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03060040 (2) r CITY OF CUPERTINO r /t �y� p J� "''' �" BUILDING DIVISION PERMIT k"VQ` Cx RAIM"ORM T111I ..ax BUILDING ADDRESS: PERMM N00 3 0 60 04 0 6223 SHADYGROVE DR �savmm ER'S NAME: EMIT�(10 4/2 0 0 3 VID & LINDA SHEFLER 1PONE: SANITARY NO. CONTROL NO. ARCNITECTIENGINEER: BUILDING PERMIT INFO BLDO ELECT O l� PLUMB MECH O t� Loa LICENSED CONTRACTOR'S DECLARATION JobDescri tion Ons 1 hereby affirm Net 1 Am Ilansed under provisions ha of Cpter 9(. gtram- p n� wish Section 7000)af Division Sof NC Business and Profusions Code.and my license is VERIFICATION ONLY _ in full forte and affect. j� �, p pqa p�q qz Dammac Clam Colnnar (ORIG. 423374/03/05/92) lf'�Otl'!a�'�AL�"_WI ARCHITECTS DECLARATION i t ndcn axed my plana shall W used m public mcnrd = JUN 1 0 2003 3ojna Licensed Professional OWNER-BUILDER OOW NEDER DECLARATION I hereby affirm that I am exempt Wm Ne Contractor's License Law for the following mason.(Saban 71DI.d,Business and Profession Code: Any City Of county BUILDING s which requires a permit to Construct, . an ct,ah.,improve,demolish. .Pair y structure t <A Fzl^ pilar to its issuance,also requires the applicant for such permit to rile a signed statement < that lm is licensed pursuant to the Provisions of Ne Contractor',Licc.Law(Chapur9 Sq.Ft. Floor Area Valuation (cmnmendng with Section 7010)of Division 3 of the Business and Proaselons Cod)or $0 dist he Is exempt sherefram and Ne basis for she alleged esemp Ion.My violation of Section 7031.5 by an appimsm far.permit subjects she applicant to a civil penalty of eT Occupancy Type Out mom than riw hundred dollen(SSW), 3j }z (J(JZ 17 - O O ❑I,mowcesofthepmpmymmyemployemwlshwagesu NNrmlemmpcnution, will do the wart and Nesimnum ism,intended oraQered fonassee.70M,Business y, I �s� and Profem mus Cade:The Contractor'.License e law daml apply b an own.of 304 — ROUGH 11Mkn4A &ns pmpcny who Wildsorimproem shearam.nd wharf n.chwork himself.through his 501 - FINAL ELECTRICAL ENERGY ownemploym,provided Nu such improvements art v.1 intimal oraBercd fared-If. however,the Wilding"r improvement is sold within ace.Sear ofcmmpletion.the Owner. 505 — FINAL ELECTRICAL builder will have the Wriest of proving that W did nm build or improve for purpose of sale). ❑I.as owner of the property,am exclusively contracting with licensed conaammr,to construct the pmject(Sec 7e),Business and Profecinions Code:)The Contrsemr's U. cense law docs not apply to an owner of property who Wilds or improm theman,and who contracts for such projects with a c"mretor(s)licensed pursuant Of the Commutes "e Lt.. Am cempt under Sa. ,Bk PCfra moron a D WORKER'S COMPENSATION DECLARA I hereby tMen under peulty of perjury am of the foltming declarations: ❑I haw and will maintain a Certificate ofC"naem m self-imure for WorkeraCompen- sation,u pmvidd for by Section 3700 of the ISWr Cade.for the performance of the work far which this permit is issued. ❑1 haw and will maintain Worker's Compensation Insurance,u required by Section 3700 of Ne IJWf Cade.for the performance of Ne work for which this permit is issued. My Workeri Compensation Insurance carrier and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKFRS' COMPENSATION INSURANCE (ITisa enm rad not W completed Vote permit Is foram hundred dollar(SIM) re WA) 1 certify that In Ne perform cc.of the work for which this permit is issued.I thall not employ any person in any manner an u to Wame subject to the Worears'Compensation ' Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this CeniBcau of Exemption,you should become subject M the Worker's Camic num on prevision of the Labor Code,you must ,J O forthwith comply with each provisions or this Permit shall h"domed revoked. 'Z� CONSTRUCTION LENDING AGENCY (.. 1 hereby al imm that Nen is a cmuuuNnn Rnding agency for the Performance of a 7 the wurk fur which this permit is luded(Sec.3097.Civ.C.) Win~. Landers Name zm)z Lcomes Address U Q I anify the I haw read this application and rete Net the show InformNun is Ig ;'" correct 1 agree to comply with N city and county omiu mces and tuts law misting to OlS'J' buildingconstruction.adhereby authorimrepresentatives"f Nis city to enter upon the above-mentioned progeny for inspection purposes. FCy'0. (We)agree to save,indemnify and kap harmless the City of Cupertino against fq liabilities,judgments,costs and expcum which may in any way Avera against mid City V Z In consequence of the germing of this permit ^' APPLICANT DNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR R 011 S� �� / — `� Re-roofs Silip0dreo Applicam/Conuacur /—/ Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant art future building aeupantsmm orhatdlc harmdous material lDiauict?efined by Ne Cupertino Municipal Cade Chapter 9.12,and lie Health and Safety d",Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.. ❑YeaWill 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 it harandous air conuminanu u dc0nc Arythc Bay Area Air Quality Management all new materials for inspection. ❑Yea I haw mad the buudaus materials requirements under Cupter 6.95 of Ne Califor. Health@Safety Cad,Sedans 25505,35533 and 25534.1 mnOcrsund dw if the Wilding es not co rmily have a tenanui me w hmumWmet normieumceofaCanifcamof up Signature of Applicant Date n.. amarvcdag"nt D All roof coverings to be Class "B"or better G ,- CITY OF CUPERTINO CUP TYOF l' O PERMIT APPLICATION FORM 03 `' N# 7� _ 1-( o - O 20 Date: Building Address: 6,22-25 Shad Gi-dve �. Owner's Name: Phone#: wt"trl Contractor: /� License#: Ivam e } 1" Contact: W ino Business License#: Building Permit Info: Bldg ❑ Elect Plu ❑ Mech ❑ Job Descri ' �S Residential �� /6yt �ai1 /z��w'�(d/t •oro Gom�merceal too"a-( Sq.Ft. Floor q.Ft.: Cost of Project: Occupancy Group: Type of Construction: 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 BB0ILER5 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of �'I 5, CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee 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 BNUSFD New Single Family Res BUILDING 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 InstalUAlterWater Pipe PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAHZHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL . BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace> IOK 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 2 of 3 alo CITY OF CUPERTINO PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group 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 BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs,Marquee ELECTRICAL BREMTHEATR Theatrical Ligbting 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 Inspection BUILDING BSWIM 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3