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05090109 (2) CITY OF CUPERTINO - ?+nss ✓*' '" '� BUILDING DIVISION PERMIT 9CONTRAGTOR INFORMATION BUILDING ADDRESS: ANTHONY WHITE PERMIT NO.05090109 •20061 FOREST AV OWNER'S NAME: - PERMIT ISSUE DATE ANTHONY WHITE 09/19/2005 .ONE: SANITARY NO. CONTROL N0. ARCHITECDENGINEER: - BUILDING PERMIT INFO BLDG ELECT PLUMB - MECH 0 0 0 0 Ips LICENSED CONTRACTOR'S DECLARATION Job Description wF 1 hereby affirm Nat 1 am licensed under provisions or Chapter 9(commencing �it3 with Scctic.7000)of Division 5afte Business and Pmfcsimxx Code,and my license is r Nilfomeondeffea GAS LINE & WIRING FOR FIREPLACE j�? Liecnu Clea Lt.N r Date Convutor [{ !Qf �9 rs pp ARCHITECTS DECLARATION �s5 syY ', f' ® W u 1 undersand my Plans shall he used as public records l s e Licensed Professional OWNER-BUILDER DECLARATION �r I hcrchy affirm that I am exempt from the Contractors Liccnu Law for the nqr po following mason.(Section 703 L.5.Business and Professions Code:Any city or county 1 e m which myvires a pcmtit sea construct,alma improve,dcmaRsh.of.,air any nrocwm �O,I1ss1 t/ $4000 poor to its issuance.also requires the applicant for such permit to rile a signed statement g l v, - < Oat Wiebeeneedpursuant tothcprovisions offtContractanLoch=Law(Chapter 9 Sq. Ft. Floor Area $tt {typ ((y rt ,, (t Valuation xi-0 (commencing with Secsion7")of Division]of the Business and Proressimu Codc)ser f ;7 fl. _ Nat he u exempt therefrom and the basis for the alleged exemption.Any violation of d i'aa Tri.. Section 7031.5 by any applicant for a permit subjects the applicant to a civil pchaity of XPA w y Occdpa'ncy Type .of mom Nan five hundred doll..(S500). I,as owner of the property,or my employes with wages as;their sole compenution, will do the work and the structure is oat intended or offered for safe 7044,Business Required Inspections and Prohold..Code:The Coacrs ta nutors License law dot apply m an owner of 9 P pmpeny who builds or improves thencon,and whodoessuch work himself or through his own employers,provided Nat such improvements arc not intended proffered for sale.If, how er,the building or improvement is sold within one year ofcomPleuon,the Owner- builder will have the burden of proving that he did not build or improve for purpose of ale.). 1,as owner of Ne property,am exclusively contracting with licensed mnoactors to consumer the pmjea(Sec.7144,Business and Professions Cade:)The Contractor's U. cense Law docs not apply to an owner of propcny who builds of improves thereen,and. who contracts for such projects with a contractor(s)licensed pursuant in Be Contractors License law. I am exempt under Sec. ._ B&P C fa Nis Owner - Date WORKER'S COMPENSATION DECLARATION ' 1 hereby affmn under Penalty of perjury one of the following decimations: ..i I have and will maintain a Cerifcote of Consent to self-insu.for WorkersComport- ad ipo,as provided for by Section too of the lobo,Code,for the pachumran¢of the work for which Nis permit is issued. ❑1 have and will maintain Workers Compensation Insurance,m required by Section 7]00 of the labor Code,for 0e performance of the work forwhich this permit is issued. My Workers Compensation If....carrier and Policy number a.: Cartier. Policy No.: CERTIFICATE OF EXEMPnON FROM WORKERS' COMPENSATION INSURANCE Mossection need not Inc comple.d if the permit is for ono hundred dollars(91r1B) or less.) 1 certify Nat in the performance of the work for which Nis permit Is issued.T shall nut employ any pcfun in any hose.,se aswbeGaTc ubjev+fp.he Warkers�om vetion Laws of California.Date Applicant NOTICE TO APPLICANT:IL after making this Ccnificate Of Exemption.you should become subject to the Workch Compensation previsions of the Labor Cose,you must .,Z fpMwoh comply with such provisions or this permitshall be deemed mucked. Z O CONSTRUCTION LENDING AGENCY PI Mrohy aMrm that there is a cpaouctinn kruling.gene,for the Performance of D: 7 the work for which this permit Is issued(Sec.B09T,Civ.C.) rt1 Lenders Name Z Lenders Address U O 1 certify Nal l have fad Nis application and mute that the above information is Ik. F correct,l ag.e.comply with all city and county ordinances and some Iawa.].hot I. O V building construction.and hereby suthodm mpfeunatises of Nis city in enter upon Ore fJ.l above-mentioned Property for inspccuon purposes. (We)agree to save,indemnify and keep harmless On City of Cupertino against IF-t ,0.A Iiabiliues.judgments,cosu and expenses which may in any way accrue againstsaid City U Z in conuquvec of the granting of this permit. ^ APPLICANT UNDERSTANDS L COMPWH ALL N N POINT Issued by: Date �— SOURCE REGULATIONS. ¢�J' � (4 U Re-roofs Signature of ApplicanUContrador Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applich.,or future building=.pan,int.u handle hu ani us material az defined by de Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety ode.Section 25 ❑Ya �Nu 552(ay? All roofs shall be inspected prior to any roofing material being installed. 7mquiremerLs Will thea applicant or fnum building t use equipment or devices winch If a roof is installed without first obtaining an inspection,I agree to remove pp 6 by ffic B it huardoa air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. mic" ❑Y., rp'No I have mad Ne huardous materials requirements under Chapter 6.95 of the Califor- ats Health&Safety Code,Sections 25505,25511 and 25534.1 undersand Naz if the Wilding notcuuntlyhaveaananLNatitismyrape hiluyrenoulythpmcupamorNe which must he �r sun= mrtate.rW y S ignature of Applicant Date •' ql' q�c5 All roof coverings to be Class"B" or better wner or ant rmi,ed agent DIO ` Community Development 10300 Torre Avenue ( Cupertino CA 95014 Telephone(408) 777-3228 CITY 0, Fax(408) 777-3333 �UPEkTINO Building De artment JOB ADDRESS: PERMIT # zooto I /k VL SO '�70%0 OWNER'S NAME: /4y\jTrbo tjj c u t TE PHONE # - GENERAL CONTRACTOR: LA e-t Fntcry,A tv ,tvp o w FAX # vurc.e-r- 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 Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing SIM M c FA'Di7 C-Tl Roofing Septic Tank Sheet Metal Sheet Rock Tile r Owner/Contractor Signature Date CITY OF CUPERTINO CUP CITY PERMIT APPLICATION FORINT-� 7'JP\P N # 3 l( J -? Date: Ito O� Building Address: Mailing Address (if different from building address): 2 v v G I (L Owner's Name: Phone#: HcM 9R 6--7 1 "-3 A h) %Ho N W j-E 1 o 2- Contractor: Contractor: ti W AJ CY2- U i `b L12_ License#: Contact: Phone: Cupertino Business License#: AwTv-1ot� wit i� F�c: wlc. 6?03—loot Building Permit Info: Bldg Elect [Zr Plumb Mech 2- Job Description: i N S 14 L l_ 4,7(1 vV t L, l 1.z 1 ,'J 4 Residential X FOP- 4A5 Fli4b Fi4t-VIL(•NCe Commercial ❑ Sq.Ft. Floor Area: q.Ft.: Cost of Project: Occupancy Group: . n?P)Z4 ox % -, duo Q--3 Type of Construction: Please check this box if the project is a V N second-story addition: ❑ 11�roject Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 Boiler<= 100,000 Btu MECHANICAL BB0ILER2 Boiler> 100K 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/Comrn/ uasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax-Resi/Mobile BUILDING BELEC1000 Elec 600V <= IOOOA ELECTRICAL BELEC1001 Elee 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 4 7 1of3 CITY OF CUPERTINO aual- CITY PERMIT APPLICATION FORM CUPEkTINO 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 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 Dis osal 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 Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Mise 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 Re air/Alter Heating MECHANICAL BREMRESAPP Remodel Res A liance 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 Sips, 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 Ternp 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 Plumbing Fee sq foot PLUMBING . PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3