04120006 (2) CI•CY OF CUPERTINO ".eau sem"
BUILDING D1vlsfoN PERMIT GONTRAGTOR INFORMATION-'%,zBUILDING ADDRESS: BROSCOE ELECTRIC PERMITNO04120006
10698 LARRY WY
^' NERS NAME: PERMIT ISSUE DATE
LARRAINE EANEFF 1658 E CAPITOL EXPWY PMB 1/2004
NE: SANTIARY NO. CONTROL NO.
(408) 223-8111
ARCHITECT/ENGINEER: - -BUILDING PERMIT INFO - --
BLDG ELECT PLUMB MECH
=oo LICENSED CONTRACT'OR'S DECLARATION
x I hereby firm that I am licensed under protvlons of chapter 9(commencing � Job Description - -
szw with Scni ]1K1M1)of Division Jofthc Businrssand Is fessirnsCMc,andmyllccrcis _
in ern fncom effect. UPGRADE ELECT. SERVICE (200 AMP)
`pi License ossa / -.O Lica art la5st0
'Fo Dam Cortrmsor 7...•f.r rrf �It.
�tt ARCHT'IECT•S DECIARATION•JKssc ryN`]sOC.
'i m< 11 uu
ndcrsnd my plans doll he dead as public records
Dyes
3u. Licensed Pntfusional
O OWNER-BUILDER DECLARATION
i i I I hereby affirm that 1 am exempt farm the Contractors License Law for the
x
no following...(Section 7031.5.Bee roes,and Pmfeetiune Cele:Any city or county
x m which requires a permit to consumer,alter.improve,demmish,or repair any nructum $1768
Uzi prior m its issuance,also mil the applicant for such permit to file a signed statement _
< Nuhculicensed pursuant tothe provisiamofd¢ConuxtarillavLaw Sq.Ft. Floor Area Valuation
a (commencing with seldom 71X)ffi of Division B of to Businesr and Professions Code)or
y dust te is exempt therefrom and the bard for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty ofar - Occupancy Type
not more than Bare hundred doll..(M).
0 h as owner of the propcny,or my employees with wages as their sole compensation,
will do the work,and the structure is not branded oro@rad hostile(Sec.7B4a,Business ,
and Professions Cade:The Ceramics's License Law does ere apply to.a owner of Required Inspections
property who Wildsmimprovor thercon,and who dassuch work himself.,through his r n
own employees,provided that such improvements me not intended oroRemd rorsale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have thus burden of moving that he did not Wild or improve for purpose of
sale J. c ., I
'r-
0
40 I.as Owner of the propery,am exclusively contracting with licensed contraction to
construct tis project(Sec.7014.Business and Professions Cade:)The Contractor's U.
cause Law door not apply to an owner of property who Wilda or improves themon,and
who contracts for such projects with a comncmgs)licensed pursuant to the Contnetor's
Lux"iLaw.
0 I an exempt under Sec. .B&P C for this masonat
o,u�Dace / �
WORKER'S COMPENSATION DECLARATION 4 `J \ „J
1 hereby anion under Rarity of perjury one of the following derclanuons:
have and will maintain a Ccnificam of Consent to self-insure for Workers Conquer-
a.as provided for by Section 37M of the Labor Code,for the perm nonce of the _
1037�1
for which this Permit is issued.
have and will maintain Wmkcr's Compensation Insurance,a required by Section ,
of the Labor Codc,for the performance of due work for which this permit is issued.
Workers Compensation Insurance carrier and Policy number art�C arotPJ�y No' V.J C 5 �
IFICATEOF X PnONFRO ORKERS'
COMPENSATION INSURANCE
(This secimsecdnm W cnmpmmd lrtherarmit is for..hundred doll.(SI00)
Ma)
I terrify that in Ne performance of the wart for which this permit or issued.I shall not
employ any person in any manner so u w became subject to the Workers'Compensation
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If.arta making this Cenifida of Exemption,you shouW
become subject to the Woher's C..'eco mon provisions of the Labor CMO,you must
.Jz forthwith comply with much provieinns or this permit shall W damcd revoked.
Z OCONSTRUC ION LENDING AGENCY
[r.�- I hamby affirm that thea is a construction lending agency for Ne performance of
C the work for which this permit is issued(Sec.3a97.Civ.C.)
fz7 Lender's Name
z lender's Adder..
V C) 1 certify thn 1 have read this application and sum that Ne above information is
correct.1 agree to comply with all city and county ordinances and some laws relating 1.
DU building construction,and hereby audience mprescnutives of this city to carer upon the
C above-roemimed property for ire,cuon purposes.
(We)agree 10 ave,Indemnify and keep harmless the City or Cupertino again"
Frg liabilities,judgments,costs and expenses which may in any way accrue against mid City
U in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOyRCEBEGULATIONS. '✓ � ��/
'wR„In}\. I' . a �/1m2tTe. l'�K'4 Re-roofs
si of AWticmUConmacarr Data
HAZARDOUS MATERIALS DISCLOSURE— Type Of ROOF
Will the applicant Lir for=building oceupmt soar or handle hao rdous marcriai
a dcrined by Ne Cu,x rdna blunicipal Cade.Chapter 9.11.and the Hcahh and Safety
Scetien:ssdx(a)?
Yar No
All roofs shall be inspected prior to any roofing material being installed.
�
Will de,applicant Or f war building Occupant use equipment or dcvias which If a roof is installed without first obtaining an inspection,I agree to remove -
1 haurdous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
vitt?
❑tics �No
[hay and the haurdn smamrials myuiremenu(coder Chapar b.YS of the Califnry
ria Hcal[hay mf CthaMMuons15SB5,Z5Suimmen53a.lu Chapwr Neifthc Wilding
docs nm cortcndy have a¢nae,Nat it my respomihilny m nouly the occupant of the
1
our s which mu"be act prior rsmmcc Of s CcNficau of Occupmc.
1C. Signature ofApplicant Date
Own out orizcJagcns i Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
✓' Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�PEI�TINO
Building De artment o 2.��
JOB ADDRESS:: q,sOl�l PER100#
i //
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: <� FAX #
I am not using any subcontracto s. 1-L 11 114
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical — e c
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
ANk Tile
%Zltlol
Owner/Contractor Signature Date
( - CITY OF CUPERTINO 6 o-a 6
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
'RWPN# � Date:
Building Address: Mailing Address (if different from building address):
o. ' n
Owner's Name: Phone#:
Y oZJd - SU1�
Contractor: License#:
Jt0
Contact: lctc�-�a3`rttecell Phone: 1) Cupertino Business License#:
g Fax:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description:
Residential 5d SE k -e e. p Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Gro p:
11 lots-o t�
Type of Construction: Please check this a project is a
second-story addition: ❑
ro'ect Size: Standard Cil Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to IM 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
i BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
�P, a? qD7
1of3Z-(S . S� �
d CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
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 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 Heater/Vent 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
B MNRAPP Rem Non-Res Appliance ELECTRICAL
B MPOLE Pole/Platform Fixture ELECTRICAL
MPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT I Repair/ Iter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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afin CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM '
CUPEfiiTINO
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
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
ESPECIAL 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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