04090100 (4) CITY OF CUPERTINO'
BUILDING DIVISION PERMIT C"ONTRA,C'TOWXl k'() tMA.xI(JN'
.3
BUILDING ADDRESS: """"04090100
" ND04090100
ERS NAME: - PERMIT ISSUE DATE
JAMES QTjTRRTR. NOV I S' 2004
JE: SANRARY OL NO.
ARCHITECT,ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACTORS DECLARATION
1 hereby affrtm lhut 1 3 licensed and m Pistons ar chapter 9(commencing Job Description
-Z� with Iia 7agp of Division Sof Ute BuainesOdiE Pm(cuimu Code,and mylieens is
j^�n� in full and arca Z-7 Licca N✓..�' GAS LINE TO BBQ
0,E Lumex Class
Date Com g' CONTRACTOR: BAYVIEW LANDSCAPING & MAINTENANCES
ARCH C I E(TS DEC TION
L
n m y;pall-M octose is rccards '
G U 'Loam mfcasi inns
OWNER-BUILDER DECLARATION
<� 1 hereby affirm met I am exempt from the Contractor's License Law for the
p O following moon.(Seefion 7031.5,Business and Professions Cnde:Any city or county
X$ which requires a permit to constroct,alter,improve,demolish.or mpmr any stfuhe
�ba
poor it)its issuance,also requires the applicant for such Permit to fila a signed statement
�� Nat he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area ValuatiGp
(commencing with Section 70DO)of Division 3 of the Business and Profcasu Cnde)or 4500
t F$ that he is exempt membrane and Ute basis fm the alleged exemption.Any violatron of
section 7031.5 by any applicant for a permit me applicant a civil penalty of pith Number Occupancy'Type
M,...more Nun five hundred dollars($500). panC
❑I,ismamomram Property,or my employe.with wage.as their sale crepeneetion, 36909007 . 00
willdo the.&.end me smactum isnotintended oraffemd foraute(S..70a4,B.in.s
and Professions Code:The Committees Lt...Law it=not apply to an owner of Required Inspections
propeny who buil o m improv.thereon,and who does such work himself.through his
awn employe.,provided that such improvements ere not intended ora@rod farads.It,
however,the building or improvement is sold within one year constriction,the owner- ,
builder will have the human of moving that he did not build or improve,for purpose of
sale.).
❑1,as owner of the propeny,am exclusively contracting with licensed contractors e
conatmet the pmject(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense law docs not apply to an owner of property,who builds or improves motion,and
who contracts for such perjects with a cont urs)licensed pursuant to the Contractors
License Law.
❑lam exempt under Sec ,B&P C for this moon
r Date
WORKERS COMPENSATION DECLARATION
1 hereby M.under penally of injury one of the following decla.bons:
ave and will mainmin a Ceniftcme of Consent to self-insure for Worker's Currier-
n,as provided for by Section 37110 of Um Labor Cade.for the performance of me
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation insurance,as required by Section
3700of One Labor Code,for Um performance of me work for which this permit is based.
My Wmk;' Comparison 1 Xynce canis and Policy Mount, :OO
Cartier:"``.-WG /L"'.wOM No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisscctinn seed nollre completed tribe permit is @rant hundred dnilars($IIXq
2o.)
I comfy that in the performance of the work for which this permit is issued.I shall not
employ My person in any urxay ma. so
subject to the Warkera Compensation
Laws of California.Dem ZZ,/ V
APPiicsnt cony"Caw
NOTICE TO APPLI�CA .IL after making this Certificate of Exemption,you should
become suhj.t to the Workers Compensation provisions of me Labor Code.you must
.J,z foMwith comply with such provisions or this permit shall be deemed mocked.
Z Q CONSTRUCTION LENDING AGENCY
(-+ I hereby affirm met them is a construction lending agency for performance of
6i rte- Uma work fur which this pcsmil is issued( 3(197,Civ.C.)
V]Q Lender's Name, ! /�l�
z Lender's Address
C
U Q I certify that I have mad this application and sum met the above information is
Dr F corms(.I agree to comply with all city and county ordinances and sets laws misting to
DU building conswction;and hereby militarize mpmsenutivis ofthis city to enter upon the
W ahovcros,judgcdproperty
st fond exporters
purposes.
gy (We)agree to save,indemnify and keep harmless the City of Cupcnsm against
Z
liabilities, ents,of
grotindof this camit. may in any way eceme agelnstaaid City
.U z in conuquenee of the gmnling of this permit.
APPLICANT UNDERSTANDS AND {'ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CE EG L S. / � 2//"/r'
�/L/ Re-roofs
Sigma ofApplicaHAZARDOU Da
HA2ARDOUSMAinj we LSDISCLOSURE Type of Roof
Will the applicant or tomo building mcupentstom or handle ha'rsrdous materiel
.defined by Ute Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
.
Section Yes 25532(a)? fa All roofs shall be inspected prior to any roofing material being installed.
Yes N
Will the applicant or future building oceupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hvemoo air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
mien P
❑Ycs �Nu
I have mA the hoadaus materials requirements under Chapter 6.95 or the Califon
ria Health&SafelyCode,SccGans 25505.25533 and 25534.1 understand met ifthe building
docs not torten ve a tenun,the(it is my responsibility to wOfy Ne,recap.,of me
requi w ' metpriormi a obaCcnificateof cmpmttyy. Signature of Applicant Date
�6
Owner urharizcJ agent Vic g All roof coverings to be Class"B" or better
CITY OF CUPERTINO
acile PE.RMIT APPLICATION FORM
CUPEkTINO
QFPN # Date:
Building Address: Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor: License#: 71
Gr
Contact�/ 30�d')FrRO;V Cupertino Business License#:
.,Phone:
Fax:
Building Permit Info: 31(1,, 4,Ae-- /�c/
Bldg 0 Z�--�3;cv Plumb mech El
Job Descri#0n: 1?eQr
Residential �1�r Commercial 0
Sq.Ft. FloorAx. $/Sq.Ft.:
Cost of Project: Occupancy Group
<L L�--
Type of Constructick Please check this bbi-iftfre project is a
s6cond-story addition. El
40i�ectsioz,c: Stan1lard 0 Large El Major El
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 1 OOK to 5 OOK Btu MECHANICAL
BBOILER3 Boiler> 500K to IM 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 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elee 600V> I OOOA ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BMVESTIGA Jnvestigation fee BUILDING
* 2-7 D "
I of 3 7 7- 4��3
,
CITY OF CUPERTINO
WCFC
CUEINO
PERMIT APPLICATION FORM
uanti 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
BOVERTEAE 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 Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Stomi/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 cfra MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfrn MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMEURN 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
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPEkTINO
PERMIT APPLICATION FORM y
Quantity .. Fee ID Fee Description Fee Group
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
BSPECIAL Special Insection BUILDING '
BSVvUM 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 Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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