �Ucc eC- - eyf7 K o CA 9501 V Owner's Name: Phone #: Ckwu -Wj --A53— 0,5 410 Contrac . License#: ��Gvade 67ee�ri� m 77031 Contact: Phone#: 3773 -23 Applicant/Contractor: Fax #: r)o,,- Building Permit Info: Bldg Elect Plumb Mech Job Description: /a5 frm S��I//CE Residential: iiia Ix- �a r1��l Commercial: Sq.Ft. Floor Area. $/Sq.Ft.: Architect/Engineer: Valuation: 01/ COQ DU Type of Construction: Occupancy Group: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances 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 BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BNEWMULTI New Multi-family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of 3 CITY OF CUPERTINO V � "n OF CUPEkTINO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Grou BNUMULTI Newulti-family Res PLUMBING BOVERTIME Ins ection Overtime BUILDING BPBACKFLOW Atmoberic 17-- EPCESSPOOL Cess ool PLUMBING PLUMBING BPERMFEE BIA g Permit Fees BUILDING BPFIXTUIRE -FP—bl,Fixture BPGAS I Gas PLUMBING BFINTERCEP F , PLUMBING iNuldK PLUMBING DrEA I Plan Check Fee BUILDING BPL NCKADD Plan Check Add Multi BUILDING BPLANCKREp Plan Check Re eat Fee BUILDING BPREPIPE Re i e Of Fixtures BPSEWAGE Sw PLUMBING ER Seage Disposal PLUMBING BPSEW BPSPRINK Sewers PLUMBING Lawn Sprinkler/Backflo PLUMBING BPSTORM Storm/Rain Water _ PLUMBINGBPTRAP Kitchen TraPLUMBINGBPVENT Alt of Drain &�Vent PLUMBING BPWATER Install/Alter Water—Pinf.. PLUMBING BPWHEATEI PLUMBINGPLUMBINGBPWSVCS Main Water Service PLUMBING BREINSPECT Reins ection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm BREMAIRHAN A/C uMECHANICAL -- MECHANICAL BREMAPPLI A liance Install MECHANICAL BREMBUSWA v Remodel 13.......... ELECTRICAL BREMFIXT Ll htin Fixtures BREMFURN Relo ation of Furnace ELECTRICAL MECHANICAL BREMFURNOv Relo Furnace> I OK btu BREMHEAT MECHANICAL Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL 13REMNRAPP Misc A aratus ELECTRICAL Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture BREMPOWER Power Device/A aratus ELECTRICAL ELECTRICAL REMRECEPT Re t1, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Re air/ Mer Heating MECHANICAL BREMRESAPP Remodel ELECTRICAL BREMSIGNAD Rmdl Si s Add Branch ELECTRICAL BREMSIGNS Remodel Si S, Mar nee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRIC AL 2 of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Seb Specific Plan BUILDING iiSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSF&2FAM Single & 2 Family BUILDING BSFNA Single Family New Add BUILDING BSPECIAL Special Inspection BUILDING I BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electricals foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL TVIPERIVIFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fees foot PLUMBING ZADDCHG Address Change BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBIDILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBIDILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75 M Btu MECHANICAL 3 of 3