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04040182 (2) CITY OF CUPERTINO ..F BUILDING DIVISION PERMIT CONTRACTWINFORMATION BUILDINGADDRESS: ONES MASONRY PERMIF 040182 5 F OWNER'S NAME: PERMIT ESUE DATE PHONE: 2004 SANITARY NO. CONTROL NO. 083777512 ARCHITECT/ENGINEER: BUILDING PERMITINFO o0o BGS ELECT PLUOMD MO Lg LICENSED CONTRACT'OR'S DECLARATION I hereby affirm mall am fernaea under provisions of Chapter v(commencing Job Description n< with Section 7000)of Division J of she Business and �ssiuns Code.and my license is pyt infuIand crf0 o �( u,.. EPAIR CHIMNEY TO GROUND UUYALE9 CunlrazA CHITECI S DELand my plana shall edmppM1', vita MAY 102004 3 0 t; Licensed P asimoral 3 OWNE UILDERmptfr DECLARATION Com ea f��B�®�� a Y hcrcM1y alfirm that 1 em exempt from dse Convector's License Law far tW B y20 following Mason.(Section 71n1.5,Business and Professions Code:Any city or county which requires a permit m cnnnrvcl,deer improve•demolish,m.,anally structure 5 3 0 0 F,zy prior to its issumee,also requires the applicant for such permit to rile a signedsumm rn ser lhatheislicensedPursuanttotheprovisionsoftheConvectorsLicenselaw(Couple,9 S Ft. Floor Area s p q• Valuation WI-$ (commeneinBwish Seaipn]r1(0)nf Division Jn(IW Business and Profvsipv COdc)or a`< Out he is exempt mcmfrom and the basis for the alleged exemption.Any violation of Section 7113 1.5 by any applicant for a permit subjects the applicant to a civil Penaltyof 3 7 SHIM 1NBm16�0 not mom out five hundred dollars(5500). Occupancy Type ❑ L as Owner of the propcny,m my employees wish wages as their role compensation, will do the work•and the swnu a is not intended or oRcred for sale(Sec.7060,Business and Professions Code:The Conua=mrs venue Taw dors not apply in an owner or .. Required Inspections pmp,ny who builds or improves thereon.end who doessuch work himself or through his Own employers,provided mat such improwmcnts arc not intended OroRerrd formic.If. however,me building or improvement is sold within a=yens of compleion,the owner, builder will have the burden of proving mat he did not Wild or improve for purpose of ml,.). ❑1,u owner of the progeny,am exclusively contracting wish licensed contractors to construct the project(Sec.7W.Business and Profealions Coda)The Conmcui Li- ' came law docs not apply man owner orpropon,who Wilds or improves duteon,and who contracts for such pmjecu with a xMiMICmr(s)licensed pursuant to she Contractors License Law. ❑l sm exempt under Sec. ,B&P C 1,this reason Owner Dam WORKER'S COMPENSATION DECLARATION 1 hereby affirm unit,,penalty of perjury one of the following declarations: ❑than and will maintain•CeNfcau Of Covens m Ylf-insure far Worker sCompcn- snion,u provided for by Section 3700 of me labor Code,for the performance of the work for which this permit is issued. ❑1 ban and will maintain Workers Compensation Insurance,as required by Section 37W of me Labor Code,fin me performance or she work for which this Permit is issued. My Wrokce's Cnrt1�Pensationln1aP1nneeeammrand PolieyrooN,ure 011ie yTA.��'t✓A!' Palley Na.% �f{ g CERTIFICATEOFEXEMPr10N FROM RS' COMPENSATION INSURAN (ThlsmeticarmcdootWcompleedif OOMmrit farar¢ less.) hundrW dollen(g1IX1) I certify Out in the perrarmv¢e Of IW wort for which this Permit is mo ed.1 shall not employ any person in any manner so as to become subjecuo the Workers'Comiximation Laws of Citifomia.Data Ait,icam NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject m the Workers Compensation provisions of the labor Code,you must .J O fonhwith comply with such Provisions or this Permit shall be deemed revoked. Zh CONSTRUCTION LENDING AGENCY (z+ Ihereby alrum that them is a construction lending agexy for he performance or W she work(m which this permit is issued(Sec.3W7.Civ.CJ Linda's Name a. Q U z Lenders Address U O I certify ren 1 ban read Nis ipplimicM and sum that she show information is V. H emrcet.l agree m comply with all city and county ordinances and sou laws enlisting to 0 U building eonswction.and hereby amhorne mpmssnutiws ofthu city manor uponshe �- aWvc-mentionedp O'Mmperty or inspectionothPurposes. F y fW e)agree to rove,indemnify and keep humless the City of CupenmO against Vl liabilities,judgments,core and expenses which may in any way accom against said City U z mconscquencc of the Snoring of shit permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-P INT Issued by: Date SOURCE REGULATIONS. tis A�( rApvhean pct ter ria Re-roofs HA 0005 MATERIALS DISCLOSURE Type of Roof Will Nc applies ,(mora building Occupant store or handle haardous material u defined by the Cupe mo Municipal Code,CTapur 9.13.and the Hcal0 and Safety GndC.Section 25532w, ❑Yea plan All roofs shall be inspected prior to any roofing material being installed. Will the applicant or ffuture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove cmlt hua sous air collum rte ,fired by the Bay Arca Air Quality Management Din,ictl all new materials for inspection. ❑YCS 1 have read the hazardous materials mquimments under Chapter 6.95 of the Califor nix Hcalm A Safcty Code,Scene.35505,35533 and 25530.l undersand this ifshc Wilding does not currently haw a Wan,that II is my rcallombilily W miry the mcop nr me mquiremen hich u be mif,o issu ec ora Ccedfcam of-- p e SignatureofApplicant Date tuner remind agent ,m All roof coverings to be Class "B"or better r Community Development 1300 Torre Avenue ItAll .20 CupeertinoCA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 �UPEI�TINO Building Department JOB ADDRES, : S , 3 PERMIT # C) 0 OWNER'S NAME: PHO p - ? GENERAL CONTRACTOR: I FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the followinginformation: 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 . L O Contrac r Signature ate §6 CITY OF CUPERTINO v o Y-Z CUPERTO PERMIT APPLICATION FORM JPPN# ( Date: y_,e7-U,/ Buildingdress: Mailing Address (if different,from building address): X873 1Jo//ire ,,P.t!. ,�✓. Owner's Name: Phone#: e `-IWe. 0?6.2 - 86'SC2,1 Contractor: License #: S 350,359 Contact: Phone: 857-o'-917 Cupertino Business License#: 4- Fax: 377 - 7S/oZ 02/,205' Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job Description: ��„ tui , 2 Residential - qCommercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project y�30O X00 Occupancy Grou Type of Construction: Please check this box if the project is a second-story addition: ❑ Quanti Fee ID Fee Description Fee Group BAPPLOTHER Other A liances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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> 1.75MBtu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING 13CONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax-Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1061 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING / BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC I Comm. Housing Mit. Fee BUILDING -2-5-3 � 7 1 of 3 amd CITY OF CUPERTINO On or PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCONR M 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 cfm MECHANICAL BREMAIRHAN 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2 of 3 \ 1 • C as CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee 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 Change BUILDING i 3 of 3