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03060132 (2) CITY OF CUPEWFINO BUILDING DIVISION PERMITCONTRAC�TORINFORMATION - .. �i?r BU I LDING ADDRESS: ADAMS THOMAS E PERMIT NO 03060132 7 eS NAME: PERMIT ISSUE DATE PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH L� 0 ±oo LICENSED CONTRACTOR'S DECLARATION 1 hereby art3rm that 1 am licensed ansa Novin,ma or Chapter 9(commencing Job Description111 p Let)wto ithSection Tlkk)of Division 3 ofd"Buvinea and ProfcssionsCoem.and my license is �+V d in License anderm"' KITCHEN & BATHRM REMODEL _ 2 L full f Clan Lr.X ;, n Date Contractor SEP 2 9 2003 P ARCHITECTS DECLARATION W1 understand my plans shall he used u public recants U 1� 1Or^ Licensed ProfessionalJ� @1'�/e 3 OWNER-BUILDER DECLARATION BU � •s <2 I hereby affirm that 1 em exempt from Ne Contractor's License Law far the V 00 following reason.(Section 71131.5,Business and Professions Cole:Any city or county <m which requires a permit to construct,alter.improve,demolish.on repair any Structure °iy prior it) issuance.also rtyuirm she applicant for such Permitm0leaSig nedaumment EiC mu at he is licensedPmsaan0thepmvisimmonheContractor'sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation ca' (commencing with Section 7")of Division 3 or the Business and Naksaiars Cock)or y $ that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of 3 592 9019 . 00 Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy—Type not morcmanrvehundred allans($50o). P Y YP Q 1,u owner of the property,or my employem with wage as their sole compensation. will do the work,and the stmnum is not intended or offered for sale(See.70x4,Bus _ /�T�T and Professions Code:The Contractor'sLiceme taw dans not apply m an owner of 141d Inspections property who builds orimproves tureen,and who doesmcnwork hfmmaorthrougbhis 102 - PIERS own employ=.provided mat such improvements art not intended oroRemd permit.If. lO3 - UFER however,the building or improvement is sold within one year of completion.be owner- builder .will new the burden of proving bat be did nm build or borrow for purpose of 104 - REBAR sale.). ❑I,as owner of the property,am exclusively convecting with licensed contractors to 105 — ANCHOR BOLTS consumer the project(sec.7IM4,Business and Professions Code:)The Convzcmrs Li. 106 - SEWER & WATER Come raw does not apply to an owner ofyroperry who wilds or improv damor,and. 202 — UNDERFLOOR PLUMBING who contracts for such projects with a convaeror(s)licensed pursuant to the Convector's ❑lam exem see Y e PChaan 203 — UNDERFLOOR MECHANICAL Date mld 204 UNDERFLOOR FRAME WORKER ION ` 205 — UNDERFLOOR INSULATION L berebyamrm under Penalty of perjury one of me following cieduations: 301 — ROUGH PLUMBING p l haw and will maintain a Ccnibcate of Consent to Self-insure for Workers comber- 302 - TUB & OR SHOWER moon,m provided for by Section 37W of be Labor Code,for the performame,of the 3 0 3 — ROUGH MECHANICAL wok for which this Nrenit is issued. ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3 04 — ROUGH ELECTRICAL 37W of the labor Code.for the performance of the work for which this permit is Issued, 305 - FRAME My worker's Compensation Insurance carrier and Policy num her am: 306 - HOEDOWNS Cartier. CERTIFICATE OF EXEMPTION FROM WOR KERS' 307 - INSULATION COMPENSATION INSURANCE 308 — SHEETROCK M,max.) ne (This Section ed not he completed if the permit is for one hundred dollars($1(0) 309 — EXTERIOR LATH I ceniry that m the rtmmanec of the k mr wnkh fen permn rs issues,I:halt oat 3 10 — INTERIOR LATH employ anyy, any an. -aj- f�r�a:�bject to the Workers'Compewtion 311 SCRATCH COAT lawse App g d 313 _ ROOF NAIL Im CEMAPPLICANT:If,a�fmr makingthis Comfi,ttc of Eacmpann,you Should 501 FINAL ELECTRICAL ENERGY orae mbject the m Workers COpmtum eation provisions of labor Code,you must Jz0 ranhwimComply with Such pravisimmorthis permd Shall WSummed rewked. 502 — FINAL PLUMBING ENERGY z " CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY [-s Ihereby aM.Nat there is a comwnion lending agency IMO,performance of Cd mework far which ddapennitarIssued(See3(?97,CIvC) 504 — FINAL BUILDING ENERGY W q lenders Name 505 — FINAL ELECTRICAL D z rid rsAed m 506 — GAS TEST V Q 1 certify that I have read this application and sum that be sbow information is a, P collect.IagreemmmplywithallcityandCountyordinmcesandsutelawsmisting1. 507 — FINAL PLUMBING 0U Wilding commuetion,and hereby authorib,representatives or this city to enter upon the — FIN L MEC ICAL yabove-mcmioncd property for inspection purposes. PCN (We)agree b.mw,indemnify and keep harmless the Cityru Cupcnit against 0 FI ° h liabilities.judgmentseeasssand g expemesmit. may in any wayacerae against said City 5 NG fJ z in eonsequene the Stabling of this Permit. APPLICA ERS S A WILL COMPLY WITH ALL NON-POINT Issued by: C WORKSDa SOURC LATI S. Re-roofs ng oureaf ApPlicanoCouracmr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant tar future building occupant score or handle hvuduua material as defined by the Cupertino Municipal Code.Charm,9,12.orb the Health and Safety It..SCe ion 25532(a)? ❑Yea tpxhf All roofs shall be inspected prior to any roofing material being installed. _ will tum a ream or mlum wddln amu ant use a If a roof is installed without first obtaining an inspection,I agree to remove Pp s P a Air Qu or devices which g hazardous air contaminants ss dcnned by the Bay Arca Air Quality Management District? all new materials for inspection. / ❑Yes 1p u I haveread the Ma M(msmamrialsmquiremcntsunder ,Chapter6.95oftheCalifnr- MaHcalth afetyCode,Sccoom25505.25533and23534.1 understand buifthe wilding dues nrot c rely quneema aumoriicmhsahility m nnolj the cecupant nt e ro e Signature of Applicant Date Date \ All roof coverings to be Class"B" or better CITY OF CUPER'l'INO na kap 'k' e as iw' BUILDING DIVISION PERMITO ECONTRACTORjNFORMATI BUILDING ADDRESS: ADAMS THOMAS E PERMIT"°.03060132 7629 NER'$NAME: PERMIT ISSUE DATE NO. PHONE: SANITARY CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH in LICENSED CONIRACnOR'SDECLARATION hap Job Description thereby )of that 1amlicensed under fhe Buinessprovisionsof Chapter9(commencing p �Zwi withllfamn]defec Division Jof the Business and Professions Code,and my license is <<p in full farce and effect. iq= Lmnuclaaa Lla.x KITCHEN & BATHRM REMODEL .._ =Fo Dare Contractor ti u I understand my pine shall he unit asCHITECTS DECLARATION —i - FINALE `�G LucnuJ Pmfcssional ' SEP 2 9.2003 3 OWNER-BUILDER DECLARATION C0 2 1 masaereby,(bent o that I ore<Busin from Nc Contractor's ;Any c Law for the OO which following mason,(Section](171.5,Businasand mpove.deciens Code;Any city arcounty .,am C m which its issu n permit m e may the a@h improve.dcmolit t fie a sig any tamcwro °i y Ila,poohe its issuance,pit n.quirts lnovisiappo ant for wch permit cense Law(Chapter Cha mem pp ofcommencingOJpursanL In tion7theorDivision3theComm�essadProflaW(Code)or Sq. Ft. Floor Area Valuation Y $ (cat he (commencing Section and of Divisionr of allgcdncxcmdProfessions Code)or _ Nat he is exempt therefrom and Be bash for Ire alleged excmpdon.Any violation of 35929019 . 00 Section]031.5 by any applicant for apamitsubjects the applicant o a civil penalty of ane APN Number Occupancy Type am mora d ah five hundred cloth.(1500). p y yp ❑1,as owner of the property,or my employees with wages as their sole compensation. will do Ne work,and the cmcum is not intended or offered for sale(Sec.7W,Business and Ot[Cd Inspections d Professions Cade:The Conumr ac 's License law docs not apply m n owner of property who builds or improves chercon,and who doessuchwork himselforNmugh his 102 - PIERS Own employers,provided that such improveni are not intended or olraeed for sale.If, lO3 — UFER however,the building or improvement is said within one year of camPletion.Ne owner builder will have the Worn of proving Nat fie did not Wild m improve for purpose of 104 - REBAR sale). 01.as owner of the propcny,am exclusively contracting with licensed contractors to 105 — ANCHOR BOLTS Conswct the pmjcct(Sec.TW4,Business and Professions Code:)The Convacmr's Li. 106 — SEWER & WATER cense Law d.snut apply toanowner ofpropcnywho WBdaorimproves themon.and, 202 — UNDERFLOOR PLUMBING who contracts for such prajccu mctm th with aconor(s)Handed pursuant e Gametes `a 203 — UNDERFLOOR MECHANICAL ❑tun roam ler Si, & ,BonePCforthiaro on 204 UNDERFLOOR FRAME WOR LER' PENSATIONDES RATION /� d 205 — UNDERFLOOR INSULATION I hereby affirm under penally of perjury,one of the following deelantions: 301 — ROUGH PLUMBING ❑l here and will maintain aCenifcalool'Conunuoself-ianum for WorYcr's Compen- 302 — TUB & OR SHOWER sation,as provided for by SmIhn JT00 or the labor Codc,for thm performana of IW 303 — ROUGH MECHANICAL work for which this permit is issued. - ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 04 — ROUGH ELECTRICAL 37OO of thc labor Code,for the perrormance of the work for which this permit is issued. 305 — FRAME My Worker-Compensation Wueanee carrier and Policy numbfan:: 306 — HOEDOWNS-, Carrier. CERTIFICATE OFEXEMPITONYFROM WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 — SHEETROCK less.)(This malt.fiend nor becampleted if the permits for one,hundred d.11.stop) 309 — EXTERIOR LATH ar 1 tenor Nal m Nc p rformawe ohne woo for whmh Int:permit Is issuer.I slim nut 310 — .INTERIOR LATH employ n'yµ any mnno/sn•sf. pnSa mbjea to Ncwarkcri campctwtian 311 SCRATCH COAT La ofP nam r (^mea T m e 313 _ ROOF NAIL .ICh APPLICANT:ILoTrmaking this CenifcateofEacmplion.you should 501 FINAL ELECTRICAL ENERGY ome subject m Inc Worker-Compcnuaion provisions of Inc labor Codc,you must ,J� onnwnneomptywimmmproriainnsomiaprm¢analWdamamatm. 502 — FINAL PLUMBING. ENERGY ? y CONSRUCTONLENDINGAGENCY 503 — FINAL MECHANICAL ENERGY C> the,work farewAihthisparchititissued(Sol.3W],CiaCs a Consultation lending �encyfnnhcperformanaof 504 - FINAL BUILDING ENERGY Wap lander':Name 505 - FINAL ELECTRICAL Z. Under'sAddmss 506 — GAS TEST U 0 1 certify Nat I have read this application and Stam that the above information is Ig, F correct.1 agree to comply with all City and county Ordinances and site laws ranting I. 507 — FINAL PLUMBING 0U building contraction.and hereby audoor7c representatives or this city to chase upon do — FIN L MEC ICAL >,{II shove-mentioned propcny for inspection purlwus. gN 1„t p, (We)agree to save,indemnify and keep harmless the City of Cupertino against 0 9 — FI \/— y liabililia,judgments,costa and expenses which may in any way accrue egein.1 said City 5 NG CJ z �Igamuanm o the gmming of this permit. / ^ ICA ERS S A WILL COMPLY WITH ALL NON-POINT Issued by: C WORKS Da RC LATI S. / agnawrc of ApplicanUConDau ummr Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future Wilding occupant store or handle hazardous material as deraned by the Cupertino Municipal Codc,Chapter 9.12,and the Health and Safety Code,Section 25532(.)? ❑Yea Mid' All roofs shall be inspected prior to any roofing material being installed. Will the appbcntorfuture Wilding occupantuse equipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Arca Air Quality Management Di...ic4 all new materials for inspection. / Dyes e . 1 have mad the hazardous materials requirements under Chapter 6.95 of the Califon nia Health afctyCodc,kedom25 5.25533.25534.1undcrs.dNuifthebuilding deco not c rt filly hate a I Na 'lisiny respona.bililY Ih Im61y the oecupnt of Ne rcyuirom Enh must Or t once oft Certificate up cy. w„ / Signature of Applicant Dale a aomori.ed aganl Dae All roof coverings to be Class "B" or better ( - CITY OF CUPERTINO �� Z CITY OF PERMIT APPLICATION FORM .3 . 6 APN # — ' O / Date: / L \ Building Address: l t Owner's Name: '/ Phone#: Contractor: License#: r Contact: Gu�ertino Business License#: Building Pe it Info: Bld E ec Pl ❑ Mec Job Des •ption: -Rrcsential ❑ Co ercia Sq.Ft. Floor ArcA: $/ q.Ft.: Cost of Project: Occupancy Group: bd D ype of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> l 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 Elee 600V <= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA 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 lof3 � l ATY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM QuantityFee 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 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 Ston /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 c MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY Remodel Busways ELECTRICAL BREMFIXT Li tin 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 A aratus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2 of 3 -- CITY OF CUPERTIA CITY OF PERMIT APPLICATION FORM CUPERTINO 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 BREMRESAPP Remodel Res Appliance ELECTRICAL 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 Insection 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