03070156 (2) CITY OF CUPERTINO r -'�" �'
BUILDING DIVISION PER1'�' CQI7rCR INk'+f)RON" ;
"
BUILDING ADDRESS: MICHAEL SHIELDS FLKM1TND03070156
OWN R' AME: GLELLA&T R9 PERMIT ISSUE DATE
NE: SANITARY 0. CONTROL NO.
ARCHITEC 1ENGINEER: BUILDING PERMIT INFO
BLDC ELECT PLUMB MECH
0 0 0 0
y00 LICENSED CONTRACTOR'S DECLARATION Job Description
m I hcrchy affirm that turn licensetl under provisions of Chapter 9(eammencing
Z, with Section 705(Bnr Division 3ofthe Businessaad Professions Cade,endmy license is ,
-^ y in full force and effect,
—� Licenu class Comin WINDOW RE ®
err Dam Cuntrecmr ry
QARCHITECTS DECLARATION
0 @ 1 understand my plansshall be used as public records
Lice...d Pnrfcromil JAN 15 2004
`DS OWNER-BUILDER DECLARATION
�y<'A 1 hereby affirm that I am exempt from the Cnmmcmr's License Law for the
p o following mason.(Section 7131.5,Business and Professions Code:Any city or county
K which reyaim.a Permit ,,construct, he,,improve,demolish,nr repair any saaethm BUILDING
m�'^
Prior orm issumce,alsu rmimme.the applicant for such pmmiuo fit...gnedsatement
IcnlneisEsensedparsanal1.the provisions ofm
theCoamorsLimasolsw(Chapter9 Sq.Ft. Floor Area Valuation
W (commencing with Section 7")or Division 3 of the B usoms and Professions Code)or
i $ that he Is exempt thcrcfrom and he basis for the alleged mcmption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Knotty of APN Number Occupancy Type
not more Nan five hundred dollars($500).
M 1,as owner of the property,or my employees with wages ss their sole compensation,
will do the work,and the swctum is not intended or offered for sale(See.7044,Business 101 - FOUNDAXA9Kd Inspections
and Professions Code:The Contsactor'a License Law dors not apply to an owner of
pmperty who builds or improves thereon,and who does such work himselfor through his 102 - PIERS
own employees,provided that such improvements are not intended or offered for sale.If, 103 — UFER
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 104 - REBAR
salt.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to 105 - ANCHOR BOLTS
cousloot the project(Sec.7044,Business and Professions Code:)The canmcmr's Li. 106 — SEWER & WATER
cmult
law data oat ply to as owner of property who builds or impmves thereon,and 202 - UNDERFLOOR PLUMBING
Who eanmd¢fe su pmjeetr with. tU)deemed p
. t6rurmanua the Cammicm'a'
Llan er 203 - UNDERFLOOR MECHANICAL
d Y'ni axe der Sec. - C to his r on
204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION42 Date
205 - UNDERFLOOR INSULATION
RATION
I hereby affirm under Penalty of perjury one or the following declarations: 301 — ROUGH PLUMBING
I have and will maintain a CamOcate of consent to self-sawn,for Worker's Compen. 302 — TUB & OR SHOWER
..tion,as provided for by Section 37M of the Isbor Code,for the performance or the 303 - ROUGH MECHANICAL
work for which this Permit is issued.
❑I have and will maintain Wtolom's Compensation Insurance,az imported by Sadion 3 04 - ROUGH ELECTRICAL
37W of the Labor Code,for the performance of the work for which this permit is issued. 30,5 — FRAME
My Worker's Compensation Insurance carrier and Policy rumhdr am: 306 — HOLDOWNS
micr: Policy No.:
CERTIFICATE OFE%EMPTION FROMWORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(This section need not be completed if the Permit is for one hundred dollars($100) 309 - EXTERIOR LATH
or Ins.)
I certify that in the performance of the work for which this permit is issued,1 shall not 310 - INTERIOR LATH
employ any pclson in any mannersn as to become Subject o the Workers Compensation 311 — SCRATCH COAT
Laws of California,Dam
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:It.after making this Ccaifiwte of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation provisions of the Lahor Code,you must
,J O forthwiIncomply with such provisions orthis permil shall mdeemed revoked. 502 — FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hcrchy affirm that there is.construction lending agency for the performance of 504 - FINAL BUILDING ENERGY �-
C�
do,work far wnirnthis permit isiaace Sec.397,Ci,c.) 505 - FINAL ELECTRICAL
W Q Lcndcr
:D z Lendrr's Name Address 506 - GAS TEST
J Cr I ceaffy that I have read Nis.pplicatma and state that the above infomtatiw is S O 7 — FINAL PLUMBING
F correct.)agree to comply witb all city antl county codira r.r;and state laws relating to
0U
building consummiml,and hereby authorin mpresentatives of this city to enter upon the FIN AtNG
AL
44) .hove-mentioned pmperty for inspection purposes.
Glt (We).,me to sav indemnify and keep harmless Ne City of Cupertino against 0 9 F I
V) liabilities,judgromm,a .rad expenses whit may in any way neem,against said City 5 Uz ineansequenc ori coring of thisperAPPLIC STANDS AN ILL COMPLY WITH ALL NON-POINT Issuedby:5 ORKS Date
SOUR R IONS. tf ,
Re-roofs
gnomic of ApplicaHAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will the applicant ur furore building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9,11,and the Heahh and Safety
Code,Section 35532(.)? All roofs shall be inspected prior to an roofing material being[I Yea Na P P Y g g installed.
wiu Ina app]card or rntarc Wilding occupant use trod rancid or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
mit hovardnus air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
istrin?
❑Yes No
(have rca ehnrardt s\materials requirements under Chapter 6.95 of the C.Ilfno-
no"
ie Health A"$afCl Coda.Seedun 55(15,35533 anJ 534.1unders�nd Natifthe)wilding
does not-durmal have.ten that h is m Ihllity m notify the cecup an f the
myu'L(men hmust 6. u af.adfi. spar¢ Signature of Applicant Date
ncr or aamorimd spear^ Otte' roof coverings to be Class "B" or better
C CITY OF CUPERTINO
CUP TYOF o PERMIT APPLICATION FORM
o � h
N# i Date: / G J
Building Addres
Owner's Name: Phone#:
h, c s1%-' r �t-Vo -
Contractor: Ie— License #:
Contact: Cupertino Business License#:
Build' g Permit Info:
dg Elect ❑ Plumb ❑ Mech ❑
bbes 'ption:
tiall� r 00 N J c �
Sq.Ft. Floor Area: S/Sq.Ft.
Cost of Project: � Occupancy Group
Type of Construction:
Ger NOUN /Lc0(4Cep,c o ARK
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI 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
BELE 200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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IMr�F�r"" � EyWI ND,(OECCISYtOfl
IlN
18 2003
J �� '--�' • ;nd �Pacrficdtions
�,alltimesBna'it'is`ua'
on 1 an or. alterations
r
�Xa?akeg�ermissidn From
bVia. q�nal
t written P Cupertino.
t o.r �'` t City of Cup
l% the bt 6P " fan and specification9
x (�� Tire slathis P permit or.to be afC
3NpLL held to P rovi51000
approval of t re violation of any P
,f City 1 idiriance or.State Law.
anv
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CITY OF CUPERTINO �s`•
BUILDING DIVISION PERMIT COZYTRACT(QR INFORMATION ,::'
BUILDING ADDRESS: MICHAEL SHIELDS PERMIT N'03070156
OWN R' AME: PERMITIS5IJEDATE
NE: SANITARY 0. CONTROL N0.
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOO LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing P
with Section and
Division 3ofthe Bues
sins and Professions Cntle,end my license is PINAL,ED
a. in full force e ane enact.
5p: LicenseCla6a Lie.r WINDOW REPLACEMENT
Oan: Cumracwr
44"� ARCHITECTS DECLARATION JAN 1 5 2004
I understand my plans shall hus
e ed as public..Ns
u,toLicensed Professional R
�01 OWNER-BUILDER DECLARATION 'BUILDING
<x 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
o O following reason.(Section 7031.5,Business and Professions Code:Any city or county
x m which requires a permit to construct,alter,imprnve,demolish,or repair any structure ,
poor o its issuance.also requires the applicant for such permit to File a signed statemcm
r < that he is licensed pursnt uato the a.visimi.rfthe Contractur'sLimit.Law(Charter 9 Sq. Ft.Floor Area Valuation
CI-a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
ex
.-
Out he is emm pt thcrefraand the basis for the alleged cun
tral .Any vision of
Section 717131.5 by any applicant for a permit subjects he applicant to a civil penalty of APN Number OCCU anc e
nm more Nan five hundred dollars($300).
P Y�YP
1,as owner of the property,or my employees with wages is Bteir sole compensation,
will do the work.and the structure is not intended or offered for salt(See.7044,Business 101 - FOUNDAfCAg1 d Inspections
and Professions Code:The Comment's License Law does not apply m in owner of
property who builds or improves thereon,and who doesauch work himselfor through his 102 - PIERS
own employees,provided that such improvements arc not intended oronered for sale.If, 103 - UFER
however,the building or improvement is sold within one year of completion.the owner
hwm).er will have Bit burden of proving That he did not bond or improve for poorest of 104 — REBAR
sale.
❑1,as owner of the property,am exclusively contracting with licensed contractors to 105 - ANCHOR BOLTS
construct the Project(Sec.7044,Business and Profusions Coda)The Commetor's Li. 106 — SEWER & WATER
cense law docs not ply m an owner of propany who builds or improves formed.and 'ZO2 — UNDERFLOOR PLUMBING
who connote so IF eeswitha tin rls)licensed oursuanuo the Conmctor's
Lit,m. 203 - UNDERFLOOR MECHANICAL
d axe der Bee. _ ?frhis We.
204 - UNDERFLOOR FRAME
w
WORKERS COMPENSATION ri ARADTION 205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of Perjury one of the following decimations: 301 — ROUGH PLUMBING
ave and will maintain a Cenificam of consent m self-insdm for Worker's Comped. 302 — TUB' & OR SHOWER
n,as provided for by Section 3700 of the labor Code,for the Performance of the 3 0 3 - ROUGH MECHANICAL
work for which this permit is issued.
❑I have and will maintain Worker's Compensatinn Insurance,as required by Section 304 - ROUGH ELECTRICAL
377 of the labor Cade,for the performance of he work for which this permit is issued. 305 - FRAME
My Worker's Compensation lnaunnce carrier and Policy num her art: 306 - HOLDOWNS
mer: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or
(This section need not he completed if the permit is for one hundred dollars(SIM) 309 - EXTERIOR LATH
less.)
1 eerily Nat in the performance of the work for which this Permit is iMOd,I shall not 310 - INTERIOR LATH
employ any person in any mannerso as In become subject o the Workers'Compensation 311 - SCRATCH COAT
Laws of California.Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If.after making this Cenifteaut of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
�z (Rahe subject to the Worker's COm m,thnnprmitsta oftherCoda. mY61 502 - FINAL PLUMBING ENERGY
becomi sunm t to the orker'nmsmns o anonis prma immao he mea revoked.
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I her by which thi Nat Nere isaed(Sec.3N7.n Co, ency ler Nc performance of 504 - FINAL BUILDING ENERGY
C' drc work for which this
permit is issued(Sec.3!197, iv C.) "
wa Q Under'sName 505 - FINAL ELECTRICAL
az Lender'aAddmss 506 - GAS TEST
U
V p I certify that 1 have read his application and smut that Ne above information is
:L correct.I agree 10 comply with all city and county ordinances and atom Jowl to sting 1. 507 - FINAL PLUMBING
C) building construction,and hereby amhorimrepresentatives ofthis city to enter upon the FIN aMECCALaheivchimli red Propery for inspection purposes.(Wc)agree I sev indemnify and kelp harmless the City of Cupcnind against 0 9 FIy liebilitiesjudgmen antl e:penaca whfe mayInany way eccme age insI said City S NG(�z in conscqucne I arcing of this per '.APPLIC STANDS AN ILL COMPLY WITH ALL NONPOINT Issued bY:5 WORKS Date
SOUR IONS. sZ
Re-roofs
gnewrc of ApplicaHAZARDOUS MATERIALS DISCLOSURE Date Type of Roof '
Will the applicant fir future building occupant nmc mi harsrtlous material
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,ScOcIyo525532(e)? Nd All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
harardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes �Nu
I havema ehavamr{ mmatcrials requimmcnls undef Chaptcr6.95 ofthe Cahfory
ilia HcalN c Cook,Sccuon 55115,25533 and 34.I understand that if due building
does n dint have a Ice that it ifi m iM1ility m nndly the rccuptn f the
mqu' hmost de se ofaanifies Signature of Applicant Date
.net
or aothori ed agent Date roof coverings to be Class "B"or better
r
CITY OF CUPERTINO J/
CITY OF PERMIT APPLICATION FORM
CUPERTINO
J h
7Building
N# Date:Addrewner's Name: Phone #:
Contractor: License#:
Contact: Cupertino Business License#:
Build' g Permit Info:
dg Elect ❑ Plumb ❑ Mech ❑
ob es 'ption:
ial H,rOO N-f
Sq.Ft. Floor Area: r
$/Sq.Ft.Cost of Project: Occupancy Group
r.
Type of Construction:
WI, daN /tt/GjCep.t„q
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI 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
�aSS,
I of
rtu
j
i
CITY OF CUPERTINO
CUP OF OF
PERMIT APPLICATION FORM
QuantityFee ID Fee Descri tion 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
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg 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 _Sewa e'Dis osal . 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 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 cfin 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
13REMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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J ° � CITY OF CUPERTINO
cuP TYOF No PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch& Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical LiWiting 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
EPEPJvH E Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
i
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