05110151 (2) CITY OF CUPERTINOra" ` ?w t' '+
BUILDING DIVISION PERMIT CON>t'R.a,C�1'ORINF'QRIAT fl c
a.¢ bt^,•o ';.�..,. ,"+ ,_seat,--' ,np;§'�,rt i w.,n.,
BUILDING ADDRESS: HOME PROS PERMIT N0.05110151
679 (4ARDENSIDE 21,
ER'S NAME: 'PERMIT ISSUE DATE
JUDY COLEMAN 245 E LAS PAT-MAR I
NE: SANITARY NO. CONTROL NO,
510) 440-1609
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG O PLUMB MECH
O
lop LICENSED CONTRACTORS DECLARATION JOb Description
luj I humby aOvm that 1 am licensed under provision!of Chapter 9(commencing
with Section 70M of Divium.3 oft the Buslatu aad Professmat Code,and my liceme u
nmm11tmroand ertea KITCHEN REMODEL, ADD GAS LINE,
n:mmc conumor �D NO STRUCTURAL
3 ARCHITECTS DECLARATION
ta
1 undersnd my plans Mall W used as public accord!
U
Mp Licensed Professional
M OWNER-BUILDER DECLARATION
A2 1 hereby aures that I em exempt from the ConaumYs license law for de
aO fallowing mater.(Section 7031.5,Business and Profession Cade:My city or county
SI� which.qui.;a permit in commas•aler,harem,demolish,or repro my mumu.
iy prima,its issuance,also requires the applicant feamch permit"Rleaalgaed Klement
C that W is licensed pummr to the provision of the COnumme,Liceam law(Chaplet 9 Sq.Ft. Floor Area Valu1*118200
$ (commencing with Section 70DO)ofDivision 3 of the Business and Prefesdan Cada)or
that ha h esemps tberesam and the bash tar the alleged ernmpdm My vlolwon of
Section 70315 by any applicant fm a permit mbjecs that applicant m a civil penalty of APN Number Occupancy Type
not mom than It.hundmd dolhn(swan.' 36232001 . 00
❑L"Water ofum property or my employee with wages as th.mmle compensation.
will do chat work.and thestameme Is mtimended"Offered fmaale(Sec.nw.Budrcas Required Inspections
and Pmfefsiani Code:The ConKca's License Law dem not apply m an owner C of q p
property emplohoWumAdedthat enimprmdwmawatahwmkhlmaalr"tMaasnhis
Ownner.th buiprovidedthatveme Imps»emmuartne year aedoroffered for oler-
WMws.thearmtheor MptawnmlhcoldwWinot year of mp.1 .theawmr-
Wilmr vriB haw dm burden of proving that he did not build"improv fm puryom of
❑1,as owner of the property un emlmlvely co tuawng with licensed cenar.7om m
construct the project(Sec.70".Business and Protevian Cade:)The Cwuacmrs Li- /
cense law dean net apply an m owner of pm arr"ho butuds or impmws dremon,and.
who comacs for such pmjects with a contrectas(O Ranted pomace m the Conlawmes '1
l ars law.
0 pun
accept undo gee .B&PCfordm mann
r Data O�
WORKERS COMPENSATION DECLSRATION
I hereby affhm under partly of perjury one of the following decimeterrs
7---,k
am and will maintain+Cewfiestaaf Consent to self-Insure for Workers Campus.
.as provided f"by section 37M of um Labor ease.tar the Performana of tiefor which this permit is ianmd.
ave Nd w1II mY0ta111 WMfCN COrllpmlad011 In1aMR,as RgNRd by SCCIIOr
of lire tab"Cade.far thO performance of the work far which this permit s W"d.
odm!y Compensation Income:ossa and Policy neumber ate:
, rGi Pi?if Policy No,r]/CISo-3N-%r
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section reed mtbocamplemd if de pends isforone hundred dollen(5100)
or has)
I certify that In the performance of the wart for which this Feats is load.)shall rot
employ any person in my manrcrm as to become subject to the Workers'Companoum
Iowa of California.Dam
Applicant
NOTICE TO APPLICANT:IL afmr making this CaniOom of Exemption,you should
become subject to the W"k"'s Compeasasion provisions of the Lab"Cade,you moa
.J 0 forthwith comply with each provisions or this permit shall W domed rewked.
z 51 CONSTRUCTION LENDING AGENCY
t" 1 hereby 41Rrm that dam is a commuted..Wading agency for the performance of
a.�.r dm work far which this permit s issued(Ser.30107.Or.C.)
GQ Lender's Nauru
Z) z Lenders Address
V Q 1 cmufy unit I haw lead this application W Km that the ahem Information is
;^ correct t&time to comply with all city and county on it mss and arum IBM relating In
QSV^ Wildingcowmction,andherebyauthosimrepresentativesofthiscityusenmruponthe
Lt7 aWw-mentioned property for Impaction purposes
C (We)agree to on.indemnify and kap harmless the City of Cupertino agairm
.w ti IIaMlides,judgmrnunso,eoses andexpewhich may In my way accrue against mid City
V z In cuuequemu Of the Swung of this permit. 's h
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUgg��gg��R��GG L• Glu^.
(� //�9� Re-roofs
Signature of App anuu:ter s Due
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will um appliesnt Or futmc Wilding Oermpmlam tubowie ha'umons material
as dented by the Caperton Municipal Cada.Chapter 9.12.and the Health and Safety
.Section 25532(a)? / All roofs shall be inspected prior to any roofing material being installed.
❑Yes QNO
Will the applicant or future building Oavpam use equlpmem or device which If a roof is installed without first obtaining an inspection,I agree to remove
croft becardma air contaminants a defined by de Say Area Air Quality Management all new materials for inspection.
Martell
El Yes u
1 have mw the haasrdous marrials mquilements under Ciupter6.9tofthe Califs.
nh Health&Safety Cade.SuctiOns25w5.25333 sW 23334.l understand thalf to building
does now n ly haw a Vnm4 Nu it h my reryonsihility m ncdfy the oceupans of the
.qui prior Signature Signature of Applicant Date
owncr err mm agrnt Dow - All roof coverings to be Class"B"or better
06/07/2006 10:46 FAX 5104401616 HOMEPROS 12001/001
Community Development
10300 Torre Avenue
Cuphoner(40 C77 95014
3228
Telephone(408)777-3226
LswFax(408)777-3333
SUPEkTINO
Building Department
JOB ADDRESS: r PERMIT #
2UC�-7f-t 6G1(Giev�. d-e l_.r. or//o/ -r/
OWNER'S NAME: Tv D, G'vjAe4, PHONE # f 510 4e-1 U •-(b Of
GENERAL CONTRACTOR: fl-ung ro< FAX# (5w)V) Lit.l G-1(i 1(,
I am not using any subcontractors: cp
Signature Date
Please check applicable subcontractors and complete the following information
61 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencirig
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wall aper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Owner/Contractor Signature ti Date
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CITY OF CUPERTINO
CUPE(�TINO PERMIT APPLICATION FORM DS �S
N# 3 b 2 .32- b Date:
Building Address,: Mailing Address (if different from building address):
U �G1 Gr�2v�5 G� 2 Cr
Owner's Name: Phon #:.
Tv�Z Cblewxne% Q; 0lyy.Z>-(6oC1
Co tractor: License#:
Contact: Phone: C�lo) 1p0--1601 Cupertino Business License#:
1M y lcm Fax:(510 NqIbl�
Building Permit Info: K �G KBwtO�e(1MJ1 j jaJ,m,)N vv�
Bldg ❑ Elect 9 Plumb W Mech a
Job Description:
Residential F1 Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
ofProiect: Occupant GrOUD:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
ro'ect Size: Standard 0' Large ❑ Major ❑
Quant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BB0ILER2 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
J BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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iffl
CITY OF CUPERTINO
cuPE o PERMIT APPLICATION FORM
QuantityFee ID Fee Descri tion 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
MIXTURE PbIg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interce for 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 Tra PLUMBING
7 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 cfm MECHANICAL
BREMfAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install hfCHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Li tin Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Re]o Fumace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREAENHOOD 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
BREIARELOCA Relocation of Hood MECHANICAL
I BREMREPALT Repair/Alter Heating MECHANICAL
J BREMRESAPP Remodel Res Appliance ELECTRICAL
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No
CITY OF CUPERTINO
CU NO PERMIT APPLICATION FORM
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
BSEIDUCOM Seismic Commercial BUILDING
BSEISMICRE IL
Seismic Fee Res BUMMING
BSPECIAL Special Insection BUILDING
BSVTIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEIIIPPERA4 Temporary Bldg Permit BUILDING
BTEMPSVCS Trmp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING .
ELECTRIC Electricil sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance 1\IECHANICAL
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 Chane BUILDING
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