03110001 (3) CITY OF CUPERTINO4'bn "h' s �¢.s o -ivr 'dY - " 'tom'+
BUILDING DIVISION
PER .�CONTRACTORANFORM aN:
f ,p'»iffi�8'G"3 r,a.�aik.°am.
BUILDING ADDRESS: PERMITNO03110001
11245 MT CREST PL
ER'S NAME: PERMIT ISSUE DATE
GARY NEWMAN 11/03/2003
ONE: + SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!00 C�
aO0 LICENSED CONTRACTORS
olhimsDECLARATION
Char Sob Description
�U lion ey 7( affirmthatlam flue Buunderprovisionsofs Code,And
p
with Section](I(lU)of Di talon 3.f NC Businca and Professions Cndc.and my license is
?c, mfmltone. efmct �f L— — REPLACE WINDOWS
,qz ucen clas sea V CONTRACTOR: EXCELLENCE IN REMODELING
it Dete Conuacmr
pp HITECTS DIc/
1 W 1 undcntand y plans shall he vuJ ei ie feenrJs
beC.
'aG Licensed Pmfeasiunal
g OWNER-BUILDER DECLARATION
<4 1 herchy affirm that I am cxcmpt from the Contractors License Law for the
O o following mason,(Section 7031.5,Business and Ptofcasions Code:Any city or county
m which requires a permit to construct,ahea improve,demolish,or repair any structure
-ZT prior to its issuance.also mquims,the applicant forsuch permit m file a signed statement
< that he is licensed Pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valu
M (commencing with Section 7")of Division 3 of the Business and Professions Code)of
�� ,at he is exempt thenfron and the hssis for the alleged....,lion.Any violation of
Section 7031.5 by any applicant for a penult subjects the applicant m a civil penalty of
not more Nan fire hundred dollars($500). LT Occupancy Type
I,noWnerofthepmpeny,.fmycmployceawildwegesutbeilmleeompcnsstian,
will do Ne work end thcaWnun is oat intended...Rated for sal.(Sec.7(144,Businus �
Required Inspections
and Professions Code:TheContractorsLuMose,Law docs not apply to in owner of
propany who builds or improves d emon,and who does such work himself or through his
own employe.,provided that such impsmtments are not intended or offend forsdo.If,
however,the building or improvement is sold within one year of completion.Ne owner
builder will have the burden of proving that he did not build or improve for purpose of
We.).
❑h as owner of Ne property,am exclusively contracting wild licensed contractors to
construct the project(Sec.7044,Business and Pmfessians COCA:)no Cmuracou'a LI-
cense law does not apply 1.an.caner of property who builds or improves Nenon,and,
who contracts for such projects with a contrumou(s)licensed pursuant to Ne Conti CMr`3 NO V
License Law. ag 03
Psql am exempt under Sec. .B&P C for this...A 2 20
Data
49, WORKER'S COMPENSATON DECLARATION Al
I hereby affirm under parity of perjury one of Ne following declarations:
I have and will maintain a Cenificam of Consent to sel6lnsun fur Workers Compem
sa0on,
As provided for by Section 37M of the Labor Code,for Ne Performance of the
work for which Of,permit is issued.
❑1 have and will maintain Worker's Compensation Imunnee,as required by Section
37W of the labor Cade,far de:pedarmance of Ne work for which Nis permit is issued.
My Worker's Compensation Insurance carrier end Policy number sm:
Cartier. Policy No.: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlsuction need nothecompleted(the permitisfcaronchundmddollars($1O(f)
or less.)
1 certify that in the perrnrmanceof he work Wr which this Pon is issue ,I shut l nm
employ any person in any manner nth cubjeCHOuls, .kart fur matt..
Laws of Californiy7ggje
Applicant
NOTIX APPLI :I�5ner i�g s fiGcne of Exemption,you should
becom object to the Workers Compensation phowB am of the labor CMe,you must .
7Q forthwith comply wit such provisions or this Permit be deemed narked.
ti y CONSTRUCTION LENDING AGENCY
I hereby aRfm that there is a construction lending agency for the performance of
Y. F>-t the Work(or which this permit is issued(See3097,Cl,C.)
YA Lcndcr's Name
z Lender's Address ..-..
Q 1 certify that 1 have mad this application and state Nat the above information is
y (~ conal.I agree to comply with all city and county ordinances and state laws mlating to
�U building convection,and hereby autharim representatives of thin city to Croat China Nc
„ a shove-mcminned pmperiy foe impcedon purposes.
y (We)agree to save,indemnify and keep harmless the City of Cupertino against ��..
N Iisbllitics.judgmcox.costs and expenses which mayin anyway atmue against acid City
;�,z inconsequcnce.f de rating of ros permit. Issued by: Date
A PPLICA .UND AND ND tVILL COMPLY WITH ALL NO -POI
SOURCE L I NS.
V Re-roofs
ignat A of4gfic.fucon fur DAM
' HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant score or handle hovardous material
as donned by Ne Cupenina unicipal Code,Chapter 9.12,and the Health and Safety
odc.Seclion255J2(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will the applicant or future building accuparl use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamrdr us air contaminant as darined by the Bay Arta Ail Quality Mamgomem
Distrix? all new materials for inspection.
❑Yes �(No
I have nAd Nc by du us uldriuls nyuircmenoun der Chapmr6.95ofNeCalifor-
niaHcalth&Safely Code ec'ons 25,5,25;17 and SSSJ4.1 unJersmnJ thotifthc huiIdirg
does not cunenly2tavt 'te oto Xis yresp.nstym npoly th aeuPont of Nc
nquinmems i[°�6 matt met tu'suance ofe Ccrdfca of upancr. Signature of Applicant Date
a3
Ower ;gent All roof coverings to be Class "B" or better
i( - ISCITY OF CUPERTINO* o
CUP TYOF O PERMIT APPLICATION FORM 03 /
APN # � / Date: ( O-;X 03
Building Address: Mailing Address (if different from building address):
11 2 U r-A
Owner' Name: Phone #:
ARV AJ�WM" 66' ZS7 SS��
Contractor: License#:
�Xaupzk eJ PWCDs�(A�& 5815��
Contact: Phone: Cupertino Business License#:
Fax: �(s77.332�
Building)errnit Info:
BldgElect ❑ Plumb ❑ Mech ❑
Job�D�em ripti n:
sidential _ JCo merci 1
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of ProctcJ Occupancy Group:
c� S
5rKqLp 4mt ( irCS Nem
Type of C struction: Please check this box i he project i
1Cv � second-story addition:
Quantity Fee ID Fee—Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1 M 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 Elee 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
I of3
-(SWITY OF CUPERTINO*
CITY orRM
CUPEkTINO PERMIT APPLICATION FO
QuantityFee 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
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 rinklerBackflo PLUMBING
BPSTORM Storm/Rairi 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 cfrn MECHANICAL
BREMKIRHAN T ---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
BREMPOWER Power Device/Apparatus ELECTRICAL
2 of 3
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
E JUN1 9
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below
Contractor Address/City Phone # Stat License # Type of work to
be performed
3. _ 1 will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
...................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Si-p tore: Date: 4,.111163
job Addr f �Yermit# 02650696
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.