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04020007 (4) CITY OF CUPERTINO BUILDINGDIVIs1oN PER C�NCRACTt)7C2INF RMA N z. 4 BUILDING ADDRESS: WM H FRY CONSTRUCTION COMP 1T"04020007 OWNER'S NAME: PERMIT ISSUE DATE E; SANITARY N0. CONTROL NO. (408) 996-8173 ARCHm Cp/ENGINEER: BUILDING PERMIT INFO _BlePG E Pf.UMB MCH woo LICENSED CONTRACTORS DECLARATIONdn I XX II U C I hereby affirm that I am licensed and pm,id.m of Chapter 9(comment s .---- -== ----_„ lob Dese p[ _tai wW Sects ] )ofDrvwen Sof Ne Buand Prufesmuns Code and my license "�� < full force d effect qi License La « S2e7b-J BATHROOM REMODEL � ' OCT �� 2004 nFq❑ Data �' Cunt oATTI r Lr a 1 un crstanJ my plans hall he used RrHmEiCTS OE ublic records Q 50: Licensed Professional BUILDING g OWNER-BUILDER DECLARATION B <S 1 hereby offirm that 1 am exempt from the Contractor's Liecnsc Law for the O o re lhTving reason.(Scorn 703 1.5,Business and Professions Code:Any city or county x m which requires a permit in cnnswct,alter,improve,demolish or repair any structure utzi prior In its issuance.also requires the applicant for such permit to file a signed statement that be is licensed for...Mr.the pmvisiomnnhe Cnmmclm x Liecnsc Lav Clorme,9 Sq.Ft. Floor Area Valuation (commencing with Section 7M)of Division 3 or the Business and Professions Code)or $ Nor he is exempt therefrom and the basis for the alleged exemption.Any violation of �,v tswva��a,..�, Section 7031.5 by curry applicant for a permitsubjecte the applicanuo a civil penalty of 36�B10I'�tdf$3e100 Occupancy Type ntmnrethannvehundreddmla,,(s50B. P Y YP 0 Las owner of the property,or my employcea with wages v their sole compensation, will do the work,and the structure is not intended proffered(.,sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to n e owner of Q p property who buildsvi i d that such u Vernon,and who harm a rsuch work himself edthrough his own employees,provided provehentIssld worerenotintendedor mpleeted for Owner, builder.Nebuilding orimprovement Issoldwithinone year of OnproNom theOwner, of builder will have rite burden of proving that he did not build or improve for purpose of salt.). ❑I,as owner of the pratil am exclusively contracting with licensed contractors to COMMet the pmjCCL.(Sec.7044,Business and Professions Code:)The Convector's Li- ecnsc law does not apply to an owner of prort who builds nr improves thereon, it who comments for such projects with a enntnctons)licensed pursuant o the Convenor's License Law. ❑I ren exempt under Sec .B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 40 I hereby affirm under Penally of perjury,one of the following declarations: ❑I have and will maintain a Certificate of Consent to selr-insum for Worker's Compere sation,as provided for by Section 3700 of the Labor Code,for the Performance of the work for which this permit is issued. rnave and will maintain Worker's Compensation Insurance,as required by Section - BO of the Labor Code,for the performance of the work for which this Permit is issued. My Work aCompensation Insurance carrier and Policy nu�irPber am: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thbsection treed not be cmollead if the permit is formm h mmol c illara piflul - (ir less.) 1 certify that in the performance of the work for which this permit is issued,l shall not employ any Person in any mannerso as to became subject o the Woderi Compensation Lawof California.Data Applicant icant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the labor Code,you must .JO fonhwi in comply with such provisions or this permit shal l be deemed revoked. ,zs CONSTRUCTION LENDING AGENCY I hereby alarm that there is a construction landing agency for to permoranca of R.a > the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name _ 0 Lender's Address U 1 certify that I have read this application and suite that the above inrmmatin is correct.l agree to com ply with all city and county ordinances and state laws relating to pU building eonswnion,and hereby authOrin representatives of this City to enter upon the W above-mentioned properly for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments.costs and expenses which may in anyway accrue against said City &W� U z in consequence of the granting of this permit '��\_....//� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2 OURCE GULATI S. �( b 7 Re-roofs Sisnamre of Applteam/Conuac Data HA74R US MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future building occupant store or handle haiumbus material as darned by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to an roofing material being Installed. ' ❑rax ON. P P � Y g g Will the appficantor future building Occupant use equipment ordcvices which If a roof is installed Without first obtaining an inspection,I agree to remove emit hazardous air comarromos as defined by the Bay Arca Air Quality Management all new materials for inspection. District] ❑Yes ON. 1 have mad the berar ous materials requirements under Chapter 6.95 of the Califory Fria Health&Safety Code.Sections M505.25533 and 25534.1 Understand itthe building does not currently have a tenant that it is my responsibility to Freely the cuoupnt Of the rc uiremcnL t mt ri missuncc ofaclalfcam of Oce nc q �"�'"usJe < �� .� y' Signature of Applicant Date fid`r pr authori'rcJ agent Dom L ° All roof coverings to be Class"B"or better c N w I LL- 4 , r, w ? J �+ rt7 f� APPRovED N A RDANCE WITH THE CITY y Q� �I CPE ►NO E AND 0 INANCES O ATE c=63 This set of piars end 1 1 be kept on the ', Pec�tications MU3 1 Ru at a,l times and it is un lawful to make any change; or alteration• L'� h same without w1,ten permission ;rorLAW the building Dept., City of Cupertino. The stamping of this p,an and speeihl:ationr �•' SHALL N07 be head to Pe:mit or to he • 4tproval of the violation of ar an • •'�f�+ity City O,d;nance or Stason tey ppro✓ ,. i 11 IV (J i FEB 1 2004 uICE COPY W W *CITY OF CUPERTIN# UD o o CUP TYOF O PERMIT APPLICATION FORM APN# . - j Date: 2 Z o Building Address '2-01121 SO/UtA$ Owner's Name: . Phone#: Q(CL{�t2l� (y02/.�a6yEQ.NO Contractor: xc� License#: Contact: Cupertino Business License#: Building�Permit Info: Bld in❑ EleA Plumb Mech 1 Job Description: We a"af— -7- Residential- 7-Residential A&Q wnS Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: ! Occupancy Group: Type of Constructio : Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILER1 Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL 13130ILER4 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> IOOOA 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 1of3 z . s� !g , i CITY OF CUPERTINO CITY Of PERMIT APPLICATION FORM CUPEI�TINO 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 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 Install/Alter Water Pie PLUMBING BPWHEATER WaterHeater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit-> 10,000 cfrn MECHANICAL BREMAIRHAN 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 i Power Device/Apparatus ELECTRICAL 2 of 3 F OITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkT O u ti Fee ID Fee Description Fee Group 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 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 BSWW Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bld 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 BMISCELL Building Misc Fees BUILDING • 3 of 3