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03080084 (2) F_Riu',�rq ITY OF CUPERTINO BUDDING DIVISION PERMIT CONTRACT,OIt INk`ORMATION LDING ADDRESS: PERMIT NOO 3 0 8 0 0 8 4 -R'S NAME: PERMIT ISSUE DATE NEWTON DONALD E 2003 NE: SANITARY NO. CONTROL NO, ARCHITECrIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 +Op LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 am licensed under previsions or Chapter 9(commencing _ Job Description with SeclLion 70(kt)of Division Sof the fb si sa and Pr fcssinns Code andmybemacis +�n m ren m,d�md err BATHROOM REMODEL )EgLic<nx crass c.p Dao cuntrxIo CONTRACTOR: H & S CONSTRUCTION (BANGA CON. ) ARCHITECT ARATION £W X Oil myPlans Shall beuse as public not FINALE® 6 XXX e a Licenuadisar�ssiunel S OWNER-BUILDER DECLARATION C f I hereby aso vfnrm on I nm exempt from the Contractor's License Law for the FEB B 1 0 2004 ❑O following reason. panel 1 IDolu Business and e,de inm Code:Any tiny ar courtly $ which myus.a a permit re ceresthe alar,nt pone,demolish,or repair any Structure ned ement =� the,hor e its censece,also an:1.the theapplicantroesuch Contractor's Limas La,(Charmcm < (comma cingwJpursSection?(XbonDivinnsn or rtheStsiness ndProfsaw(sCode) 9 $q.F[. Floor Ar Valna[,�y1500' 2 F o (cat M is exempt Sermon nd of basis 3 n(me alleged Business and on.Any violation or then he is exempt therefrom end be basis for He allcgc0 exmption.Any violation or r�ssn 4sPlOO Occupancy Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of 3 Wy�2`fil�l➢ not more than five hundred dollars($500). P Y Type ❑T.as owner of the property,or my employees with wagesss their sol.compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044,Business RR�� and Professions Codc:The Contractors License Law does not apply to an owner of 101 - FOUNDATI'HK�d Inspections property who builds or improves thereon,and who doesauch work himself i r through his own employees,provided that such improvements are not intended or offered for Sale,If. 102 — PIERS however,the building or improvement is sold within one year of completion,the owner builder will have the burden of proving that he did not build or improve for purpose of 103 - UFER sal`')' 104 - REBAR ❑ I,as owner of Out propeny,amconclusively contracting with licensed contrecmram 105 - ANCHOR BOLTS construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-cannot Law does not apply to an owner of property who builds or improves thereon,and 106 — SEWER & WATER who contracts for such projects with a comracmpursuant r(s)licensed pursuano Ne Contractors License Law. 202 - UNDERFLOOR PLUMBING 11071 m exempt under Sec. ,B&PC for this mmon 203 - UNDERFLOOR MECHANICAL r Date 204 - UNDERFLOOR FRAME WORKER'S COMPENSATION DECLARATION I hereby affnn under penalty of perjury one of the following declarations: 205 — UNDERFLOOR INSULATION ave and will maintain a Certificate of Consent actGinsum for Worker's Compen. 301 — ROUGH PLUMBING ,as provided for by Seen..3]00 of me labor Code.for the peeforopmee of the 3 02 - TUB & OR SHOWER work for which this permhisbound. 303 - ROUGH MECHANICAL ave and will meimam Wo is Compensation Insuonce,as reyvirctl by Section of the Labor Code,forth rrormana o304 - - ROUGH ELECTRICAL orker C pensation tette terrier nd P licy number art; 3 05 - FRAME r. aw Po'y No.: w 3 0 6 - HOLDOWNS C RT ATE OF EXEM N FRO ORKERS' COMPENSATION INSURANCE 307 - INSULATION [this section need not he completed if the permit is for one hundred dollars IS 100) 308 - SHEETROCK Icentury 309 - EXTERIOR LATH employ certify that in the p any mann of the wok for which Nis permit is issued,l shall not Lawso California,on Darty manner snumbecome subjccuomeworkcricompcnsanion 310 — INTERIOR LATH Laws of CalifoDemApplint 311 - SCRATCH COAT NOTICE NOTICE TO APPLICANT:IL atom making � this Certificate of Exemption,you should 313 - ROOF NAIL becomel to the Worker's Compensation pvisions of the Labor Code you mull Z mrthwihcoreplywhnx.bpmriamnaorthiaprmuanmlMaamedrevnk.d. 501 - FINAL ELECTRICAL ENERGY CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY I hereby affirm that there is a cornu etion lending agency for the performance of 503 - FINAL MECHANICAL ENERGY x> the work for which this permit is issued(Sec.3(197,Cl,C.) j]Q Lenders Name 504 - FINAL BUILDING ENERGY Lender's Addmas =)z 505 - FINAL ELECTRICAL U O 1 certify than 1 have read this application and state than me above informani in is 506 — GAS TEST Fcorrect.l agree to comply with all city and county ordinances and state laws relating to 7 V building construction,and hereby aumorim eepresenmivcs of this city to color upon the — F I NALL PLUMBING ahovc-memioncd properly for inspection purposes. a (We)agree to save,indemnify and keep hammldes the City of Cupertino against 08 F I L to Had lilies,judgments,costs and expenses which may in any way account against said City Py inconsegocnec oft ingot this permit. '�sl-Val APPLICANT U ERS ANpS AND WILL COMPLY WITH ALL NONPOI T Issued by:5 ING Date SOURCERE U AT S. Re-roofs Si mor Ap o CoMp6t., e HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will me applicant Or furore building oestipium store or handle otallous material alined bynhc Cupertinu MunicipalChaprer 9.12,and the Health and Safety . Section zss3z(a)] All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant or futu7drt g occupon[use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove in haaamous air conmminanud by the Bay Area Air Quality Management all new materials for inspection. ❑Yes I have mad the hsrerdnus materials on,ancmcno endc,Chapor&95 print Califnr fla� nix Hcahh coy Cwlc,Sections 25505,35533 and 25534,1 uMcrsmnd Ud if Ne building U docs cu dy have a Icnan4 than in is my respomihilin Ise rum y the upon Of)ha reyuir c which must be in pdono' cmncamo c re of Applicant Date n eda cm , All roof coverings to be Class "B"or better CITY OF CUPEWFINO BUILDING DIVISION • i N"$.T*RAx CT'`.Q'R'AV.FORM�TI, �E ° BUILDING ADDRESS: PERMIT N003 080084 OWNER'S NAME: PERMIT ISSUE DATE NEWTON DONALD E 2003 IONIC SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 00 LICENSED CONTRACTOR'S DECLARATION rf 1 hereby a(ftrm that 1 am licensed under provisions of Chapter 9(commencing Job D@SCPIpt100 wiNSec ion]Oflll)nf Di " SofthcO since and Pmfcssinm CoJc j;E}��fa'< iLDniacftc.enllsfc'o 1 ass dacnrrJmyp�laAnRsCshIaIIlTlhEcCTcusyy.�ce�rd.��l�N ranscptlu�hAliReAreTcInOrJNs ' andmyliccnu is off BATHROOM RE M ODEL Mik(LEE LIW & S CONSTRUCTION (BANGA CON. ) _�� LiccnJ.Pxsnnal FEB 10 2004 OWNER-BUILDER DECLARATION /try i x 1 hereby ill Erm that 1 nm exempt from the Contractor's License Law for the S o O following ren.eon.(Seed..71131.5,Business and Professions Cede:Any city nr county `<m� which requires a promr to construct.alter,improve,demolish,or repair any evucum BUILDING "�y prionniu issuance,also requires the applicant far such permiu.fie asigneJ statement S¢ thatheislicensed pursuant tothe provisions ofthe Contractor'sLicense U (Chapter!) Sq. Ft.Floor Area Value 500. �tt� (commencing with Section 7")of Division 3 of the Business and Profcssinns C.tle)ur �3$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjecu the applicant to a civil penally of 3Fz1$D12xlm er00 Occupancy Type not mom than five hundred dollars($50)). ❑I,ea owner of the property,or my employees with wages as their sole compensation, will do the work,and the strvctom is not intended or offered for sale(so'.7W.Business �R��❑� and Professions Code:The Contractors License Law does not apply to in owner of 101 - FOUNDA'PP�S d Inspections property who builds or improves thereon,and who does such work himself or through his own employees,provided that such imprevemenu arc not intended or offered for sale.If. 102 — PIERS however,Ne building or improvement Is sold within one year of completion.Ne owrer- builder will have the burden of proving Nal he did not build or improve for purpose of 103 - UFER ail`')' 104 - REBAR ❑Lasowner of the Sec.? ,Bam usiness contracting Code:)TheeCharaccmrsm 105 - ANCHOR BOLTS constmn the project(Sec.7W,Business end Profcssinns Code:)The Character's Li. cense Law docs not apply to an owner of progeny who builds or improves thereon.and, 106 — SEWER & WATER who contracts for such projects with a contractor(s)licensed pursuant to the Cenuaetoh LicerseLaw 202 - UNDERFLOOR PLUMBING ❑I and exempt under Sm. ,B&P C for this acsson 203 - UNDERFLOOR MECHANICAL Owner Dam 204 - UNDERFLOOR FRAME WORKER'S COMPENSATION DECLARATION I bomb,reform sada,Penally of do,me,of bellowing deelantmme: 205 - UNDERFLOOR INSULATION L]I have and will mai rule a Conifcnm of Conunuo sell'-insum for worker's Cot 301 — ROUGH PLUMBING sultan,as provided for by Section 3700 of the labor Code,for the performance of the 3 02 — TUB & OR SHOWER work for 01have whichthis Kricaaintiasiazuce. 303 - ROUGH MECHANICAL ❑I have and will maintain Wo cr's Compensmlon ,,far which h his peril by Section 3700 of the Labor Coda forth ace"oneof Ne work for which this permilisissued. 3O4 — ROUGH ELECTRICAL My Worker'Snmpensatian urancc artier nd P lmyna.hcra2 j 305 - FRAME 'er: comas. Po' iR& .yi 306 - HOEDOWNS C RT CATEOFEXEM NFRO ORKERS' COMPENSATION INSURANCE 307 - INSULATION (This section need not he completed if the permit is for one hundred dollars n I00) 308 - SHEETROCK I crifi') 309 - EXTERIOR LATH eemit,that in the performance of the work for which this permit is issued,I ernil net 310 - INTERIOR LATH employ any person in any manner snaztubecome subject to the Workcri Cnmpcnietion Laws of California.Data 311 - SCRATCH COAT Applicant NOTICE TO APPLICANT:If,of cr making this CeniOcetc of Exemption,you should 313 - ROOF NAIL become subject to the Workers Compensation previsions of the labor Code,you must = z forthwith comply with such provisions or this ptermilehallatdeemed revoked, 501 — FINAL ELECTRICAL ENERGY OCONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY I hereby affirm that 0 To is a construction lending agency for the performance of 503 - FINAL MECHANICAL ENERGY "` D$ ? the work for which this permit is issued(Sec.3097,Civ.C.) � / i Ca LendcrsName 504 - FINAL BUILDING ENERGY CL/ Landers Address � z 505 - FINAL ELECTRICAL J p 1 certify that 1 have mad this application and sum that the above information is 506 - GAS TEST correct.I ague to comply with all city and county ordinances and state laws relating to ^J V building contraction,and hereby auNmne,representatives of this city to color upon the — FIN PLUMBI G above-mentioned property for inspection purposes. N y (We)ague 10 save,indemnify and keep harmless the City of Cupertino against O 8 FI L ti 14 lixbilideajudgmcnu,costs and expenses which may in any way accrue against said City J 7 inconscqucncc of in g oflhis permit t1- APPLICANT U ERS ANDS AND WILL COMPLY WITH ALL NON-P01 T Issued byt 5 ING Date SOURCERE U AT S. ' Re-roofs Si rc afAp nVC cmr HAZARDOUS MATERIALS DISCLOSURE a Type of Roof Will the applicant or future building uccup5nl store or handle hanardons contend az de,Sed Section the Cupertino Municipal Co e. hapur 9.12,and the Health and Safety Code,Scctton 25532(a)? ❑Yes All roofs shall be inspected prior to any roofing material being installed. - Will the applicant or future build g nX.pam trsenqu;patent ar devicts which If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air econominanu as def d by the Bay Arca Air Quality Management all new materials for inspection. District? [3 Yea; Na I have road Ne havaNnus menials requirements under Chapter 6.95 of the Califon ilia licalth cty Cadc,Sailors]9505.25533 and 25534.1 understand that ifNc building JCee n curt I y have a mmol that it is my impact hit it to Do ly the upant of it uyuito c Mhich must poor til' ecepa'Ccxufcauo cy re of Applicant Date o std a tot t All roof coverings to be Class "B" or better p- AY OF CUPERTINO CTY Oi PERMIT APPLICATION FORM 0 3 0'?v v� CUPEkTINO APN# Date: Build g dress: Mailing Address (if different from building address): �� /G-VE Ow s Name: Phone#: � 01 JY- C"2sra- 11Tl Contr c # J C a t: Phone:�z,?.70_ oQsl Cupertino Business License#: v Fax: mg P—rmit Info: Bld ct ❑ Plumb Mech El cription: /_ Residential E3 4*FM.//rciaI� Sq.Ft. Floor Area: $/Sq t.: Cost of Project: dil Occupancy Group: Type of Construction: f Please check this box if the project is a second-story addition: Quanti Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to I M Btu MECHANICAL BBOILER4 Boiler> IM 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 Elee 600V<= IOOOA ELECTRICAL BELEC1001 Elec 600V> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housin Mit. Fee BUILDING lof3 C*Y OF CUPERTINO C fl OF PERMIT APPLICATION FORM 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 BOVERTWE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g 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 Mise Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL 2 of 3 " CITY OF CUPERTIPA CITY OF PERMIT APPLICATION FORM CUPERTINO Qua n ' Fee ID Fee Description Fee Group BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Ap2hance ELECTRICAL BREMSIGNAD Rmdl SiEs 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 Mumbing Permit Issuance PLUMBING PPLBG- Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3of3 w /Q —rD) i GSA . j DECEIVED AUG — i 1p OFFICE f J APPROVED \ \ IN ACCORDAN WITH THE CITY OA V :1k CUP ARDINANC.fS � OAT SIGNED This set of pi s and specifications MUST j oe kept on job at all times and it is uo4 i ,, s or, a era ans on same without written permission from the building Dept., City of Cupertino. The stamping of this plan and specification9 SHALL NOT be held to permit or.to be aG 400toval of the violation of any provision• 11 any CHy Ordinance at.State Law. d