04070164 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTR &*TORpINE-URMATIOI
BUILDING ADDRESS: PERMIT NQ 4 0 7 016 4
17 COTTONWOOD DR V
OWNER'S NAME: PERMIT LS513E DATE
CURTIS CHRISTEN
ONE:
SANITARY N0, CONTROL NO.
ARCHITECnFNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� t�
Loo LICENSED CONTRACTOR'SDECLARATION Job Description �®
C w 1 hereby affirm Nal 1 am licensed drum,provisions of Chapter 9(commencing
o bh Srnion]0(IB)of Division3of the eta' sand Profs bre Code.andmyliconxis Kf p
';�R in mufoq,nde a fn p q n!( ELECT PANEL UPGRADE .(200 AMP) Jut +�
'�– `t""m I ��=–�— CONTRACTOR: B & B ELECTRIC . V(=p Dab Gonmxb`� �� n�20
04
w ARCHITECTS DEC�ION 4
undcfstanJ mY plans shall he used in public mortis
7yU ��3wF LiccnxdPntfcssional Q®
a'Og do,
OWNER-BUILDER DECLARATION
1 Wmon .(Baru Nes 11. eacmpt from the Catim.Co :Any o law for the tl
'0 following reason.loauun Rpl.4 Business and improve,
d rioli Code:Any city.,roomy
SiaQ which royuimsae.aimmcnnsthealcor,impmw,de nmitt,me asiranyswsum
pus W is cert encs,pursuant
mqn dim the applicant forsuch Con permit W filos a cigar(summcm
< thaheuliccnwd Soctimtwthcomvuisns.of she
it
eLaw ssions usp¢r9 Sq. Ft. Floor Area Valu QIp00
p r$ (cat he is ung with sernfrom and the
basisofor m NC Rusinexe and Professions Csatlq or
i —
thatheu exempt any arum and the baso for the ilkgcd exemption.Any l N uon of
section 7031Z by vry applicant for apemsit subjcca the applkantwacivil pnulry of APN Number Occupancy Type
not mom man Bw hundred dollars(Soo). 36917042 . 00
r
❑I,as owner of the property,or my employers with wages as their sole compensation,
will do dx work and the structure u not intended aroRenA for sok(Sec.7U,a,Business
and Professions Code:The Consracmes Liar¢Law dors not apply to an Writer of Required Inspections
pmPeny w ho builds or ice proves Hereon,and who does such wick himam f or through his
awn employees,provided Nat such impmvereenu an,not intended oroffemd foliate If,
hawew,,me Wilding or improvement is sold within one year of completion,dm owner.
Wilder will have the WNen of proving dust no did ram MUW or improve for Purpoe of
sale).
Q 1,as owner of the propcny,an aclusivcly...unsung with licensed conuuwrs W
c.nsducs the pmjm(Sec.7 x,Business aM Na(arimn Cade:)The CondasaYs V.
case law dors not apply in an owner of Property who Wilda or improves thereon,and.
who contracts for such pmjem with a consracuu(s)licensed pursuant W tiro Conuactols
CLiss'M law.
Iam accept under See .Bh P C fur this recom.
I'M
wner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby afrirm under Poalty of perjury oro of cote following dalantions:
I hawand will outrai iscerd0cateof Cooter.to self-usum fm Woher's Compcm
ation,w provided far by section 37M of the Labor Code,far the performance of da,
I
for which this permit k issued
r
I have and will maintain him
Kdo eofdnCompensation forwh,az tonfhis pend by Section
camelabor Code,(or the performanceof the work forwM1icM1 this permit is issued.
ortors Compcnntian lnsuramc wiser and Panumber ase:
mer. Pairy
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
('ITisscon. not bocomplctediftbo permit is foronc hundred dollen(Slip)
or lax)
I unify mut in d� cif. aMc o me work f r whi h this pnsnit u issued,l shall not
caPpl.yany pcor n)manncr .az c cujc o me W.rkcrs'ComPensasian
Laws 'C
California.p t
NOTII$NOTtI�Q^^t�
..TO APPL m tg this C•ninesof of,Labor od you should
become subject m m her's exons or this previsions of the labor Cnde,you most
.JO foMwithcomply wire provisions or this pormit shall bodamcd ranked.
Z CONSTRUCTION LENDING AGENCY
�-. I hereby olErm thin them iso construction lending agency for me Kill ....f
a the work fur which this permit is bound(Sec.3091.Civ.C.)
Lu A LendcYs Name
Z Lender's Address
V 0 1 certify that 1 haw sad this application and ram that the above infwmauun u
F coh c I agree W comply with all city and county oNinances and aura laws misting to
0(J Wilding consuuction,and hereby aumorim representatives of this city to cnmr upon the
Y'W show-mcmiunod pmpcny(m hoPecuon purposes
(W agree w save.indemnify and keep harmless the City og Cupertino against
F'(aj) liabilities jus mcna.ca,a andeapcnsca which they in any way same against said City
V Z inconmex,im. of the granunC of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W AL NON-POINT Issued by: D to
SOURCE RE �
_ Re-roofs
m
s ignewd DDiOaHAZARDOUSMATERIALSDISCL05 RE ate Type of Roof
Will de applicant or future bulldinCeaupantsWm or ntichv but
material
az defined by the C.PenlnoPal Code,Chapter 9.12 and the Health and Safety
Code.section 25532m)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya N
Will the applicant or fmumrrrrb���lading acedPaat men equipment or dcviecs which If a roof is installed without first obtaining an inspection,I agree to remove
emit h.1a 11.s air canteminan dcfincd by Ute Bay Area Air Qualiry Managcmcm all new materials for inspection.
District'
❑Yes Nu
[have M ehvardmasmateriaurequimmcntadnder Chap rS95ofine Cshlor-
-
nuFialthhsafely otic, au25505.25533and2553d.[tmtk dmmillthc Wilding
doe,not eurmmly a ate s.Nat it is my responsibility W noul ms o pant or the
requireme isw is m t etpdorwissuanreof,cem�mgo upon yQ Signature of Applicant Date
r
err,err adm. ed asont te All roof coverings to be Class "B" or better
-• - Community Development
10300 Torre Avenue
. -"�- Cupertino CA 95014
Telephone(408) 777-3228
CITY 0,� Fax(408)777-3333 UPEI�TINO
BuildingDe art ent
JOB ADDR PE #
ftoNQ10dj of -20 �a
OWNER'S N v PHONE
GENERAL CONTRACTOR i L FAX #
I am not using any subcontractors: Ajz �L Q 7
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical I i L — (Doc(
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
TIl
Olt)Contractor Signature `A D e
amCITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM `'� 'lf
CUPERTINO
JP\PN # 3lJ / O Z Date: b Q
Building Address: Mailing Address (if different from building address):
(112 Coftdo
Owner's Name: hone #:
COCTiS ,-i J r o s 2 :� — d
Contractor: ticense #:
Contact: Phone: Cupertino Business License#:
52, Fax: 0e6) " I
Building Permit Info: /
BldgEl Elect [d' Plumb ❑ Mech ❑
Job Description,/
Residential C� Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
Adik J H0 — second-story addition: ❑
Pr ject Size: Standard Lar e ❑ _Ma or ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 1 OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to IM 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<= 1O00A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy- BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee r/ BUILDING
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Z�G. 3 2--�
1 t L S CITY OF CUPERTINO
CUP TOF YO 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 cfrn 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
All BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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j CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Sips 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
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 Chane BUILDING
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