06010008 (2) 'CITY OF CUPERTINO
BUILDING DIVISION PERMIT '• CONTRACTQR INFORMATION
BUILDING ADDRESS: DELTA ELECTRIC PERMIT No.06010008
"22176 RAF LN
OWNER'S NAME: PERMIT ISSUE DATE
ACLE HICKS 724 COLLEEN DR 01/03/2006
NE: SANITARY NO. CONTROL NO.
(408) 224-0176
ARCHITEC SNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION O O O O
1 horeby affirm Out 1 am licensed under provisions of Chapter 9(m rmoncing Job Description
wit Sc
clion 7M)of Division 3 ofthe Business and Professions Code.and license is
- = neuro to= RECESSED LITS & SWITCHES
Lleman Cla Lk.9
Da._k E TSTEmr
RCHr3EC o DEher R1 ON
01I understand my plans shall he used as public meets
Licensed Professional
S OWNER-BUILDER DECLARATION
<� I hereby affirm Nu I am exempt from to Conuzctm's Lieenae Law far the
i.
00 following mouton,(Salon 7031.5,Business and Professions Code:Any city or county
s m� which requires a permit to mmwct,alma improve,demolish.or repair any structure 2 O 0 0
Prior.its issuance,also mquires the applicant for such permit to rile a signed statement
< Nat he is licensed pursuant to the Provisions Of the Commetuh License Law(Chapter 9 Sq.Ft.Floor Area Valuation
zII-M (commencing wish Section 7")of Division 3 of the Business and Professions Come)or
— Nat he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Nc applicant to a civil penalty of Occupancy T
not more Nan five hundred dollars(SS0a3 p Y ype
❑I,es owner ofted property,or my employes who wages as Ncir sole compensation,
will do Ne work,and Neamrmum isnotinanded or offered forsake(Sec.7014,Busidess ,
and Pmressions Code:The Contractor's License law does not apply in an owner of Required Inspections
propeny w ho bui Ids m improves Nanton,and who docs such work himsel f or daough his
owe employees,provided that such Improvements art not intended moRered foredo.If.
however,the building or improvement is sold within one year of completion,she Ower.
builder will hale the burden of proving Out W did not Wild or improv for purpose of
mile.).
O 1,as owner of to property,am exclusively contracting with licensed contracmrs an moi/
consumer On project(Sec.70x4,Business and Professions Code:)The Contracmr's V.
move law dors not pplman owner of property.wW Wilds or improves thereon,and,
who contracts;for such projects with acontractor(s)licemedpursuam m the Convador's
L Law.
❑l
License
am am exempt under Su. ,B&PCfor Nis reazon
Ower Dale
WORKER'S COMPENSATION DECLARATION
1 hereby a?nn under pemhy of perjury one of the following declaruiom:
1 have and will maintain a Certificate of COment to seif-her eforWorker'sCompen-
7[3:7]IW
ion,as provided for by Section 3700 or she labor Code,fm she Performance of the
k for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance,as requited by Seton
of Ne Labor Cade,fe,On Performance of the work for which Nu permit is issued.
Wmrkes'aCCote'nisi fir l �u{WW{i�m77�c��a�rriu��andPaIiry{/;umbe `� r�rtiu:�] _k_XEMPTIoliry No.{t,{ERS' J�
Cl T ATE OF E% MPr10N FROM RKFRS'
COMPENSATION INSURANCE
(Thu section need not W complied hf de permit is fmoee hundred dollars(SIM)
or less.)
1 cenifv Nat in the arformanm of Ne work for which Nis Permit is issued.1 shall not
employ any person in any mannerso u to Wmmc subjeduo to Worhon,Compem alien
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certifies.of Exemption,you should
become subject to the Worlmrs Compensation provisions of d.Labor Code,you mase
.J z foMwith comply wits such provisions or this permit shall W deemed revoked.
'ZO CONSTRUCTION LENDING AGENCY
(� Thereby&TIM Nat them is a construction lending agency for the Performance or
E
> thc work for which this Permit is issued(Sm.3097,Cir.C.)
4 L emko'.Name
7 Z Lander'.Address
U 0 1«nify Nat 1 have read Nis application and sum Nat Ne above information u
ly Pcorrect.I agree to comply with all city and county ordinances and suis laws relating to
C)U building construction,and hereby auNarien mpresenutives of Nis city to enter upon the
oned
fty
W aWvices,poroems.cst fond ca coon purposes
F
P. (We)-9.tp save,indemnify and keep harmless the City of Cupertino against
UZfA incoitielloco of the gumming exOis Permer it. may in any way acemc against said City
in consequence of the granting o(Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU RCER LATIO I2 r�r
o(Applic cut,
�—r��—)�I•--�teP Re-roofs
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or run=Wilding occupant mom or handle hanardous notional
I-der ncd by the Cii rum Municipal Code.Chapter 9.13.and Ne Health and Safety
Code,Section 355J3(e)?
❑Yea ❑No All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I
Will On applicant or fuwm Wilding occupant tau equipment or devices which g agree to remove p
it hamodnm air contaminants ss defined by the Bay Arta Air Quality Management all new materials for inspection.
7nia
trict?
❑Yes FIN.
I have read Ne lame dmssmaterials rcyuircmcnu under Chapterri.95 critic Califor-
Health&SafctyCedc,Sectors 25505,25533 and 25534.1 usecosand thttif Ibe Wilding
s not cumcnlly have a mint,Not it is my responsibility m nosily On emomo t of On
ommemtsw mouls�mespd rmiss irfltCctriento rOcmpncy' Signature of Applicant Date
�.> r�r
Owner m,athnm ed gem I Date All roof coverings to be Class"B"or better
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Assessor's Parcel Number: '' Lf cp
Name of owner. pso L4
Project address. -zz L
Contact person. Phone.
C) Fax. (!t)
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside thearage?
• Is privacy protection planting required for the project? .14 t:
On what floor(s) is work being done? 12-1-
Brief descnption of work.
Code editions: 2001 CBC (Y -N)2001 CFC (Y - N)2001 CMC (Y- N)
2001 CPC (Y - N)2001 NEC (Y - N)
Effective 11/1/02 wewe1 cd 1-� .0
Plan Review Process Work Book Page -8-Revised 4/28/04
- Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
a ?6 - �rT 6b 1000
OWNER'S NAME: 5 PHONE # 5/ /
GENERAL CONTRACTOR: I FAX # LIOR ?.=)L 3O=),
I am not using any subcontractors: c3
Signature Date
Please check applicable subcontractors and complete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical -71
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood I --
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
• Tile
fo
Owner/Co tra ignature Da(e
CITY OF CUPERTINO
CUP TYOF O PERMIT APPLICATION FORM p
N # 2 Q4 � Date: / 3
Building Address: Mailing Address if different from building address):
Owner's Name: Phone#:
Y6eas of
Contractor: License#:
7Y� EL�C712i� S'25 a-
Contact: Phone: — Cupertino Business License#:
Fax:�ay-30. 'e qO
Building Permit Info: -
Bldg ❑ Elect gL52Plumb ❑ Mech ❑
Job Description: I
Residential `� Vl 1S q .�tJlU-Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Proiect: c7 Occupancy Grouu:
($OV 16%� R 3
Type of Construction: Please check this boa if the project is a
U(�
second-story addition: ❑
roject Size: Standard Large ❑ Major ❑
uant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER1 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
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�° CITY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM
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 PLUM 1NTG
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/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstaWAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfln MECHANICAL
BREMA]RHAN A/C Units <= 10,000 cf m MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREAENHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNNRAPP 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 Re air/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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CITY OF CUPERTINO
CUILA
CITY
TYOFF' PERMIT APPLICATION FORM
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 1VIECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BS)VW Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEi\IEPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Elcctrical sq foot ELECTRICAL
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERAMFEE Mech Permit Issuance MECHANICAL
PPERMTTFEE Plambing Permit Issue PLUMBING
PPLBG PlumbingFee s foot PLUMBING
PLLONGRNGC PlanniLRCo / uti-FaPLANNING
nlnmMlm
PLLONGRNGR PlanRi
PLANNING
ZADDCHG Address Change BUILDING
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