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04050129 (2) ' CITY OF CUPERTINO ` BUILDING DIVISION PERMIT Cf)NT,RAICT R IiiMATIU1�t�. ' BUILDING ADDRESS: PERMTTND04 0 5 012 9 OWNER'S NAME: PERMIT ISSUE DATE MICHELL REYNOLDS NE: SANITARYNO. CONTROL NO. r`, 1TECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 coo LICENSED CONTRACTOR'S DECLARATION a V I M1creby affirm toll I am Iknucd under pmviaione of Chepmr 9(commencing Job Description eZp wOh Scaioa90UT.r Divi'on3 (Ne Buvnraaend Profcesiuns Code,end�r licen¢ia ^< in full farce andcnect. � JQ ' SJ WATER DAMPAGE REPAIR ON FLOOR j� Liaenn etas ` ARCHITECTS DEc N ONTRACTOR: PRESTIGE BUILDERS �- Date Conunmr UIUnderstand myplans shall heunit as public records BATHRM/DRYWALL/DOORS/FLOORING C Licensed Professional g 3OWNER"BUILDER DECLARATION 4 f I he."an.Unit I am exempt from the Contractors License Lew for the Coo following mason.(Sestion 703 1.5,Business and Pmfea bum Code:Any city ar county $ which.quirts a permit to construct,alar.improve.demolish.Or repair any swaurt _ y prion,,its issuance,also requires the applicant for such Permit o file aligned summent < In.,heislicensedpursuanuothepmAitiomOfOmConunmriLicenseLaw(Chapter9 Sq.Ft. Floor Area Valuation z (commencing with Section 7000)of Division 3O NC Busincssand Pmfeniona Coddia $ That he u exempt therefrom and the basis for Us alleged exemption.Any violation of. nC 2 5 0 0 0 Section 7031.5 by any applicant for a permit subjcns the applicant to a civil PenneP y Type of APN Number Oeeu aTy e Out mom than foe hundred dollars($500). ❑I.at owner ofthe property,or my employees with wages a their sole compensation, will do the work,and the swcture is not miended oroffeled for sale(Sec.7044,Business and Profentions Code:The Contractor's Licemic Law dace not apply W an owner of Required Inspections own eny who builds i improve.dthasudmmprove who amssuch win d oroff red for ugh his . ownemployees.provided pornmimprommenUarcne year fcoroRered tarsale.B, however,the building or improvement is old within one year of completion,the owned .In), will ban Ute Wrden of proving that k did not build or improve for euryon of Y y sale.). ❑1,u owner of the property,am exclusively confessions with licensed retractors l. construct the project(Sec.o an Business and Profession.Cadeo The Convector's sed cause Intra docs not apply to U owner of property who sed p or improves thereon.and v who contracts for such prolecta with aconmctar(q licensed pursuant the Contractors / Lkeva intw. x ❑lam exempt antler Sec ,B@PCf,,r thin.ason Owner Date WORKERS COMPENSATION DECLARATION I herby affirm under penalty of perjury one of the fallowing declarations: 1311,of ave and will mainaln a CertlEcam of Cano Imadf-insumforWarkorsCompcn- .as provided for by Section 3700 of the Labor Code.for the performance of the Ffor which this permit is issued ave and will maintain Worker's Compensation Ins unnce,as.quired by Section the Labor Code,for Nepfforinance of the work for whichthisparmitlxbound.orker' .am ema0on Inco..comaead Poll,nmber am: -7/ 2 Oor. Policy Na. 0 2 / CERTIFICATE OF E(EMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not W completed if the Permit is for One hundred dollars(S IBM or less.) 1 ccnify that in the performance of the work for which this permit is issued.l shell not employ any person in any manner an as in become subject o the Warkers'Compeneation Laws of California.Dam Applicant NOTICE TO APPLICANT:If,after making Nis Cenaacete of Exemption,you should become subject in the Worker's Compensation previsions of the Ichor Code,you must 0 O forthwith comply with such provisions or this Permit shall he deemed invoked. z0 CONSTRUCTION LENDING AGENCY 14 l hominy eMrm that then bee connuctinn lendull.in ncy for the pedormenm of !�7 the work for which this permit is issued(Sce.3097,Civ,C.) W�Q Limiters Name Lenders Address U Q I comfy that I have rtad this application and sum that the above information is fy cortccL 1 agree to comply with all city and county ordinances and Stam laws relating to ' Q E. building construction,and hereby amorise rep esennitives of this city to enter Open Ne U shove-mentioned property for inspection purposes. LF^+y (We)agree to on,indemnify and kap humleu dm City of Cupertino againsl ti rA iiabilitiea.judgmems,cos andexpenses which may in anyway arse against svdCity V z memocil aceafthe ming of this Permit. APPLICANT UN STANDS D WILL COMPLY WITH ALL NOWPOINT Issued by:9 Date SOURCEREGU ONS. ^2C' Re-roofs Signature Aindicant/Commemr Dam HAZARDO IALS DISCLOSURE Type of Roof Will the applicant or fiat (ding occupant at=or handle hasardous material as defined by be Cupertino Municipal Code,Chapter 9.13,and the Health and Safety Alawmik.Se❑mYeson 25532M)? ON. 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 OR hanardous air comiminards as defnod by Ute Bay Arca Air Quality Management all new materials for inspection. ict? ❑Yes ❑NO 1 have mad the hoankso materials requiremenm under Chapter 6.95 of the Califor- iliaHealthASafca Code.Section 25505,15533 and 25534.1 undcrsmnd Mat if the building docs not cone ham a moan ]I is my rtaponsiM1ility m notify U.occupant of the ♦ rcyuircmen ichmuslbc Ipd iaseanceoraCeNlinti, eapaney. Signature of Applicant Date S t All roof coverings to be Class "B"or better Owner or amhadood acct Dam CITY OF CUPERTINO . ' '`' BUILDING DIVISION PERMI ?"C , d,1NTXtACTQI2""TNF©1�M.A.T BUILDING ADDRESS: PERMITNO04050129 0815 P7NINSTMAR AV EWS NAME: PERMIT ISSUE DATE MICHELL REYNOLDS ONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGELECT PLUMB MECH (� I 0 OO LICENSED CONTRACTOR'S DECLARATION - g g 1 Wmby amrm the,I em licensed under provisions of Chapter 9(commencing Job Description wiOSaxHmi7XK)of Divi'on fthc Business and Pofcssi�m Code.and license is eio, mmnrortxanTerre C' 7-a S WATER DAMPAGE REPAIR ON FLOOR � License Clas Lic.# contremce ­CONTRACTOR: PRESTIGE BUILDERS ARCHI TS DEC N I BATHRM/DRYWALL/DOORS/FLOORING underaunJ my plans shall he used as .hl pm rccorJs Dyu Licensed Pmlcssional gOWNER-BUILDER DECLARATION <q 1 hereby.olTum.'haul nm exempt from the Cmareen is Liecrum Law for the C p O following mason.(Section 703 1.5,Business and Profcvsinm Code:Any city or county which mgWa rea permit to construct,alter.improve,demolish.or.pair any.shimm. i^ prior us its issuance.also.quites the applicant for such permit to rile a signed statement pp < thathcislicensedpurauantinthepmvisiovnftheCommcmriLicenulsw(Chapmr9 Sq. Ft.Floor Area Valuation Y�-$ (commencing with Section 7M)of Division 3 of the Business and Professions Code)or La that he is exempt therefrom and the basis for the alleged exemption.Any violation of. $25000 Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of. APN Number Occupancy'Iype o mo.than ave hundred dollars(5500). ❑I.as owner of,M pmpeny,or my employcm with wages w Wcirsole eompensatian, will do Newark and the st.eture is not intended or offered for sale(See.7094,Business 3 2 ES 0 3 0 2 9 , and Profusions Code:The Convector's License Law does not apply in an owner of Required Inspections property whobuildsar improves themomandwho does such work himself or though his +awn employees,provided Nat such improvements art notintended oroRered forsale.If, however,the building or impownwoR is sold within one year of completion,the owncr- buiider will Mere the burden of proving that he did not build or improve far purpose of .Ed.). SEP 2 d 2004 ❑1,as owner of the property.am exclusively contracting with licensed eo muscmrs to construct the pmject(Sec.7044,Business and Profusions Code:)The Contractor's U. came Law does not pply in an owner of progeny who builds or improve themon.and, BUILDING.S who contracts for such pmjecw with a compactor(s) B���®'r(s)licensed pursuant to the Contractor's gY`VgG License Law. ❑1 am exempt under Sec. .B&P C for this reason er Data WORKERS COMPENSATION DECLARATION I hereby affirm underpenalty of perjury one of the fallowing dalamtions: ❑1 have and will maintain aCerOfcate ofComenuo ulf-Insure for Warker's Compen. sation,m provided for by Section 3700 of the,Labor Code,for On performance of the .,it for which this permit is issued. ❑I have and will maintain Warker's Compensation Insurance,u required by Schon 3700 of the Labor Code,for the performance of the work for which Nis permi,isissued. - My WmlmeY mpensadon lnsumna canicr and Policy number tic:/—a/ Cartier. SOT Polity No.f0O2 . (k CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (ITissection need rat completed ifthe permit is forone hundred dnllare(51W) or less.) 1 cenify that in the performance of use work far which this permit is issued,I shall not employ any Person in any mannerso as to become subject to the Workers'Compensation Laws of California.Data Applicant NOTICE TO APPLICANT:V.after making this Cenifeale of Exemption,you should become subject In the Worker's Compensation provisions of tim Labor Code%you must OZ folhwith comply with such pmvisinns ar Nis permit shall be domed ranked. ZsO CONSTRUCTION LENDING AGENCY (ti res I hereby alarm Nat them is a construction lending agency for the performance of a ?„ the work fur which this permit is issued(Sec.3097,Civ.C.) Q Under's Name ]z Lender's Addreas O Q 1 certify that 1 have mad this application and slow that the above infommtlue is ITT F correct.l agree to comply with all city and county ordinances and state laws mixing to QV building construction.and hereby autharin repromatmi a of this city.enter upon the rU above-mentioned property for inspection purposes. (We)agree to save,indemnify end keep harmless the City of C.pema.against nFi h liabilities,judgments,cos and expenses which may in any way acerae against mid City V num APPLICANT UNN0 STANDSthts D WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGU ONS. 0-7 Re-roofs SigmancarfApplicanVC.a—'r Data HAZARDO RIALS DISCLOSURE Type of Roof Will the applicant or fum- riding occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety ode, C]Ycs No axss3ue)? All roofs shall be inspected prior to any roofing material being installed. ❑Ye ❑ 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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes ONO 1 have mad thehamrdous makrials.qui.ments under Chapkrb.95 of Ne Califor. if.H�Lm &Self i Code,Sections 25505,8533 and 75534,1 unders.nd thatifibc building docs orm hast a Icon at tis my sponsibility.noury the occupant of the mquin tch must be tpd issuance of a Cenificam,of Occupancy. Signature of Applicant Date Owner tar authorized aFen �. Date All roof coverings to be Class "B"or better MFY.12.2004 6:11PM FIMPI<CiRL 117f: BROKERS P. MICHE'_.LE t-O.716 P.2 MAN SKETCH ADDENDUM Borrower/CIi�1�G Pro art Fuldtnee ' .TN unt M1 AVF CITY ---^- —.---S-A�NZA CLAZA State C 2I C e Lander C 1�4,W�iJD BUILDING SKETCH $fie�(�/►�it!"J , mix 22 9 ` BEDROOM BEDROOMn7 0 tL 30 GARAGE BATH 'S sLl BEDROOM y1 15 c 43 � KITCHEN t� - Ga ! V.. l � � LIVING ROOM toK DINING " _ . � AR& 23 �1 24 GSC FAMILY ROOM y 3Md'to DtL ., 27 15 C.c Ccprrm carr . i 97 ; Ism r j� t�t 3c rs rn r 9ITY OF CUPERTINO CUPE��TFINO PERMIT APPLICATION FORM APN # L` 2 I n (( b 13 Date: p Building Address: Mailing Address (if different from building address): Io2r/ P �Nsuc �R -AJ c�P R �© CAL Owner'same: Phone 1e��Jo 0 ) P- O'� 25- `0 Z Contractor: License'#: CoCt: Phone: 6v) Zq-Y227 Cupertino Business License#: Fax: 4VU -yy Building Permit Info: Bldg Elect Plumb Mech Job Description: r Residential f� Residential )Rolk(f R CWN R � Commmeerci 1(❑� � Sq.Ft. Floor Area: $/Sq.Ft.: 14/4 fir: Cost of Project: Occupancy Group: 2SDod Type of Construction: Please check this box if the project is a RTN-Rc�oe r p 6 Al d)ooRS (7,L CC second-story addition: ❑ Project Size: Standard Laze ❑ Major ❑ 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 1 of 3 SIN TY OF CUPERTINO CM OF PERMIT APPLICATION FORM CUPEkTINO uantity 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 I PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piging 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 iinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER InstalVAlter 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 BREMAMHAN 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 BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL 2 of 3 r '?, �� *CITY OF CUPERTINC* CUPEf�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance ELECTRICAL 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 BSPECLAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING , BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Busifiess License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL w MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance :> MECHANICAL j PPERMITFEE l Plumbing Permit Issue PLUMBING PPLBG Plumbin Fees .foot ,;,' i ;,. PLUMBING ZADDCHG Address Chane BUILDING 1 r � f 3 of 3