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04040096 (3) CITY OF CUPEitTINO �g,'�v "«.�k�� 1-a♦nt' �- BUILDING DIV ISI ON P�R CO t\Tg�t?VTCIRT111'OA BU ILDING ADDRESS: PERMIT NO. 04040096 n-Ug CREST OWNER'S NAME: PERMIT ISSUE DATE VONE: SANITARY OL NO. ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 �Oo LICENSED CONTRACTOR'S DECLARATION lob Description nsp I Wmby affirm that 1 am licensed under provisions of Chapter 9(commencing 7fwith Sermon ndc, uc,Hji.n Jor NC Business and ProRssions Code,and my licence is R g v Fr m<n, in full forte.nae ct �y�9V1111� ipp1' ;�z acto=r lass � yam' tic.« �.J7�SZ REMODEL 2 BATHS/WATER HEA Zoo Dam ' � canrano <f CONTRACTOR: JEFFREY MILLER INA COON- RACTOR ARCHITECTS DECLARATION r I urWcrstand my plans shall W=it as public recants JUI 22- 2004 uvt Licensed Professional 0� OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Continues License Law for the [SHIP p o following mason.(Section 1131.5,Dusincss and Professions Code:An cit or countrg� - X m�+ which mquira a permit In construct,Our,improve,demolish.or repair any structure � ilk fl 11 m_y prior m is issuance.also mquincs the applicant for such Permit file a signed stammem ja< that he isliccnmd momantm the provisionsofthe Cmunico s License Law(Chapmrg Sq. Ft.Floor Area VIllua,[t�JB oo zi$-m (commencing with Section 7")of Division 3 of the Businessand Pmfasinns CnJe)m 7.SU y Nat W u evempt Ihemfrom and Ne basis for the alleged eumptioa Any violation of Section 7071.5 by any applicant for a permit subjects the applicant 10 anvil penalty of APN Number Occupancy Type nn...than five hundred dolls.(1500). C]1.as owner of tha pmprly,or my employers with wages as their sole compensation, 32637010 . 00 will do the work.and the structure is not intended or offered for sale(Sec.7014.Business and Professions Code:The Contractors License Law docs not apply to an owner of Required Inspections property who Wildso,improves thanomand wh.docsatichwmk himself.,brought his employees,provided than such improvements are not intended.rofered forsale.If, however,But building or improvement is sold within one year of completion.the owner- buildco will have the burden of proving that W did not Wild or improve fm purpose of sale.). 1,as owner of the property.am exclusively contracting with licensed eonN4Cmrs to . eunmmct the pmject(Sec.7064.Business and Professions Cade:)The Contractors Li- case Law docs not apply to an owner of property who Wilds or improves Nemon,and who contracts for such projects with a contractor(s)licensed pursuant to Be Contractor's Licome law. [:]1 am exempt under Sec .B&P C for this moon Owner Date WORKER'S COMPENSATION DECLARATION 41 1 hereby affi m under Penalty of perjury one of the following declarations: ❑1 have and will maintain aCenificme of Consent to self-insum for WorkersComfort, sation,as provided for by Secuon 3700 of the IaW,Code.far Ne performance of the work for which this permit is issued. 1 have and will msimain Workcis Compensation Insurance,as requited by Section IDB of NC labor Code,for the performance of the work for which this permit is issued. My Worlmess.C�on,crosa�tiionn Insurance carrier and PNa num �a�G23 Cartier.Ss rta" (Tw.+C L CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This seednn meed not beeomplemd Blhei+c.it is Ronne hundmddollars(1100) . m Ices.) I crdfy that in the perfmmmce of the work for which this Permit u issued,1 shall am employ any Person in any manner so as in become subject o the WOrIMM ComPensatien Laws of California.Dam Applicant NOTICE TO APPLICANT:If.after making Nis Certificate of Exemption,you should Wc.me subject to the Worker's Comfy notion provisions of the Labor Codi,,you must OQ forthwith comply with such provisions w Nis permit shall be deemed mocked. CONSTRUCTION LENDING AGENCY I hereby affirm that them is a concoction lending agency for the Performance of lY> But work for which this Permit is issued(See.3097,Civ.C.) Is7 0 1dre Nam. �z 1<nder's Adtlmu [J 0 I certify that I have rail Ws applicmiom and sate that 0.aWm information is B, E. correct,l agme to comply with all city and county ordinances and state laws relating to 0CJ b�lding construction, ata ction,and hereby maborim reprcmtioes of this city to cnmr upon the fdl v m mentioned property for impeedon purposes (We)agree to save,indemnify and keep harmless the City of Cuperlin.against .Fi N into ties.' dgmem,co is nd..,cases which may in any way accme against said CityS— , C)z no.., a, . c timgoft 'spermit. .. APPLIC U DER AND ND WILL COMPLY WITH ALL NO OI Issued by: Date SOUR ho f Re-roofs tgomur o p isZonlrm, t AacBOGUS MATERIALS DISCLOSURE Type of ROOF Will the applicant m fumm building oecup.,smm Or handle hvallous mammal as defined by the Cupenino Municipal Codc,Chatter 9.12,and the Health and Safety Code,Scotian 25532(.)? All roofs shall be inspected prior to any roofing material being installed. Yu Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove • emit harardoue air contaminants as dcuncd by Ni,Bay Area Air Quality Mamagcmcm all new materi for inspection. District' ❑Y.a I have mail Ne miandow materials mquimmenu under Chapter 6.95 afire Calircr- niaHa &Safmy Codc,Sau 25505.255]]and 2SSJ4.1 unJcrsmntl thaifthc building -�au Jars t c rally a m that it is my msponsiolity to notify the arca sot Df N. m e whim IpooranissuanceofaCenifieareof Sig a eo pplica AD o n ,a nmrdagcmt am All roof coverings to be Class"B"or better fl �� CuPF2�, � 9Sor�t APN 326-37-aro-cs� APR 15 nu4 �� c d�,.!2,AKO 6r-211 �� i_� ,irk IT X_Orr " 21 _ If M FD M 'Co ch v � DO • � aQall N W-311 - / lM QAC rfmi 7F11 MY 09 > mro AND � SIGIN Ibis set ,, a and specifications MUST, lie kept on the job at all times and it is ung lawful to make any changes or, alterations on same without written permission from the building Dept., City of Cupertino. The stefiping of this plan and specifications 3NALL NDfi be held to permit or to Ian or, i0 eye®6f the ykilatlon of I ordinance or Stato any Aylalona AW- e APR 15 2 04 3'O„ x 2'-0" � DO e k e � ti • 2'- 10"-' jN .00 O � 0 t�� CON -- 3 ' 10 FF 3 '4 • T • 3 '0" x 3'0 ' 0 LQ GSI � APR 15 2ii�l4 Q H _ ,, x s ( — *ITY OF CUPERTINO CUP CITY Of O PERMIT APPLICATION FORM � cf v c( ° 7� APN '374 -37-O/U -v v Date:yX10 y Buildin Address: Mailing Address (if different from building address): la3Y j C�sra'a b2 Owner's Name: Phone#: MAolfteEr i"Azo" Contractor: License #: &J-MRAs N,UM*rUZ 7S7IrS2 Contact: Phone: %k-576-697< Cupertino Business License#: ffrr1 Fax: Ydf-, K6-/3Y6 Building Permit Info: Bldg 9Elect ofPlumb Mech Job Description: per,, Residential ElL 064- SAS R OWC 4.1 Commercial ❑ Sq.Ft. Floor Are ! $/Sq.Ft.: Cost of Proct: Occupancy Group: .1 Q�d 3 Type ofion: Please check this box if the project is a second-story addition: ❑ • Quanti Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances 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> IM 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 1of3 � PT OITY OF CUPERTINO o CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BNUCOMME New Comm Electric ELECTRICAL BNUCONV M New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTWE 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 Stonn/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> I 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 Sips Add Branch ELECTRICAL AML I BREMSIGNS Remodel Signs, Marquee ELECTRICAL 2of3 N� i( CITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO 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 Insection BUILDING BSW1M Swinuning 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 • 3 of 3