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03110059 (2) CITY OF CUPEWI'INO MI BUILDING DIVISION PERT CONTRACTOR INFORMATION `f BUILDING ADDRESS: TERRY BROWN, GEN CONTRACTO ERMIT N003110059 EL CERRITO RD LOT 31 OWNER'S NAME: 14S10 BIG BASIN WY PERMITISSUEDATE AMAR UPTA 11/12/2003 NE (408) 868-1640 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO 0 BLDG ELECT PLUMB MECH 0 0 0 0 o LICENSED CONTRACTOR under DECLARATION F❑ 1 hereby that l am licensed Bu ander and Proons ofC Corks. 9(commencing Job Description .<W withsection]11(X1) (Divi:ion JOfthe Business anJ Professinm Co@.and my license is r Lic.x mmuro¢camer 2- INSTALL SEWER LATERALS Liccnx Clas ` am O Cunt,acw ,j ARCHITECTS DECLARION JAN 2 0 2004 e R 1 understand my planhe sshall used recordsas public records JyU vol Licensed Professional S OWNER-BUILDER DECLARATION BUILDING y a T I hereby ro... ,(firm than I ore exempt from the ,.Wuar Co License Law for the v ` 'V�a 00 following mama.(Section](131.5.Business and ve.driinns Codc:Any city nr county <m which requires a permit to ennsuun,etre,,improve,demolish,nr ropmr any evuctum $40000 pnorto its issuance.also requires the applicant forsuch Permit to File a signed statement < that he is licensed pursuant o the pmvisinns of the Contractor's Liccnx LOW(Chapter 9 Sq.Ft. Floor Area Valuation eF0 (commencing With Section 70M)OfDivision3ofthe Business and Professions Code)ur 13719031 . 00 i tat he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil Penalty Of APN Number OType nm mare man five hundred drift,,(SSW). Occupancy Y YP 01,res owns,of the property..r my employees with wages ns menmle corn minion. will do the work.and the swnum is not intended or offered for sale(See.TOW,Business Required Inspections and Pmfessipns Code:The Couummum's Licctax Law docs nut apply wan owner of q p property,who builds or improve thereon,and who doessuch work himself or through his Own employees,provided that such improvements are nut immmdW or offered for sale.If. however,the building or improvement is sold within one year or completion,the Owner builder will have the burden of proving that he did not build or improve for purpose of sale.). El 1.as owner of the property,am exclusively contracting with licensed contractors to consumer the project(Sec.7044.Business and Professions Code:)The Contractors Li- rax law docs not apply tO as owner or ympxny who Wilds or improver menton,and who summers for such projects wit a comracum(s)Licensed pursaam to the Commences Liccnx Law. ❑ 1 can exempt under Sec. ,B&P C for this reason \ Owner Dale WORKER'S COMPENSATION DECLARATION I hereby aRrm under penalty of perjury one of the following declarations: 1 have and will maintain a Cenifieam of Consent to self-insure for WOrker'sCumpm- smion,as provided for by Section 37M of the Labor Code,for the performance of the work for which this permit is issued. ❑ 1 have and will maintain Workers Compensation Discourse.as required by Section 37110 of the labor Cook.for the performance of the work for which this Permit is issued. My Worker's Compensation Insurance earner and Policy number aa: Carrier: Policy NO.: _ CERTIFICATE OF EXEM PrION FROM WORK ERS' COMPENSATION INSURANCE (This xetom need not hecompined if the permit is fmone hundred dollars($100) or less.) 1 sero y than in the performance of the work for which his permit is issued,I shall not enn".yanyperin ymanner so m bs hecome sukjem to the Workers COmpcnechon 1 , Lawx of Cahf D Applicant �7 n NOTICE TO It,after making Nis Cenifteam of Emmption,yen should hecome subject to the Worker,Compensation provisions of Ne Lahr Code.you mux = O forthwith comply with such provisions or this Permit shall W deemed¢voted. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a consuuminn lending agency lm the Performance of x the work for which his permit is issued(Sec.3097.Civ.C.) y Hfender's Name 3. Lender's Address Z) 2 U Q 1 cenify that 1 have read this application and stale that the above infomtatiun is V. F conch.1 agree to comply with all City and county ordinances and state laws relating to C U building construction.and hereby uniform representatives of this city to enter upon the above-mentioned property for inspection purposes. Fa (We)agree to save,indemnify and keep bru mess the City of Cupertino against fq liabilities,judgments,costs and expenses which may in any way accmc against said City U to consequence of the granting of this permit. ^-� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCGULATIONS. Re-roofs &gnawrc of ApplicaHAZA DO Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant Or(mux Wilding occupant store or handle Health matfett u def Sed by the 32(.)?nn Municipal Coda Chapter 9.13,and the I1cahM1 and Safety ode.Section 25532(x7? All roofs shall be inspected prior to an roofing material being installed. ❑ret ONO P P � Y g g 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 it harardnus air contaminants ss defined by the Bay Area Air Quality Management all new materials for inspection. islrieL? ❑Yes 0 N 1 have read the hanNnus materials mquiromcnts under Chapter 6.95 of the Califon ni.Hcalh&Safety Codc.Sccdum 25505,25533 mdZ5J4.l and mwd thm if the Wilding docs nut eurtendy hate a tenant,hat it is my ,mspoushility to notify the arupant nr he roquiE s nichmusteemglpiorto.asuanG esof.cemrcamorOccupancy. Signature of Applicant Date owner nr amnnmed agent D„e All roof coverings to be Class "B” or better CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM N # ( / v3 Date: Building Address: !�L CE�� Owner's Name: Phone #: C�uP'T� off 6, c2'—f Contractor: License#: Contact: ✓ Cupertino Business License#: Building Permit Info: 1 Bldg ❑ Elect ❑ Plumb F Mech ❑ Job Description: tlw 57?f�t— 5e.L-+/e-- L Residential [X > Lf}TEE!�LS Commercial ❑ Sq.Ft. Floor Area: /j/h $/Sq.Ft.: Cost of Project: 4ot000 Occupancy Group r Type of Construction: Ur19�RC�Ro�/✓D ----------- Quantity 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> 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 BMITIGATC Comm. Housing Mit. Fee I BUILDING 2,3 �76 1of3 , / ,/�� - Z � - CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTEVIE 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 c8n 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 Fumace> 1 OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREVE RAP Rem Non-Res A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2of3 ( = CITY OF CUPERTINO ; CUP TYOF O PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL 13REMRESAPP Remodel Res Appliance ELECTRICAL 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3