06120100 (2) CITY OF CUPERTINO77717771;7.7-7-77,777
BUILDING DIV ISION PERMIT CONNTTRACTORIATkORMATION, p
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: ATE
WAGNER KARL 12/19/2006
NE:
SANITARY N0. CONTROL NO.
ARD111=0ENGINEER: BUILDING PERMIT INFO
BLDGEIFCf PLUMB MECH
0 0 0 0
lop LICENSED CONIRACrOR'S DECLARATION Job Descrl tion
w FF I hereby affirm that I am licensed under provisions of Chapter 9(commencing {3
i`w$ with Section]O(g))of Division 3Ofthe Business and ProfcssionsColk,andmylicense is 200ANP PANEL UPGRADE
in fall farm.m.rect-
X7915
Lieeny{IurS Com / -1
Date `L{. CSDECr
ARCNI(ECTS DECLARATION
�a< I understand my plain shall be used u public merits
idO
°0
Licensed Profcssionel
OWNER-BUILDER DECLARATION
,c 1 hrcxo slims thin 11. exempt from the fimems ars License Law for dte
:o o following mazoa(section 103 LA Business had Pmfcsxions CWc:Any city os county
m which requires issuance,permit to construed alcor,impmsu demolish,or repair any simmer
1—r^ this to Wisl ensed alwmquithe the provia applicant for Co mrmt'sLieea Lawjed sutemem
iSC (cmmimingwi p&ctim7o )dDivi ion3of CBuacmr'andcf iamC pter9 Sq. Ft. Floor Area Valuation
that he is exe with Section]000)of D osis f 3 of alleged
exempt Professions Calc)ar $1700
Not he u exempt shuofrom and this basis it be alleged exemption Any violation of
an,..]than by icy reddollaIns apermit wbjc<m dte appl¢antmativil penalty a( Number Occupancy Type
not term than Bae Wnemt aanara(sham. 36909035 . p y YP
❑I.as owner of the property.or my empioyem with wager as their axle compensation, '
will do the work,and Ne structure is our intended oroRered far rah:(Sec.7614.Basi.
and Professions Code:The Contractor's License Law deet rot apply to an awner of Required Inspections
Own enylo,�a.pmvirimpawthimrowmeho doesouchwink hwmelfmtfor We hu
awn employrra,provided that such impmvemmu are not intended oroRemd far salt.If.
however.Ne buildingb r improvement u halt within arc year of cwophe for the owned
ask,) will base 0te burden of proving that h did not Wild or improve fax Purpose of
wteJ.
❑1,as Owner of the property.am exclusively contracting with licensed contractors to
ceramics the pmjen(Sec.7614.Business and Professions Cade:)The Cantract er's Li-
me Law dos mat apply to an owner of property who Wilds or imposter tutus.and.
who contracts for such projects with a conuxtmr(s)Eanxd pasoani w the Conmmanes
License Law.
❑ l am exempt undo Sec ,B&P C for this reawn
Owner' Date
WORKERS COMPENSATION DECLARATION
I hereby,aRrm under Fatally of perjury ane of thin following doelaations:
41[him and will mainuin a CutiBnte al Consent as self-insure for Worker's Crmpcn.
cation,as provided for by Section 3700 of the labor Cade,for the Performance of the
7ar for which this permit u issued.
w 1 have and will maintain Workers Compensation Insursnce,as required by Section
3700 of NC Labor Cods.for she performmce of dte work for which this pemrir u issued
My Wor'ker's Compensation In....carrier had Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
rlTu section need not be cunpleted if Ne permit is far one humb et,aBars(SIM)
or less)
I certify Net in the performance of the work for which this Permit is issued.1 shall not
employ any person in any manna ha u,h�bcepgtesuhicnro the Workers'Compensation
Laws of California Date �� aKC 1I A((,,
Applicant
NOTICE TO APPLICANT:If,after making this Ceninate of Exemption,you should
Warne subject to the Worker's Compensation provisions of the Labor Code,you must
.,O foMwiN comply with wch pvvisians or Nu permit dull W dmmctl mwkcd.
E y CONSIAUCTION LENDING AGENCY
'i—� Ibemhy affirm that then is a cmnswcurat lending agency loot the performan¢of
athe wank for which this permit u issued(Sec.309],Civ.C.)
W Q Lender's Name
7 z Lenders Addros '
U O 1 certify Nat I have read this application and state that she aWve information is
Ly cornet.l agree to comply with all city had county ordinances and sac e laws rtlating to
0U building conswesion,and herby authorir rpracntruwS of this city to enter upon roc
,hove-mmudgmJ pwpc set for map van which es
may
H W (we)agree r save,indemnify and keep barriers the City or Cupcnum against
t,lZ liaansix,inudgmcnhe'ramand of thisexpenses which may in anyway ammo against said City
V 2 inearoCAN're of Negn ANDS this permit.
'—' APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION ^ ISI,,�
^ 121 nit) Re-roofs
Signature of ApphcanUContractor Dain
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant stare or handle mem ors material
as defined by the Cupertino IM pal Code.Chapter 9.11,and the Health and Safety
Code,Section 15531(x)? All roofs shall be inspected nor to an roofing material bei.
❑Yon Na p p y g g installed.
Will the applicant Or future Wildingaccupant use cquipmcmt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hu,mous air mnmminanu n rkBned by the Bay Am.Air Quality Management all new materials for inspection.
District?
❑secs erfiu
I have real the hamardmus materials mquin mem,uncer Chapier6.95 of th Califon
no Health&Safcry Cade,Sxuam 15505.25533 W 2553,.l understood thuifNc Wilding
docs not curently have a asnam,that it is my rap sedihility to notify the occupant of th
myuirt ^w^irhmusthmet pr{ormissuan"rfiCc(d(Kateo/Dtt,,,n1�lo Signature of Applicant Date
Owner or awh.n,c grnt C rXt../f Date. All roof coverings to be Class "B"or better
Community Development
" 10300 Torre Avenue
p Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
46UPEkTINO
Building Department
JOB ADDRESS: \p-y Y CO\6 4r r tiVe— PERMIT #
ld d
OWNER'S NAME: Caro,6kh eY- PHONE # /-108- h 3 - 10 3 8
GENERAL CONTRACTOR: FAX # n q
I am not using any subcontractors: �. , 12-1 1 g Ic�6
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
•
Owner/Contractor Signature Date
CITY OF CUPERTINO
• 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36909035 .00
DATE ISSUED. . . . . . . : 12/19/2006 .
RECEIPT #. . . . . . . . . : BS000000031
REFERENCE ID # . . . : 06120100
SITE ADDRESS . . . . . : 10248 COLD HARBOR AV
SUBDIVISION . . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : WAGNER KARL
ADDRESS . . . . . . . . . . : -
CITY/STATE/ZIP . . . : CUPERTINO CA„ 95014-3327
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY WAGNER KARL
ADDRESS . . . . . . . . . . : '
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3327
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----------- ---------- ---------- ----------
BELEC200 METERS 1. 00 29 :43 0. 00 29 .43 0. 00
BSEISMICRE VALUATION - 1, 700. 00 0: 50 0. 00 0. 50 0. 00
EPERMITFEE FLAT RATE 1. 00 38 .37 0. 00 38 . 37 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 68. 30 0. 00 68 .30 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
--------=-------- --------------- --------------------
CHECK
------------------
CHECK 68 . 30 5353
---------------
TOTAL RECEIPT 68. 30
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL
CITY OF CUPERTINO 01 20K�0
C]TV6F PERMIT APPLICATION FORM
CUPEkTINO
N# 21 „��6Q ^� Date:
Building Addresss�\Y�'I�y �Q1 Col 4C'�Of ,Mailing Address (if different from building address):
Cv. `no C,K Ci6o\LA
Owner's Name: cr ` ' QI\he—r Phone#:
Contractor:n 1, s � �1�1 �'�; C- License #: �j_1 / 7� 1
Contact: '" Q Phone: Cupertino Business License#:
MN\��e_ Fax: �O g $ 81
Building Permit Info: \,KQ16kId tOq YVv�
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: 1
Residential Commercial ❑
Sq.Ft. Floor Area: �QQ Sq.Ft.:
Cost of Project: I V Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
roject Size: Standard 2(� 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
•
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CITY OF CUPERTINO
aTMOF 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 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 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
MBRE
POLE Pole/Platform Fixture ELECTRICAL
OWER Power Device/Apparatus ELECTRICAL
ECEPT Rc tl, Switch & Outlets ELECTRICAL
ELOCA Relocation of Hood MECHANICAL
EPALT Re air/Alter Heating MECHANICAL
ESAPP Remodel Res Appliance ELECTRICAL
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Jam- 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 MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
13SWIM 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 Mechanical sq. 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
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