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04110106 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTQR INFORMATION n -BUILDING ADDRESS: GENERAL LIGHTING SERVICE PERMIT N`64110106 10591 N DE OWNER'S NAME: PERMIT E SITE DATE FRED 13ARNHART 975 CHESTNUT ST 11 /17/2004 ONE: SANITARY NO. CONTROL NO. (408) 298-6670 ARCHITEC(ENGINEER: BUIIDING PERMIT INFO - BLDG ELECT PLUMB MECH a�aOp LICENSED CONTRACTOR'S DECLARATION Job Descri to " C I rcb affirm at 1 am licensed under Bions of chapter 9(commcncing -.- b wilts Smu )af Divis+on3of NCB sin Prufcssiu+u Code,end myliccnw is _may inlbBr MdeffbrL !!o yb d b /` RECONNECT METER zOil g n Dart, Class G U'. O=p Lien lunars,sur7�—Cool clor(euTPY6 vUIT 5 ✓pt r �` --- " ' " ae�war nd nd my plaoss�CTSD h rte/ 3 0 Liccnxd Pmfcssionel OWNER-BUILDER DECLARATION <2 I hereby,(sec that l am exempt from Nr ContmasCo License Law for the p o following rensmn.(Section](GIS,Business and wn,de tins Code:Any city or manly ,1 m 0 which its issuance. ss a a Permit m cnnswct,aafter,pplicant Impmse,h Norio t fi math any swcmre - -- Fiya poor mits�ensed c,owrit1.thsthe urfAsoicans forsucun,Cahncrmiuo 0lc asignad summcm — —__ that Amending wit pScccon In the of Divisions tMConuacmr'and Pro Law(Chap¢r9 _ Sq. FI. Floor Area Va Ion (commencing with Sec0on 7")of OivisionJof the Business and Professions CMe)mrin $ that he u exempt lhertfrom and the basic for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects me applieanl m a civil penalty of not mom than ryebuMreddollars(55W), ¢ 0 Occupancy Type 0 1,in owner of me pmpeny,or my employees with wages ss their sole compensation, will do the work,and the swctuv:is not intended or offered for sale(Sec.1W,Business and Per evtima Code:The Confiscates License law does rut apply man owner of - - Required Inspections property who builds or improves thereon,and who dean such work himself or through his ownemplowers,provided that such improvements she not intended oroffemd forsale IL however,me Wilding or improvement is sold within one noutdcompkuon,demwer- buildv will lave me forces of praying that he did not build or improve for purm se,of sale.). 0 1,as owner of the prepcny,am exclusively contracting with licensed mnuactors to - construct the pmjen(Sec.700x,Business and Professions Code:)The Conuactor's Li- cense law docs not apply to an owner of pmpcny who Wilds or imprem themon,and - whocontnctsforsuchprojecsswithaconuactmr(s)licensed pursuant to the Conuacm6 -• -__ , - _ . License law. 0 1 am evempt under Site .B&P C for this muon Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm once,penalty of perjury ane of the following declarations: I ban and will maintain a Cenifica¢of Consent to self-insum for Worker's Compen- 7�cm imn,u provided for by Section 7]00 of the Labor Code,for the pcRormance of 1W W for which this permit is issued. 1 have and will maintain Wirker's Compensation Insurance,as required by Section 00 of the labor Cods,for the performance of the work for which this permit is issued. Warl s orag�nsauon lnwnna 'erm�Iiey_♦7/raw: 066 Yog YC FG a Pqn qty/'/�� CERTIFlCATE OF FJCEMPnON OMWORKERS' ' s COMPE,ISATIONHNSURANCE (Thisseclion need not W complemd If the permit is formic hundred dollars(SI00) for less.) I cenify font notion peO(oamnnec of the work for which this permit a issued,l shall nut employ any pe.a.In My mMner w a5 la become subject 10 fine Worked Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Cenir+cam of Esemplion,you should become subject in the Worker's Compensation provisions of the Iathr CMB you most .JZ forthwith comply with such provisions or this permit shall W deemed mvokM. Z O CONSTRUCTION LENDING AGENCY Ihereby a im that then is a eomwction lending agency for me Performance of (Y tW work for which this permit is issued(Sec.3Pa9],Civ,C.) Is7 0Lenties Name ddress 0' Lender'sAgrees U Q 1 cenify that I have read this application and suite the te that aWn information is (•-' correct. 1 I agree 10 comply with all city and county Ordinances and sum laws missing to , C) V aovWilding construction.edet,and hereby im,e tion purposes.rescnutives of this city to toms upon the W aluvc(weMent)are to saveterty for inspersiontic,ho (We)agree to save,indemnify and kap harmless me City of me againino id City 1 F-' N lie consequence ftheeosuand es pensu which may in any way attmc againstsaid City 1111 v U z APPLICACNTc of DEgranANDSlhis N it. COMPLY WITH ALL NON-POINT Issued by: Date RpT SOUR t.G)JL 0 t t /1��� Re-roofs Si tum mf ApplicanVCr Data HAZARDOARDOUS MATERIALS DISCLOSURE Type of Roof Will y t applicant or forum building Occupant.Chpsafore m handle Health sd Safer l as refined by the Cupertino Municipal Cade.Chapter 9.11,and the Health and Safely AMJFWr.or:25532(a)' Nu All roofs shall be inspected prior to any roofing material being installed. .._ Will the apprrsofor future Wilding Occupant use equipment for devices which If a roof is installed without first obtaining an inspection,I agree to remove mit he ardour air contaminants in defined by the Bay Area Air Quality Management all new materials for inspection. Distort? 0y. 1 have mad me havarmms materials mquimencnks under Chapter 695 of me Caldor- .isHeslth&Safety Cial Sections 25505.15533 aM 255M.l undentaM that if tM Wilding Of not cusm ly hast can n'umyr 'roibility nufytheoccupantofde .7 hieh s br to issuance ofe Ceni0c c X �j Signature of Applicant Date Owner or summit d a ant - All roof coverings to be Class "B"or better Community Development F 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408) 777-3333 �UPEkTINO Building Department Jos AD0DS�` , n �� &-'zxD PERMIT # OWNER'S NAME: Z3 S/fir/ PHONE # S,-eP Z-q F 6?. 7 a GENERAL CONTRACTOR: epeijeis Y/ I W# 4,tO r- 6 37 9 I am not using any subcontractors: 7 Signature Date / Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing " ✓ Electrical /1011 t�C l Ct 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 Ah ile 'Q . bw#er Contractor ignature Date l acCITY OF CUPERTINOCUPYOFFINO PERMIT APPLICATION FORM APN # 6 l- U 6 Date: Building Address:/O$ g �-� /V 1joe , a�li�g/�Addr� (� re fr building address): Owner's Name: // IPhone Contractor: Q / /� License #: Contact: P/ ne:(p1{6 3tV Cupertino Business License#: Fax: -VF679 Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential ❑ Commercial Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: / Please check this box if the project is a .I-./ CGU /J/ii�`f/� _ second-story addition: ❑ Project Size: Standard ❑ 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 I 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 Elee 600V> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL Ei:plBENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING z� 70 lof3 s- 3v, / 7 t Its ' CITY OF CUPERTINO CirYOF' PERMIT APPLICATION FORM CUPERTINO 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 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 > 10K 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 2 of 3 5CITY OF CUPERTINO CITY°F PERMIT APPLICATION FORM CUPEkTINO 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 BREN'IVENSYS 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 BUS IC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elee Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3of3