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04120067 (2) CITY OF CUPERTINO .'„•;. •^mnkna- atria " ' - '�'� ?:= wet - __-- _ - BUILDING DIVISION PERMITCONTRACT-ORANF.ORMATION -BUILDING ADDRESS: - PERMIT NO 04120067 -- 10185 EMPIRE AV OWNER'S NAME: PERMIT ISSUEDATE ANN ANGER/CAROL WOODARD 12 /10/2004 NE: SANITARY NO. CONTROL NO, ARCHITECDENGINEEIL BUILDING PERMIT INFO W, BLDG ELECT PLUMB MECH 0 0 0 0 um0 LICENSED CONTRACTOR'S DECLARATION - 00 JobDescri tion ' w❑ I Wreby affirm that I am if Que Business under provisions of Chador 9(commencing - P - O aiN Section 7IXIU)a(Division 3O(NC Busirw•..eM Professions Code.and mylicer.c is ^<,m in full force and effect ' ELECT SERVICE UPGRADE (-220),- - p q i License Class Lic.g Dam Contractor ARCHITECT'S DECLARATION - m-+ 1 undersand my plans shall be used u Public..'a *, �yU ;off Licensed Professional \ - 3 OWNER-BUILDER DECLARATION .. 1 hereby affirm that 1 am exempt from the Contractor's License Law for the O o following mason,(SW6un 703 1.5,Business and Prof.iov Cade:Any city or county which requires a permit to Carts '.after,improve,demolish.or.,no any utoctum rZi Met kiss licensed purnm rem,1W moomems.1'for such Patton tononse,aw(cha mem - Nlift withSection7 h)ofDisiovoftheCanuumhndfori law(Chapmr9 Sq.Ft. Floor Area Valuation x�Fm (commencingncepthecoiou,andth Division of theeged Business Any Cruse)or W $ Nat he u exempt IACR(rom and Urc baso far doe alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of J 2AT941li"OrO Occupancy Type - dot more Nan Five hundred dollars(5500). I,as owner of Ne pmpeny,or my employees with wages as their sure compensation. will do the work and the swchm,is not inlertded or offered forage(Sce.?044,Business - Required Inspections - and Pmfesshms Code:The Conuacto's License Law dots trot apply m an owner of - q P prepertywhO Wildsor improvesHereon.and who daessahwork himmIfar through his - Ownemprayees,provided Nm such improvements are not intended oroRered forsale.If. - however.Ne building Or improvement is sold within ouc ye.Of complevan,the--Cl- builder wnerbuilder will have the Wrden of proving that M did not Wild a improve for purpmc of - sal.). es Owner of the property,am exclusively contracting with licensed contractors to construct the pmjcn(Sec.7044,Business and Professions Code:)The Contrmtor's Li. cense law docs not apply to an owner of property who Wilds or improv thereon.and. - ^•-' �--"- - "' - wh conuac%for such projccu wiHacont mr(s)liansedpummntm Ne COnuactoes -- - eve Law, lam ounder Se .B k P C for Nis reason - — - Ow r Da __ --' O K OMP A ON ECLAMTI - 1hereby aRrm under penalty of perjury ore of oll mg tlaleruions: I have and will maintain a Certificate of Consent to self-insure for Wo leer'sCompen- utirn,v provided for by Section 37M of Ne labor Code,for Ne performance of the work for which Nis permit is iuued. n I have and will maintain Worker's Compensation Insurance,as mquimd by SecdOm - 37till of use Labor Code,for Hw performadomof the work for which this permit is issued. My Worker's Compensation Ir mance artier and Policy number sue: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE - (This section need not Lccompleted if the Permit is for one hundred dollars($100) or less.) 1 certify,that in the perfmmenee Of d w work for which this Permit is issued.I shall - employ any person inany to.nef so.W become subject o tK Workers'Compensation - IawsofCalifomiaDatc - -_ Applicau NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject m the Worker's Compevefion previsions of the laMr Code,you must �aZ forthwith comply with such powisimu or this permitm.11 be deemed.,.ked, Z O CONSTRUCTION LENDING AGENCY [r.N•. 1 hereby Num Nal Nero is a coosvuction lending agency Int the performance of C > the work for which this Permit u issued(sec.MYL Civ.C.) V] 0 Lenderi Name -- --- P. I.cnticr's Address U Q 1 cer ify that 1 have mad this application and sure that the above mformadun is IL F' conceL I agree to comply with all city and county Ordinances and sum laws relating 10 0 U Wilding Construction,and hereby auNorim opmaenuriv of this city m enter upon the r W abovomwnlioned Property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against /^ liabilities,judgments,Cos.and eapcves which may in any way meow against said City / CJ U z Aconsequence of the UN ERranungof OS Ars month. ND WILL COM LY WITH ALL NON-POINT Issued by: Date It SO EGULA _ Re-roofs c of App HAZARDOUSMATERIALS DISCLOSURE a Type of Roof Will the applicant or future building Occupant store or handle bayous material as defined by the Cupenino Municipal Code,Chapter 9.12,and Ne Health and Safety ode,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Ym on Will rite applicant or fm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove mit harafdnus air mntaminan. defined by He Bay Arta Air Quality Management all new materials for inspection. District? ❑Yes No I have mad the hada I mawralsmquimmenuunder Chapwr6.95of Ne Califor- ria Heal Safcty Cade Sadona25505,25533and25534,1um1Crx.d Nmifdbe Wilding Ad�ncntiy ha 0 nanL NaitumWhic clpwismancodxCCmfiCmC OccOancY. Signa[ureofApplicant Date as agent All roof coverings to be Class "B"or better Community Development 0 Torre Avenue CuOpertino CA 95014 Telephone(408)777-3228 � CITY OF Fax(408)777-3333 UPEkTINO Building De rtment JOB ADDR S PEN&T # a?—C714 OWNER'S N # �6 GENERAL CONTRACTOR: FAX # 36Okifl I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting lei Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner ctor Signature Date t (gip' CITY OF CUPERTINO � / Z� aG7 CITY OF PERMIT APPLICATION FORM CUPERTINO MM'APN # 2 / JD Date: 0 Buildin Addres : ilin Addr ss (if d ferent f m bui ing address): Ow is Name, Phone#: Co r tor: license ontact: e U9 ,f—.44 .93 Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect Plumb ❑ ech ❑ Job Description: Residentialom ercial — Sq.Ft. Floor Area: $/S t.: C f Pro ect: Occupancy Group: T C nstruction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard Large ❑ Major ❑ Quantity Fee 1D 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 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 BELE 1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING I of 3 � '-J E ` CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM Aft CUPE{�TINO 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 Pb1g 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 Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pipe PLUMBING BPWHEATER Water Heater/Vent 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 BREMIZECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CITY OF 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 BREA'IVENFAN 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 Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3 of 3