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04060012 (2) CITY OF CUPERTINO ' e.aa: + � BUILDING DIVISION PERMIT exaCONTRACTQR INF�OTZ111ATION RUILDING ADDRESS: PERMIT NO0 4.0 60 0 12 81d1k07 HYANNISPORT OR OWNER'S NAME: PERMIT ISSUE DATE WILLIAMS PHYLLIS 4PIE: SANITARY NO. CONTROL N0. ARCHITECT/ENGINEER; BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLIRATION Job Description a❑ I hereby affirm that I an licemed under pmviuons of Chapter 9(rommenciny ,OTlW with Section lWD)of Division 3 of the BUmzi�_ ProfessmlCode,and my liceve is �a in fulltarte ndeta L p 66 CHIMNEY REPAIR TO ROOF LIVOPJALSO jg? Licen Cleu Lic.N ^=O Dam br Con ARCHITECTS m D ON shallW 3y 1 undersunJ my plans shall used as m records JUN 7 2004 a< DyU LLo y Licused Pmfcui.nal OWNER-BUILDER DECLARATION p'� 0 9pp t�Is� .� 1 heathy alirtn that I am exempt from thC Convectors License Law for the �.uitt.DING a n O following reason.(Sauon 703 1.5,Business and Professions Code:Any city or county �.% II which requires a permit to construct.alter,borrow,demrdtah,or repair any structure prior to its issuance.also requires the applicant for such permit o Glc a signed statement —�< that he is licensed pursuant to the pmvisiom of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation x€$ (commencing with Section 7000)of Division 3 of Me Business and Professions Cash)or .. that he is exempt therefrom and the basis far the alleged cmmption.Any viola(on of Section 7031.5 by say applicant for a Permit mbjecu the applicant m a civil penalty of 3,�ittIsWAinliet-0 0 Occupancy Type not mom Nan five hundred dollars(5500). 1,u owner of the property,at my employees with wages a their ark compensation, will do the work and theawctum is not intended m.Renal forsde(Sa.7D66,Business Required Inspections and Pmfeu ssimCode:The Comnctors Liceve Law does not apply m an owner of q P property who Wilds or improves@ereon,andwho doessuch work himselfor through his own employ=.provided out such improvements are,notinterNed oroRered twists.If. hownwr,the Wilding or improvement u mid within one Sea of mmpleuon,the Owner. builder will have the Wade.of proving Na he did not Wild ar improve for purport of sakJ. Q 1,as owner of the Property.am exclusively contracting with licensed mnuactors m construct the project(Sec.7064.Business and Professions Code:)The Conuacter's Li- Om ac Law does not apply man owns of property who Wilds or improves themon,and who contracts ten such pmjeea with a contractor(s)licensed pursuant m the Contractors Liana Law. ❑I am acmpt under sic. ,B&P C for this mason 1�91 er Data WORKER'S COMPENSATION DECLARATION ' I hereby affam under penalty of perjury ane of the following daclwionc: have and will maintain a Ca drima of Covent w self-insure fm Wmace.Compen. n,u pmvidcd for by Sccua.3700 of the Labor Code.for the performance of the for which this permit is issued. have and will maintain Wmker's Compevauon Ivuranm,u required by Section of Ne Labor Code,for the performance of the warts far which this permit is issued. !kvsC; nsatlon Insurance ai.and PPOLICy num7CEER11RCAM OF EEMPf10NFROM WORKERS'�(��(/ � COMPENSATION INSURANCE 7 G ((hussedion need notbecmnpleted if the Permit is for as hundred dollars(SIM) In Mail 1 certify Nat in Ne performance of the work fm which this Permit In issned,I:bail not employ any person in any manner an an to become subject to tM Workers Coom adon Laws of California.Data Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become:object m Oc Workers Compensation proviaiov of tha Ube,Code,you must .�Z forthwith comply with such provLdav or this permit shall m domed revoked. Z'A CONSTRUCTION LENDING AGENCY (gin I berth,art.that then u•maswcunn arm g agency for the performance of !Y> the.,it far which this permit is issued(SC,.3041.Civ.C.) W A Undcr'a Name fY lander:Address V O 1 certify that 1 have read this applicaiam end state that the shove informed..is Wt" correct.I agree to comply with all city and county ordinances and state laws relating m V abow-gcavned construction.sad hembyanthodm rtOICS. uvcs of this city reenter upon the Y'w shout-(We)agreproperty for inspectionpurposed. (We)agree to save,indemnify and kap harmless the City of Cupertino against iy Iiabilhicipdgmens.C..andexpenses which may in any wayaccmpagaina said City V in ti APPLICANT eUNDERSTANDS Aor the granfing of nND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUrEREGU TIONS. . ,t.-G,L ICL.AIc*�r �0 Re-roofs sig rcof Applicant/ onmcmr ' Dam Type of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hausdous material u defined by the Cupertino M.I Code.Chapter 9.13.and see Health and Safety Cats.Sauan 35532(x)? All roofs shall be inspected prior to any roofing material being installed. 1-3 Yes Will the applicant or future Wilding Occupant use equipment or&VIM which If a roof is installed without first obtaining an inspection,I agree to remove haurdaus air conaminans defined by Ne Bay Arta Air Quality Management all new materials for inspection. wuict7 ❑Yes u I have mad the haraNnu materials requirements under Chapter 6.95oftheCalifor- nishealth&Sataycade,Suction,25505.25533 and 25536.I undersand that if the Wilding docs not currently new a tenant that it u my responsibility a mill,de asupam of the mquircmenuw a be met Priortosatao faCmlficamof Zeapancy. Signature of Applicant Date All roof coverings to be Class 'B"or better Owner okiiatuhrnAdagent CITY OF CUPERTINO 1 of 1 PERMIT RECEIPT OPERATOR: suem COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35611014 .00 DATE ISSUED. . . . . . . : 06/01/2004 RECEIPT #. . . . . . . . . : 25683 REFERENCE ID # . . . : 04060012 SITE ADDRESS . . . . . : 8107 HYANNISPORT DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : WILLIAMS PHYLLIS ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4063 RECEIVED FROM . . . . : JK MASONRY CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . . , TELEPHONE . . . . . . . . : 44EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW. BAL ______ _____________ __________ __________ __________ __________ __________ BENERGY PERMIT FEE 1.00 23.10 0.00 23 .10 0.00 BPERMFEE VALUATION 3,000.00 77.00 0.00 77.00 0.00 BSEISMICRE VALUATION 2,865.00 0.50 0.00 0.50 0.00 BPLANCHK PERMIT FEE 1.00 62 .25 0.00 62 .25 0.00 __________ __________ __________ ---------- TOTAL PERMIT 162.85 0.00 162 .85 0.00 METHOD OF PAYMENT AMOUNT NUMBER ____________ __________________ CHECK 162 .85 2006 TOTAL RECEIPT 162.85 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ____ ________ ____________________________ 101 FOUNDATION 312 CHIMNEY REBAR & STRAPS 514 FINAL PUBLIC WORKS © - CITY OF CUPERTINO CUP-IfYOF O PERMIT APPLICATION FORMERT APN # � / Date: Building Address:. Owner's Name: ��`�� ��� _ l Phone Contractor: �// License : Contact: I / Cupertino Business License#: I Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech �— Job Description: Residential >�, ti-• �b 0 F' W Commercial ❑ Sq.Ft. Floor Area: r ��frPON 3C $/Sq.Ft.: Cost of Project: I Occupancy Group: Type of Const ction: l Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bld Permits . foot BUILDING BB01LERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 am CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM Ak CUPERTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTDAE 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 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 Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm 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 2 of CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch& Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BRENMPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3