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05080171 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATIQN' : ./^'f BUILDING ADDRESS: CU O PLUMBING PERMIT NOO S O H 0171 939 BUBB RD OWNER'S NAME: PERMIT ISSUE DATE HEATHER SIMMONS 10297 S DE ANZA BLV 08/19/2005 NE: SANITARY NO. CONTROL NO. (408) 253-0618 ARCHITECT/ENGINEER: BUILDING PERMIT INFO 0 BLDG ELECT PLUMB MECH 0 o t� X00 LICENSED CONTRACTOR'S DECLARATION r 1 thereby0¢Trion Nat I am licensed anter pmvi'ons of Codle, 9 mylicc=is Job Description Rwith SccJon7g10)of Division Sof Jr Businm and Profesdons Cade,and myliccr leis in full fora and efacttL1�/ ` COPPER REPIPE a_Za= License Cl s ,L,.�a Lic.At y /C iFp Dam IyA/!X Comrxsor pp7W A CHI SDECLAR TION I �n+3 les rs Jmy PI shall use 4puM1lic rtcnNx taG Licca d mfcsswnT —� OW NER-BUILDER DECLARATION 1 hereby AITIM Na 1 am escmpt from tW Contrumte License Law for the 20 following..n.(Scedun 7031.5.Business and Pmfessium Cole:Any city or county Which requires a permit to eonarsoM.also,improve,demolish,me repair any nntemm prior m its issuance,also require the applicant for such permit to file a signed statement < that be is licensed pursuant to the provisions of the Contractor'sLicenseLaw(Chapter 9 Sq.Ft. Floor Area Valuation Wn (commencing with Section 7")of Division 3 of the Business and Professions Crile)or y _ Not he is exempt therefrom and the basis for Oe alleged eumpOrm.Any violation of Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of CC Occupancy Type not mom Nan five hundred dollars(5500). I,as owrucr of the property,or my ernployas with wages a Nc'v sale mmpcnsation, will do the wort and Neswctum is maimendcd oroRered forsak(Sce.7W,Business Required Inspections And Professions Code:The Commences Lt..law doe oat apply m an ower of fl P property who Wilds or improves thereon,and who does suchwork himself or Btrough his Con employee,pmvided that such improvementsart not intended oroRered for sale.If, however,the building or improvement is sold within one year of completion.the owner- builder will baro the burden of proving Nat he did not build or improve for purpose of sale.), 1,as owner of use progeny,am exclusively contracting with licensed cenuacwn to Construct the pmjca(See.700,1,Business and Professions Cada:)The Conwewrs Li. case law dors not apply b an owner of property who Wilds or improves themon.and. who contracts for such projects with a contaactor(s)licensed pursuant m the,Conuutoes License Law. ❑1 am exempt under Sec .B&P C for this mason Owner Dole WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarankma: ❑1 nam and will maintain a Camra¢of Consent o self-insure for Worker's compen- ation,As provided for by Section 3700 of the labor Cade,for the perfmmamx of the work for which this permit is issued. I have and will maintain Workers Compensation Insunna,as required by Section W of the labor Code,for the performance of the work for which this permit is issued. My Worker'/Coymp�ensation In eCarter and Policy number ver: Caoier: i/'al�' /�r/ CERTIFICATE OF EXEMPDON FROM WORKERS' COMPENSATION INSURANCE (Tbu seed.xad not beeomplered rose lermit is fore.hundred dollen(SIM) lass.) 1 cenify that in the perfammmee Of the work for which this Permit is imued,I shall not employ any person in any manner so as to tecomc subject to the Workers Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:If,after making this Ceniricate of Exemption,you should become subject m the Worker's Compcwtion provisions of the labm Code,you most .JO fonhwith comply with such pmvisimrs or this permit shall he damcd moked. Z CONSTRUCTION LENDING AGENCY l hereby affirm that Nem is a convection lending agency for the performanse of the work for which this permit is issued(Sec.3097,Civ.C.) Wil Q Lcndcr's Namc ,=Z Lenders Address U O 1 cenify that I have rad this application and item Net Ne above information is D,P cornett I agree w comply with all city and county ONinences and state laws relating to 0U Wilding comaustetion,and hereby authorim representatives of the city to enter upon the r W abuvcmentioncd progeny for inspection purposes. FL (We)agree to save,indemnify and kap harmless Ne City of Cupertino against H rq liabilities,judgment,Coss And expenses which may in any way¢cane against said City U Z income ucneAtfNcyramingofthispctmit. �✓ r/ ^' APPLICANT�UNDERSTANDS ANP- (LL TH OMPLY WIALL NON-POINT Issued by: Date SOURC��GULATI N _ o Re-roofs fids•4 St on HAZAROD MA ALS ISCLOSURE Daw Type of Roof Will Nc applicamor future upannwreorhandc hwardousmaterial as defined by Nc Cupenim.CJtugutfud Code.Chapwr 9.13.and the Health and Safety - code.Onset zss3z(a)? No All roofs shall be inspected prior to any roofing material being installed. Will the applicant or.tam building accapant use equipment at devices Comm If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air contaminants As defined by the Bay Area Air Quality Managcmcnt all new materials for inspection. District? ❑Yes NO. I have mad Oc oraz Nous materials reyuiremcns under ChaPmr695Of the Califn ria HcalN&Sof yC6dc,Sad5ns25505,25533ind15534.1.nJc .dthwirft Wilding dasnot cuµtlyhawotcrient t �esponsihility w modify the oceupant of the requimmc me m 6a prior trance of aCemliateofOccupancy. Signature of Applicant Date Owner O/a h.n.d agent / o m 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 Ike artrnent JOB ADDRESS.- PERMIT fbu�J n Gf SS 6I OWNER'S NAME: R��� ,Smrviorl5 IPHONE # Z5 3oco I GENERAL CONTRACTOR: AX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the fo owing information: 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 / o Roofing Septic Tank Sheet Metal Sheet Rock Owne n"actorSignature Date azras CITY OF CUPERTINO CITY of PERMIT APPLICATION FORM �� / CUPERTINO Ah 1PN # ��_ I i • � Date: � d� Building Address: n nf - Mailing Address (i different from building address): Owner's Name:HerAOCSITmonsPhone #: ' /� �� ��2 Contractor: rn� n Im • License#: Contact: Cupertino Business License#: {/j �� Fax_ Building Permit Info: ^/ Bldg ❑ Elect El Plumb 2 Mech ❑ Job Description: pPX t�e Residential ET, Commercial ❑ Sq.Ft. Floor Area: I u� S/Sq.Ft.: Cost of Project: IFSODD _ Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ �roject Size: Standard ❑ Lar e ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> l OOK to 5OOK Btu MECHANICAL BBOILER3 Boiler> 50OK to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILERS 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 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING Amok BINVESTIGA Investigation fee BUILDING 1 of 3 124, 37 tv CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quanti Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housin Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCONRvIM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTME 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 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 Fumace MECHANICAL BREMFURNOV Relo Fumace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINIIOOD 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 App ian�ce ELECTRICAL 2 of 3 mfflV, CITY OF CUPERTINO CITYOF 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 1\IEECHANICAL BSCBLVD Scb S ecific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL S inial Inspection BUILDING BS WIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERbI Temp&rary Bldg Permit BUILDING BTEMPSVCS Ternp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Nlech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3