05110052 (2) CITY OF CUPERTINO -�r' �' +* AYE
BUILDING DIVISION PERMITRC,bNTR:4.C, QR'I,1Q�R,MIQ
BUILDING ADDRESS: "'a"(05110052
10411 LANSDALE A
• OW NER'S NAME: PERMIT rSUH DATE
DAN GORDON 1111019005
NE: SANITARY NO. CONTROL NO.
t ARCHITEC(ENGINEER: BUILDING PERMIT INFO
' 'BLDG O P T O
LICENSED CONTRACTOR'S DECLARATION' Job Description
1 hereby affirm that 1 am licensed maker monmd.of Chapter 9(enmmencin{ p
Nth Suction 70M of Division 7 of the Business and Pretensions Cade.and my license u
toI.nramean REPAIR WATER DAMAGE . (1 WALL/FRAME/SUB FL. )
�Z Clenso Lie.
Dam cenuact r4? �...-. ..f F CONTRACTOR: T J JOHNSON CONSTRUCTION
211
yttyp�tv9 ARCHITECTS DECLARATION
1 S 6 1 understand my plans mail he wad at public recoNs
MLkcnad Professional OWNER-BUILDER DECLARATION F'a a� ID
1 hereby aln m that I em attempt form the[01142004`3 Lleeaa Law for Nee��e ®® AAA
o O fallowing aeon.(Section 7031.3,Business and PmtrsM
sic m Cade: y city or county
5$ which mquims a permit to construe,alar.imp.,demolish.or repair my wueture
-Z'y^ prior m its Issuance,also squire the applkan,forsuch permit m Oke a signed statement
< manimislicensedpurwuntbtMpmvisionsofamConuamraLicenseLaw(CIAPIM9 Sq.Ft.Floor Area Valu [10000
$ (commencing wall Section 7000)of Division 7 of the Business and Prolmiom Code)or
that he a exempt therefrom and the basis for the alleged eaaapOm My violation or man gmt 110h DOE%
Section 7071.3 by my applicant for a permit abjeeu the applicant to a class penalty ofApN Nygn Occupancy Type
trot mom than few hundred dollar 3($S=. 6 911 U U
I,aowneroftikepmpenymmymeployeuwedngauthelema=ppe don, _
willdo the work,and theavucmm is notimmumd maRemd foruk(Sec.7046,BusinessRe aired Inspections
and Protestant,code:The commerce,Uepnm Laoesw dsot apply m reowner or 9 p
pmPeny who builds w i mpmven thereon,lib who does aueh work himw b or through his
we employees,provided thatsuch Improvements tie not Inundated ororered for sale I.
however,the building or improvement Is mid within arc year of mmpletiw,the owom-
builder will have she burden of proving that he did not Mid or improve for purpose of
sato.).
❑1,u owner of du property am exclusively contracting with licensed contractors to
construct de palm(See 7044.Business and Pmfeadons Code:)The Comommes U.
items Law does sot apply m an owner a gamp rty+tn builds m bnptn.thecoon.and.
who co a mu for such projects with a comm tors)licensed purswm he the Coutraemra
License Law.
C3I sum exempt order See ..B At P C for this reams
Owner Data
WORKER'S COMPENSA71ON DECLARATION
I hereby affirm under penalty of perjury,me or use following deawwwtt>:
I lam and will maintain 4 Cardlicam of Coment to self-Imam for Wmkers Com m-
sNon,u provided for by Section 7700 of the Labor Cade.for the performac of Ne
work rod which this permit is Issues
❑I lave and will maintain Workers Compensation Interstate.u mgksed by Section
7700 of the Lstmr Cade.for the performance cause work for which this permit is issued '
My Workers Compensation Insurance carrier and Policy number ase:
Cartier. CY 4iv..dS'1` policyNo.: —�
C�FICA 0FE7(EMPTI0NFROMWORK
COMPENSATION INSURANCE
(Thi urian need mtbecompleod Ease permit is rorone hundred dollars(SIM)
or au)
1 certify that in the performance of the work rod which this permit Is Issued.I mail not
employ any person in my manverm as in became subject to tin Workers'Compewden
Laws of Califomia.Dam
Applianl
NOTICE TO APPLICANT.If.after m4tlng this Onaliam of Exemption,you should
become subject m the Worker's Compensation provision of the Labor Code•you muss
.JO forthwith comply with each provisions or this Renk shall Im discountcowled
z 2 CONSTRUCTION LENDING AGENCY
a
[.v I hereby grim Our Hera Is a ennsVucOnn lending agency for the performance of
Ri vim„ the work for which this permit Is issued(Sac.3097,Clv,C.)
dQ Lenders Name
a z Lenders Address
U O I certify ren 1 haw read this application and task that the show Infamuden Is
gL carr---1 agree k comply with W city and county ordinances and auk laws missing m
Q building construction,and hereby author=mpaeamam of this city to enter upon the
W above-mendaned property for inspection purposes.
(� (We)agree to taw,indemnify and seep hamdess the City of Cupertino against
ate.,I,] liabilities,judgments.mass and expenses which may In my way memo against aid city
t.>Z in consequence of the gaanang or thu permit.
r APPLICR{{U{{{TTT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - Date
SOURGULATIONS
, 11� Re-roofs
sIg arAppll H OUSMATERIALSDISCLOSURE D Type of Roof
Will de.pplicuum or run=building occupant core orkandle,harsNaw material
u defined by tie Cupenum Municipal Code.Coupon 9.11,and the Heath and Safety
ads,o�25532(.)7 'm No All roofs shall be inspected prior to any roofing material being installed.
Will N0 applicant or future building oavpant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
mishmmous air conumimnu as dc0oed by the Bay Ams Air Quality Management all new materials for inspection.
Dimict7
❑Yea u
1 haw mad the huudrmsm[close mquimmenes undcrChmam6.93 of the C-Iifor.
out HeaIlk Safety Cade,9uctiom253Ul,7S377 and25l71.1 wvknuM thBlf sic building
door ret c Asve 2 L dot h a my responsibility ro Mary tle aeupmt of de
myulmmcnow hmau t 'ormissumccofaccrdikakaf cup Signature of Applicant Date
owneranuthari7nd,gent oak All roof coverings to be Class aBn or better
Community Development
10300 Torre Avenue
1Yr Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
$UPEKTINO
Building De artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: tv o ,./ PHONE # �-
GENERAL CONTRACTOR FAX# 9r><b p fhb-
4tPA
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS-NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
V Masonry d , \ a�ao�,v Z2,$ S' 0/ 3//0
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal72 .
Sheet Rock T ,C� %S t za a i-T r✓L
• Tile
Owner/C actor Signature Date
CITY OF CUPERTINO -
CUPEfZTINO PERMIT APPLICATION FORM p �' /( 0 �.S^�
N # ,� / 7 / ' V 6 �� Date: �N
7—U
ilding Address: Mailing Address (if different m building address):
�L01 o5
ner's Name: �N G Phone #:
D 0
ontrLicense#:
Contact: Phone: a%'S*Vkk Cupertino Business License#:
Fax: aSolb'1lOq
Building Permit Info:
Bld&A Elect ❑ Plumb ❑ Mech ❑
Job Description: �x�
Residential ® , \motto .a F ay toe v Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Prciect: Occupancy Group:
2 :3
Type ot Construction: Please check this box if the project is a
l/ N
second-story addition: ❑
'ro'ect Size: Standard l Laze ❑ 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> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75MBtu 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/M6bile 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
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1 CITY OF CUPERTINO
CUP PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BN=IGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
F BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum . PLUMBING
BPCESSPOOL Cesspool PLUMBING
13PERMFEE 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 rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstalUAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
13REMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAMIAN A/C Units <= 10,000 cfin 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
BRENMAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
13REN MISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platfonn Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREN=SAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPEf�TINO PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group ,
BREMSIGNAD Rmdl Sips 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 Inspection 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
EPEP2 TTFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE 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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