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04090278 (2) ;. -CITY OF CUPERTINO - - BUILDING DIVISION' PERT CON'TRACT(�R BUILDING ADDRESS: PERMIT NO. SONES MASONRY 04090278 OWNER'S NAME: ._.. ..... .. PERMIT ISSUE DATE - AL CAROL NE: - - SANITARY SirOL NO. ARCHITECT/ENGINEER: - BUILDING PERMIT INFO B E PLUMB MECH 30p LICENSED CONTRACTOR'S DECLARATION _. uF bunchy a0hm that 1 am licensed under provi lona mr ChaTc 9(commencing s with Sc n7QNJ)of Dlviaion3of ase Business an nm'�a,Cbode,'endmylicenuis iSS Io esu Ip[ Off b DEC ,PIZ Lie Q a Lin q - - -CHIMNEY •Z-- 2004 M Da¢ Cuntrutor - ARCHITECTS DECLARATIT �i tan urs rad In all hd u n BUILDING ;c� Licensed P-Tea31 a / •-_ _ .. _. .. U tato . 3 OWNER-BUILDER DECLARATION I I hcrchy sRrm that 1 am exempt from but Condolences License Law for the p O following mason.(Section 7031.5,Business and Professions Code:Any city Or county E:20 m � which-quires a Permit to construct,aler,improve.demolish,or repair any structure - y;vo prior to its issuance.also requires the applicant for such Permit to file B aignedsulement ££ < 4499 thatk is licensed pursuant-Ne provisions or Ne Commuter's License law(ClmP-r9 - Sq.FL Floor Area Valuat On yZF$ (commencing with Section 7")of Division 3 of the Business and Pretoria...Cock)., dust k is exempt therefrom and the basis for due alleged cumpdon.Any viohtion of Section 7031.5 by any applicant for a permit Subjects the applicant to a civil penalty of 32WNaV4nbgroo Occupancy Type non mare than five hundred dollars(5500). - ❑I,uownerofthepmpmyormyemployeuwiLh agum0eirmiccompenwtlon, will do the we&,and theswctu-is notinended oreffered foraele(S.C.7044,Business and Pmresaians Code:The Conunemor License Law does not apply re an owner of -. Required Inspections property who builds orimproves thereon,and who doessuch work himselforthrough his - ownemployaes,providsd that such improw.0 arc natinueded croRered forsale.If, however.the building or improvement is sold within one year of completion,she owner. - builder will have the burden of proving that he did ban build or improve for purpose or saic). ❑1,as owner of the propeny,am exclusively contracting with licensed contractors to c natolct the prejecs(Sec.70",Business and Professions Cade:)The ConuacwYs Li. - cense Law does not apply to an Owner or property who builds or improves thereon,and who contracts for such prejecs with a eommmer(a)licensed pursuant-the Conroetats License law. ❑Ism exempt under Sec. ,B&PCforthiamuon 137'W wner Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under Penalty of perjury arc of Inc following declarations: I have and will maintains Cervifscrtoof Conxenuoself-insure for Wmkeb Compen- - ion,u provided for by Section 3700 of Ne Labor Code,for the performance of the - rkforwhichthispermitisissued. - — - 1 have and will maintain Worker's Compensation Insurance,u required by Section of the labor Code,for the Performance of the work for which this permit is issued. y Worke 'Cn 1 oral) PloaamnC/q carnia end Polity nemkr am:rtier I '� lieyNo_V ' J11' CERTIFICATE FEX^MPION FROM WO S' COMPENSATION INSURANCE (This section need not k completed If tic permit is foronc hundred dollam(EIM) ' Or less.) 1 certify that in the performance of the work for which this Permit is issued.I shall not employ any person in any manner so u-become subject o rhe Workera'Compensatian - Laws of California.Date Applicant NOTICE TO APPLICANT:If.after making this Cenireae of Exemption,you shooW became subject to the Worker's Compensation provisions of the labor Code,you must .e'f. ZM fawida com ply with such provisions or this No.![shall k deemed invoked. z'y CONSTRUCTION LENDING AGENCY F••m Iherehy affirm that there is a construction lending agency for the Performance of - [� F�-m due work fur which this permit is issued(See.3()17,Civ.CJ RWi 0 Lender's r7 z Lender's Atltlrrss U Q 1 certify that 1 have mad this application and state that the shove infom ulm,is IT.(✓ CarecL 1 agree to comply with all city and county ordinances and se-laws minting to 0O building construction,and hereby amponce represcraavef of this city-enter upon the W above-mentioned property for iupecaon purposes. ,r�yy G (we)agree to save,indemnify and keep h.less the City of Cupertino against jy,n liabilities,jndgmCne,taxes and Cxpenrce which may in any way accNe against said City - — U z in consequence of the granting of this permit. - m—' A (CANT UNDERSS+TANDS AND WIL COMPLY WITH ALL N ON-PO Issued by: Date s u�gR, yeµ Id �„_ _ ir_ ,� 9 Re-roofs Signal -pplicant,Coumctar Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof HI the applicant or future building uccupent store or handle Incurious malarial . as fined by the Cupertino Municipal Cods.Chapter 9.12,and the Health and Safely ale.Section 25532Elf materia/beAll roofs shat] be inspected prior to any roofingng installed. ❑Yes ><NNu Will the applicant or future building cecupant use equipment or device:which If a roof is installed without first obtaining an inspection,I agree to remove mit hale dnus air comamiwna de0ncd by the Be,Area Air Quality Management all new materials for inspection. District? Year No In wmad the krardnus maWrialsmqui-mens under Chapwr6.95 of the Califor- doesnlW&Sntlyy Code,wn&nL ueiti my mnd25534.1 undsrstand Nodi(uehuilding dols not currently have a Wvnt this it is my mepouihility m nosily the aceupant of th - naim .which mast,metoreir a ccnincaWofaca an Signature of Applicant Date own or authodxed agent n ssu oDate All roof coverings to be Class"B"or better Community Development g 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 j6,UPEI�TIN0 Building Department JOB ADDRESS: PERMIT# /D/Pb oqo'?o 2.78' O R'S NAME: tgn P # -�/Z GENERAL CONTRACTOR y / FAX # I am not using any subcontractors))!� ! )21L�"3 2 U Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork. Cement Finishing Electrical 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 Tile • cGu��e � �2 �'� d /Contractor Signa Date V CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM APN# 3?, 6 /g. 0 y/ Date: 9 dvo Buildin Address: Mailing Address (if different from building address): �o Owner's Name , /�M f/�� Phone #: Contract4r: A /a�/[� !il License#: 2 UU3 y7 Contact OY�I . Phone: 85'7- Cupertino usmess Li`ce'nse#: J S Fax: 3*71--7M C2/aaS Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job Descripti da-ma- Residential a-m L ed Chiari Residential `/ Commercial ❑ Sq.Ft. Floor a: $/Sq.Ft.: Cost of proj ct:4 /� Occupancy Group. Type of Con 7A Please check this bo he ct is a second-story addition: Project Size: Stand M& 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 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 B19VESTIGA Investigation fee BUILDING 2, 7 2,1 1of3 „ /—/ �� L� --- CITY OF CUPERTINO 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 BREMAMHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT - Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CUPI�TINO PERMIT APPLICATION FORM E uanti FeeID Fee Descri tion Fee Group BREMSIGNAD Rmdl Si s Add Branch ELECTRICAL BREMSIGNS Remodel Si s, Mar uee ELECTRICAL BREMTHEATR Theatrical Li tin Fix ELECTRICAL BREMVENFAN Vent Fan Sin le Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb S ecific Plan IF G BSEISMICOM Seismic Commercial NG I- BSEISMICRE Seismic Fee Res NG BSPECIAL Special Inspection G BSWIM SwimmingPool G BTEMP Temporary Power ICAL BTEMPPERM Tem ora Bld Permit ING. BTEMPSVCS Tem Dist Svcs ICAL BUSLIC Business License ING ELECTRIC Electricals foot ICAL EPERMITFEE Elec Permit Issuance ICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE PlumbingPermit Issue PLUMBING PPLBG PlumbingFees foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3