05120121 (2) CITY OFCUPERTINO ;naw
BUILDING DIVISION PERMIT CCNT.RA.CTQIi YNk`O.t1VYA'TI 5„hi :
BUILDING ADDRESS: PERMIT NO.0 5120121
ER'S NAME: PERMIT ISSUE DATE
PHILIP & ERIN MOBL Y 12/20/2005
NE: SANITARY NO. CONTROL NO.
ARC HITECfMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300
LICENSED CONTRACTORS undcrS DECLARATION
ee 1 ion 7 affirm that 1 am of she
Bu under and
Prof ss of Chapter 9(commencing Job Description
with ilre.]d.ffe(Divbion 3o(me HuLnwand Profwioa Cade,and my became is
,, in full farce endeRec4 C]�E DEL (NON-STRUCTURE)
o Z License Class Lk.M �Q'1l
Dave Centimeter-
ARCHITECTS
DELL
DECLARATION
�y lundcueand my plans shell be uudupublic rccaNt
is n
u. Licensed Professional 9ry elq
5 OWNER-BUILDER DECLARATION 4U ss
i<y I hereby affirm that I em exempt from the Contractor's License Lew for the
j:0 o following mason(Session 7031.5•Business and Profcadous Cade:Any city area
$ which requires a permit m cneswcL alar,Improve,dcmollah,or repair any at u $30000
pdo a its issuance.also requires the applicant for such permit to...---
that
Mea-igncd sou
p_< that he is licensed pursuant a the previsions of the Comactor's Ucceso law(C he rea Valuation
yep (commencing with Section 7000)of Divulan 3 of the Business and Post onsC
i 3$ Dat he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Session 7031.5 by any applicant for a permit subjects the applicant ro a civil peouity,ofAPW
not mart than fn's hundred dollars(M). r Occupancy Type
❑I.as owner ofthe property,m my croployces with wages u Neu sets compensation,
willdo the ack and lheshuclure u not inunGAm offered forshm(Sic.7044,Business Required Inspections
.eau Professions Code:The Contracur's License Law dors act apply m an owns of q P
property who builds a improves thereon,and who doessuch work himself ear through his
awn employees,provided Nat such improvements art not intended proffered for este If,
however,the building or Improvement is sold within on year of oompletion.the owner.
Wilder will have the burden of proving Nn he did amt Wild or improve fm purpose of
talc.).
❑1,u marcs of the property,em exclusively comrsning with licensed cromm ms u
construct the project(See.7044,Bwinw and Pmfesdam Cade)The Contractor's U.
tante Law duct amt apply to yyss owner of property Who builds or improves Merton.and
who contracts for such pmjcctl iNeeon=ms)licensed punuant to the Cormsemrs
Liceve
❑lam nd Sa: ,B h PC forb mayn
Dau
WORD. R'SCO(PENSATIOND� LARADamN
I hereby affirm under penalty of perjury arc of the following declaratioru:
I have and wN Immune a CeniBam of Consent m self-insum for WortrfsCompen-
Inden,u provided for by Section 3700 of the labor Cade.for the Performance of the
wart for which this permit is Issued.
❑1 have and will maintain Workers Compensation[assurance.as required by Section
3700 of the Labor Code,for the performance of the work for which this permit la issued.
My W(rker-Compew0on I...carrier and Policy number am:
Carim, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need ret Mcompleted if the permit is far ane hundred dollar(3100)
or men) .
1 certify that in the performance of the work for which this permit is inued.I shell ret
cmployany p9,rennin aym odes omen ono de Warken'Compewtion
lawsa(Call(dmi4 Dage
APluan 7A /1
NODCE TCs P CA :IL after m :ing this Cent' cave of Exemption.you should
become subject to the Worke s Compensation provisions of the Labor Code,you must
forthwith romply with such smvuioa or this pefmil sMll be dc.m.d naked.
„Z,a O , CONMUCTION LENDING AGENCY
.�
[+ Ihor by which thi Wtmertusued(S . lending30 ,C ,agency for are performance of
C' r7 dm work for which mu permit is iss¢tl(Sec.3(191,Civ.CJ
4 Q Landers Name
7 z lentler-Address
U0 1 certify that 1 have rad this application and seam that the shave information is
W F correct.I agree to comply with all city and county ordinances and sum laws relating be
0U building concoction,and hereby authndae mprsenutives of this city to enter upon the
W above-mentioned property for inspection purposes.
kL (We)agree to ave.indemnify and kap harmlw me City of Cupertino against
rA liebilt0a•judgmenu.eoms and expenses which may in any way same agues said City
in U
APP C NT UN Eptence,of Use R uNDS ANDof WILLWILL COMPLY WITH ALL ON- INT
s c aac n . Issued by: Date2--
INS ti
l Re-roofs
Signa nfAppli on r ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcxupantsare ar handl.haaardaa..most
ss 4urcd by me Cupertino Municipal Cade,Chapter 9.12.and the Health and safety
c,Orion 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
%C�mly
o
-/- e applicant or uwm building occupant um equipmat or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Ius air cmnumircnu as defend by IM Bay Arte Air Quality Maag.ntenl all new materials for inspection.
"am”? s lar
read the mamdtlsrtquinmenu under Chapter 6.95 afore Cabin.
ar-YC a 'am25505.25533 and 75534,1 undmsufd that if the Wilding
ntly h0 ren 6 that it u my mspomibility u avory ft osupant f meichmu pdorm uanccofacenificeteoSignature of Applicant Date
thmded agent D m
All roof coverings to be Class"B"or better
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All d'mmaiom jd=dm gF rn= Mom Milia ]Tris ism ' 'nil drsigp mrd must wt be . Dc34pwc:10n 2005
aL&ja b vC irmamm=job site and Kedv m by Meyc eels ar aopid udem•pplw•ble fee Aioted:]N1=ow
�df edjoe ;fitjob coditiom. Iw bm;d M job order plpced .
PaM" MOBC01-.20"kit .
I _ P pPloorPlm Dpw ng i<:I Smlp:012'-1'
CITY OF CUPERT O
CUPEIZTINO �ERMIT APPLICATIOORM US /�/
Address: Mailing Address (if different from building address):
? 0 MVV r-� , / 2jouEN #
?T4l Name: /�� O [d PV
4 J�� —
zif
Contra c G Licens #:
Coqt: Phone ,WD p Cupertino Business License#:
/ 0 Fax:
Building ermit Info: 61
BldgX Elect Plumb Mech
Job escript•on:
Residential Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
C�Aff Proi ect Occupancy GrouD:
Type
of Construction: Please check this box if the project is a
second-sto addition: ❑
ro'ect Size: Standard Laze ❑ Major ❑
Quant Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBO]LER2 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
1 of 3
F
PERMIT
CITY OF CUPFRTTAin
CUPE(ZTINO APPLICATIOORM
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
BPLANCEIK 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 PLU111B7NG
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY .. Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BRETNIFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Fumace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMlSC Mise Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switcb & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating 1AECHANICAL
BREMRESAPP Remodel Res A liance ELECTRICAL
2 of 3
01TY10,
CAOF CUPERTINO •
cuP PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Si , Marquee ELECTRICAL
BREMTHEATR Theatrical Li&hting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems NfECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEAIP Temporary Power ELECTRICAL
BTEAIPPERA4 Temporary Bldg Permit BUILDING
BTEMPSVCS I Temp Dist Svcs ELECTRICAL
BUSLIC I Business License BUILDING
32 ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFFEE L Mechanicals . foot MECHANICAL
MPERNHTFEE A4ech Permit Issuance MECHANICAL
PPERWTFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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