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04120015 (2) CITY OF CUPERTINO BUILDING DIVISION PERNO SCONTI2ACTOR INFORMJ, N ;n BUILDING ADDRESS: FISCHER PLUMBING & CONST PERMIT N004120015 10370 FAPALLONE DR OWNER'S NAME: PERMIT LSEUE DATE RICHARD GRIMM 2766 SCOTT BLVD 12 /01/2004 ONE: SANITARY N0, CONTROL NO. (408) 727-2426 7ARC111=1ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O D O O XLICENSED CONTRACTOR'S DECLARATION mI hereby affirm that I am limned ander provy�asof Chapter 9(commencingJob Description NSccli.a Fr](fty�of Divisioa3ofthc Busincd 4m asimsCudeledicylimnsis intitamea �� 3��! BATHRM REMODEL jcnx Cly a Lic.pte_ 2Contr �7 ARCHDECTS DEC I undesn5nd my plans shall be used asp h' rtcords ;LLU oG Licensed Proposal unel ` S OWNER-BUILDER DECLARATION I hereby affirm on 11. exempt from Use sionsCContractors s:enseAny c Law for the X p o which(ollowingre moxa.(Seabee](13L5,Business and ve demolish, Code:Any city or county X m v, which requires a permit to ui=t a alter,improve deermit t ere pair any strucluouthern $8000 'a�� prior 41 its issuance.also Rquiret the applicant for Stith per111iI lO Be aSigncd 5tllemcnl XzdtilheislicensedPursuantto(bepowisimuoftheContmeturiU.O.law(Chr,mr9 EESq. F[.Floor Area Valuation FFG (commencing with Session 7")of Division 3 of the Business and Prafcssinns Cadc)or i that he u exempt Ihemfmm and On basis for the allegod exemption.Any violation of Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of or Occupancy Type not more Nan five hundred dollars(S500). ",�I,azowner of she pmpcny,o my employees wish wagezastheir cele eompensalion, will do the work,and Neswclure is not intended oroffemd for sale(Sec.7(44,Bosimem and Prefectures Cndc:The Contracmes no 1s License taw dot apply to an owner of Required CLOns property who buildsarimproves thereon•and who decssuch work himself arthmugh his Own emplaycas,ping orilM1mvsuch imismid ithin not inmMWmpeered for mletL J�� howeveroebuildingde Ourawmem issoldwithin one yetiof ddoro offered the owner- builder / will have the burden of proving Nm he did act build or improve for putpos of sale.). ❑1,as owner of the properly,am exclusively contracting with licensed contractors to Ot<� comtruct the prejem(Sec.7614,Businev and Preleesiom Cade:)The Conlmemr's U. V come law docs not apply to an owner of property,who builds at improves thcamn,and who contracts for such prejecks with a conlOeml(s)licensed pursuant to the Conuacmts Licence law. I are exempt under Sec. B k P C for this rcsson Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby aRmt under Penalty of perjury one of Ne following declarations: 1 have and will maintain a Cmdriente of Consent m Self-insure for WorkersCampco- sation,as provided for by Section 3766 of the tabor Code,for the performance of IM work for which this permit is issued ❑I have and will maintain Workeri Compensation Insurance•as required by Section 37110 of the Labor Code,for the performance of Ne work for which this permit is issued. My orkfs Con,josidonIInsuraranee carrier and Policy num a rare: / Cam /'2I-I/VCV! C�t/I�xi.✓..Iaicy Na' /� Cev>6- CERTIFICATE'OMrM RB h /ORKERS' COMPENSATION INSU CE (ibis mount need not be completed if the permit is forces hundred dollars(SIW) m loss.) 1 eenifv that in the performance of the work fir which this permit is issued,I shall not employ any person in any mennerso as lex bWeme 311 to the Workers''Cornfromdon Laws err CaBmmia.Due Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should bare,suhjml to dm Wmkcr's Compcnsuion provislom of the Labor Cods,you mull .JO forthwith comply wit such provisions or this Permit shall be deemed¢voked. Z CONSTRUCTION LENDING AGENCY [-+ tw I hereby affirm that there is a construction lending agency for the Performance or . IX > the work for which this permit is issued(Soc.3097,Ci,C.) Lua Lendces Namc C Landers Add. U 0 I certify dial I have read this application and sore Nat the above information is fir.P e m eL 1 agree to comply with all city and county eNins news and cute laws relating to 0U building conswetion.and hereby authorim mpresenlatives of this oily menterupon the W oho c-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless Be City Of Cupertino against H y liabilities.judgments.eosu and expenses which may in any way accrue against mid City U Z in cansquenec of the granting of this Permit. ^ APPLICANT lJtIDERSTANDS Aj4D WILL COMPLY WITH ALL NON-POINT Issued by:S4��Ca Date 5 URCE LAT(oNS.; ' Re-roofs sig um fAlt,ki nVCrnvae'ar, Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hmsrdous ma¢rial a defined by the Cupertino Municipal Code•Chapter 9.13,and to Health and Safety Code,Section 35532(a)? '/ All roofs shall be inspected prior to any roofing material being installed. ❑Yrs I Ido will mea applicant or future building t use I or devices which If a roof is installed without first obtaining an inspection,I agree to remove PP gbytheB aAirQn emit hazardous air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection. Distrin? ❑Ycx Nu 1 have mad tho tu",s usmaterials tcyviremenb under Chapter 6.95 of the Cxlter. nia Health d SafetyCode.Sections 25505.255 and 35534.1 undcrsuM this if do building docs not eurtcntly ha ren t.that it i res,mibility m notify the occupant Of the reyuirtmcnrs yid el poor �nm on cerdaeate ra m Signature of Applicant Date owneraraG_rixedasent / Dale All roof coverings to be Class"B"or better an OCITY OF CUPERTINO� ' ITPERMIT APPLICATION FORM ° `� CUPERTINO APN # 0 / / Date: Buildi J (,dress: b� Mailing Address (if d fferent fro building address): /03�D f-ora ��onZ �r. Owner's e: Phone � R, e' QI�Gf m� Contrac . / I/ J License#: SGy GC LC/71 b/ c e/� S A Cont t: ,� // ,ff 7.2 7. 2 Vz Cupertino Business License#: Y . T2i2 ISj6 ri Fax: Building Permit Into:. -Bldg ❑ Elect ❑ Pl b ❑ Mech ❑. Job Description: �� - Residential ❑ r ❑ Sq.Ft. Floor Area: $/Sq: t . Cost of Project: Occu ancy Gr up: Type of Construct n: Please chec th'L0xor-It the project is a 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 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 BELE 200 Elec Svcs 600V <—200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1of3 �v � � ant, CITY OF CUPERTINO* CITY OF 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 BOVERT1Iv1E 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTFAP 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 cfln MECHANICAL BREMAHUiAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lightin Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res A liance ELECTRICAL 2of3 IkITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO; 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 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 Issue -"`' PLUMBING : PPLBG=_t _ _ _'_- Plumbing Fee.sq foot - _. PLUMBING r _ ZADDCHG, .. -'-- _ Address Chan e BUILDING — -- .,.-_ Ax - - r � , i 3of3 - LBY. VEDY V DEC Zor+ .. c � o � � O 3 S v a SPARK ARRESTER f --- o s oC V i a S rAA . -01— I J — �,,a ttMV,:S� r--- OS�Nm s anet epj4met�n e� - in a4� - -s --` !r Sh1e oh the wh chants °�c yob f --am L y a0 �ptut tDKeeety stn to+► �•1 e+nittr;onT dU/dA UZ n � o c7 H 1 CITY OF CUPERTINO BUILDING DIVISION PERMIT kCONT"CTOR IN FORMATION BmLDING ADDRESS: - FISCHER PLUMBING & CONST PERMIT N004120015 10370 FARALLONE DR 'rsNER'S NAME: PERMIT ISSUE DATE RICHARD GRIMM 2766 SCOTT BLVD 4 _ NE: SANITARY NO. CONTROL NO. (408) 7.27-2426 ARCHITECT/ENGINEER: BUILDING PERMIT INFO PLUMB MECH LI l� Lop LICENSED CONTRACTOR'S DECLARATION no Yw I hereby affirm mat I am liZNd umkr prov'' m of Chopmr 91commcnciog Job Description 'ICU - <ZE with Scnion 0011 fDivi.km3ord¢Husi:cc ro ssium Codc.and my licensees „ inmdrorcea f« ieb� 3�S6iG BATHRM REMODEL FEB z Liccn c ClLic.N � Dam Gant _ . - 1005 - ARCHITE DEC Z¢ 1 un�y plans shall be used as pgpJi recnrds ��(t OoU I11L1� �A II/� a� Licensed Psufellioind IYnI\\Vn`/l/^ OWNER-BUILDER DECLARATION f I hereby,(Soc that 1 am exempt tram the truntncsrs License Law for the xp O fallowing seas..(Small 91..1.5. ,. lw,. and Protrusions Code:Any city or county m fL soneh mgmms a permit rn ennrsct..lmr.improve.demmkm,sur repair,ray arscmm $8000 portion its ihmanee.alm requires theapplicant forsuch pnmdIn fileasigned statement -- =< that le is licensed p.r..ortothe psvisl.mordice ContmcmrsUmmvlaw(Chapmr9 - Sq. Ft:Floor Area Valuation ' pF0 (commencing with Section 7000)of Division 3 of on,Business and Professions Cade)or that M is exempt therefrom And the basis for be,alleged cxempuon.Any violation of Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty of ar - Occupancy Type --- - not more man five hundred dollars(55001. ' Ca show of me pmpeny,ur is employcm wire wagmssau(role wmpemnneas _ will dothe ushina and meswnureie omret i License row do s ad,Apply 70sa,Business ana property ono code:The wsmaemr, ndwho Law dem not apply lf an mw.er Of - Required Inspections .._ . propertywho Wilds, roored dmtsuthereon,endwho docssuchworkhimselfermsiod his owneer.oyms,provided pr such impswmenutad not intendedtraphi ed(resale If, basso.me Wilding.,den of proving that me,did Wear of cprove for Neons,of builder will pave me burden of proving Nat he did not build or improve for purpose of - - - - • __ - - _ - _- , salc.I. I,as Owner of the portal am exclusively contracting with licensed Containment to consumer me Project(Sec.7004,Business and Professions Code:)The Conlracior's Li , terse law does not apply on an owner of property who Wilds or improv themon,and who cotnracts for such pmjecu with a conuactor(s)licensed pummauo me Contractor's Lkeme law. ❑1 am exempt under Sec. .B&P C for mice resson 137M er Doe WORKER'S COMPENSATION DECLARATION 1 hardly AM.under parva y of perjury,rim of me following declarations: hew and will maintain a Cenifimm of Consent to self-insure for WorkesCompen- n,as provided for by Section 37M of the Labor Code,for me performance of the for which anis permit a issued. have and will maintain Wurkeh Compensation Insure ax,m mouired by Section of the labor Code.for the pedonamuce of the work for which oris perm it is issued.k Ac. .ration Insurance carrier and Policy num tam: i Or /2 ) .R6tiry N v�U7 Le"Z23 73 CERTIFICATE OF 'X P19MrER hi/b \YORKERS' COMPENSATION INSUR CE (This section need not he completed if the permit is mr.ne hundred dn11ans(SIM) m teal.) 1 ceni fy than in the perfomomme of the work for which this permit is erred,I shall not employ any person in any manner tan as to hmome subject o the Workers'Compensation laws of California Date _- Applicant NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should bttome subject to me Worker's Compensation provisions of de Labor Code,you must .J 0 forthwith comply with such provinom or thin permit shall be dimmed rwked. Z ._�.. CONSTRUCTION LENDING AGENCY [—i I hereby affirm that mere is a coma uction lending agency for me perfurmxnec of E thc work for which this permit is issuedi(Sec.3097.Civ.C.) G0 Landers Name ,a Z Lender's Address U C 1 Gerry mar I have read his application and sue that the shove information is torten.I agree to comply with all city and county eminences and stale laws relating to Q C.1 building Construction,And hereby aumodse tepresenmiv of this city to enter upon the almvd-mentioned proper for impection purposes. (We)Alla.m save,indemnify and In,hemiuss me City of Cupeninu against F N liabilities,judgments,costs and expcmes which may in any way see=against andCity S) V Z in emisegmnee of me granting of this permit. - ^' APPLICANT DERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date S URCE L NS.: U Re-roofs Sig mm Ayp ucenvec r Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant smrc or handle ha�ous material _ As defincd by he Cuper ino Municipal Code.Chapter 9.13,and he Health and Safely ndc.Section 255320)? All roofs shall be inspected prior to any roofing material being installed. 0Ycs u Will the applicant or fuTTTZty/mrc building occupam tire cyvipmcm rte devices which If a roof is installed_without first obtaining an inspection,I agree to remove mor h., d.aa air cnntemi ants As fined by h Bay Arca Air Quality Management all new materials for inspection. Disuiet? ❑Yes No Ihaverem he bacamnus materials ray' menu under Chapter 6.95 of me Califory Iia Hcalm&Safety Code.Sections 25505.25 and 2S53a.l undcrsuM that if de Wilding docs not curmmly h ten Our it respoddahty An nodfy de occupant of me mguimmcntsw ' rot sprier I ceofaCeruficamef ae an . Signature of Applicant Date Owner or roe none.gent �� am All roof coverings to be Class"B"or better