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04050003 (2) CITY OF CUPERTIN0 BUILDING DIVISION PERMITCO NTRAC—T,,OR�sINFORMATI,O�;a BUILDING ADDRESS: PERMIT N'04'050003 OO4,050003 ale •OWNER'SNAME: PERMIT ISSUE DATE KOH SHIRLEY 40 ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH +0' LICENSED CONTRACTOR'S DECLARATION w I hereby art,.Nat I am licensed under panevdi ts of Chapter 9(commencing Job Description ZE with S. 7 )of Divlsion3ofthe Busineu d Profcations Code.aM my lie..is to inrmuI effect. ✓d / REPIPE/REPLACE WATER HEATER &PARTIAL SUB—FL . p'n z Licenu� Lie.N 1"1el — �i��n Dam comecwr ARCONTRACTOR: VIRDI CONSTRUCTION: CHITECT'S DE N I I undcrsuint p yy shall W used as Pu he records to 3 w t; Licensed Prol fessiona OWNER-BUILDER DECLARATION I hereby aIfom that Tam esempt from the Convactoh License law for the 0 o following mason.(Section 703 1.5,Business and Profusions Code:Any city or county K$ which requires a permit to construct,alser.improve,demolish,or repair any structure Hzi prior to its issuance.also requires Oc applicant for such permit to File&signed statement 6 that he is licensed pursuant la the provisions of the Connector's Limner law(Chapter 9 Sq.Ft. Floor Area ValuaF,�olls 00 5~$ (commencing with Section 70X))of Division 3 of the Business and Professions Code)or - that M is esempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant o a civil family of APN Number Occupancy Type not tome man five hundred dollars(s500L P Y YP 1-1 I,as owner of the pmpemy,or my employees with wages as their to compensation, 36927015 . 00 will do the work.and the aumcture is not invaded or offered for sale(See.7044,Business and Professions Code:The ConvacwrY License Law does not apply W an owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his awn employces,provided that such improvementsare not inteMed oro(fered fmsale.If. however.mebuilding ori.of rovi isold within ane year ofimprovtiformeowner- howev will have Irk burden improvement i 0ul within ma build m improve for du own of r- sale.). O 1,as owner of me progeny,am exclusively contracting with licensed contractors in consumer the pmjed(Sec.7W,Business and Professions Code:)The Contractors U. t<� cense law does not apply to an owner of property who Wilds or improves themhn,and V/ who contracts for such projects with a conuacwKs)licensed pursuant o Ne Contractors License Law. I am exempt under Sec. .B&P C for this moan Owner Date O< 7031, WORKER'S COMPENSATION DECLARATION l 1 hereby WE.under penalty of perjury one of the following dedarafions: I have and will maintain a Certificate of Consent to self-insure for Workers Counter. '0() mn,u provided for by Secuon 3700 of the Labor Code,for the performance of dm rk for which this permit is issucd. 1 haus and will maintain Worker's Commmafigl Insurance,o required by Section of the labor Code.far me performance of the work for which this permit is issued. ylees mCensatihn hen¢carrier and Poli,routibcr(4(a��:_�S Picyyy Na.:�L�C CERTIFICATE OF E% FROM WORKERS' COMPENSATIO SURANCE (This section and not Wcomplesed if use permit is throne hundred dollars(2100) or less) I certify that in the performance of the work for which this Permit's issued,T shall not employ any person in any mernerso as w become subject to the Workers Chmpersation Laws of California.Date Applicant NOTICE TO APPLICANT:It.emir making this Car iBcate of Exemption,you should become subject to the Wohcr's Compensation provisions of me Labor Chile.you most .JZ forthwith comply with such provisions or this Permit hall be deemed revoked. ZO CONSTRUCTION LENDING AGENCY [-+ I hereby affirm mat the¢isaehnslruclinn lending.Emmy I'nr the perfoonan¢of G' the work for which oris permit is issued(Sec.3097,Civ.C.) W QLender's Na me Z)P. Lender's Address U O I certify mal I have mad this applicaian and sow that Oc above ofhtmmiun is 1L F-' correct.1 agree to comply with all city and county ordinances and suite laws relating to 0U Wilding construction,and hereby ambodu representatives of this city to cnmr upon the �'Lv a1Wwc mentioned PmKny rex inspection purposes F'6. (We)agree to save,indemnify and keep harmless the City of Cupertino against N liabRide,judgmcros,easmandexperses which may in any way a¢me against said City U in coroequenec of the granting of this Permit. APPLIC NDE TANDS AND WILL COMPLY WITH ALT/NON-POINT Issued by: Date SO`R ULAT ,S�{� I`'.' -\, qct I/��_/, S f�/O Siurch An'trxictor !P t/.�—AVL' / Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the,applicant or future Wilding¢cdpant sore hr haMlc h—rhWs material as defend by the Cupertino Municipal Code.CIrepuir 9.12.and Ne Health and Safety CoJc.Section 25532(&)7 []Y. [ Nu All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes *No I have mail Ne Wsamtms materials requirements under Cliamer6.95 mine Califon nia Health is SafetyCWc,Sections 25505,25533 snd8534.1 understand the don,building does not currently have a tenant,mat it is my mspon htlny m v Ty the.......f the myuiremc hi' m IWmttpfiorwssuanc r niece hracup cr. Signature of Applicant Date lagan t / � O q own�nra�agCnl It.�/ S�Dal �I All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue J Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEkTINO Building Department JOB ADDRESS: 776 C i PERMIT# Cu ar.,�v-D Ol� o S�o 0 0 OWNER'S NAME: �� 1 ,q HA// PHONE # GENERAL CONTRACTOR: / FAX #�j , 5/o -979-�3I am not using any subcontractors: w�� vel c� 1/Y9 �/�/l 3 L 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 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 p Owner/Contractor Signature Date • • Community Development s i 10300 Torre Avenue ✓ Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 PEkTINO Buil4ing De tmento4,s 3 JOB ADD c�q 776 11 P IT # OWNER'S N j(/y11} IP14 PHONk# v - - d GENERAL CONTRACTOR: J �p f W tau p FAX # o - _ o I am not using any subcontractors: � /'' _`•� 3 � 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 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 3 e r/Contractor Signature 1 Date C Q- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO qp\PN # c� / S� Date: Building Address: G7 6 C a Mailing Address (if different from building address): Gu e o. Owner's Name: Phone#: S-/a — 8/g Contractor: License Sr9 �►��r-�a��'�2 Contact: Phone: Cupertino Business License#: _ Fax: 1'Z,Ul 1201 l e-1v Building Permit Info: B1d9 1 Elect ❑ Plumb 9 f Mech Job Description: G. tf Lea-" y C-- (L� , %u CA- r-1--le 5 Residential ❑ Sv -Hoer H t'r L-,,4 ,.vkecuggmmercial L1 Sq.Ft. Floor Area: S/Sq.Ft.: Cost of Project: Occupancy Group: r Type of Construction: Please check this b if the project ' a second-story addition: roject Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER OtherAppliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERl 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 <= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investi ation fee BUILDING ' 1 of 3 {aC CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM 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 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMA.IRHAN A/C Units <= 10,000 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL 13RENINRAPP 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 2 of 3 CITY OF CUPERTINO cuP T-YOF o PERMIT APPLICATION FORM ' Quantity Fee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmd] Sips Add Branch ELECTRICAL BREMSIGNS Remodel Sips, 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 BSPECLAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICA12 MPERMFEE Mechanicals . foot MECHANICAL; MPERMITFEE Mecb Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING • ZADDCHG Address Change BUILDING 3 of 3