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03120090 (2)to CITY OF CUPERTINO BUILDING DIVISION PER1V*CONTIiCT.ORhINr012MFN BUILDING ADDRESS: - PERMIT NO 03120090 OWNER'S NAME: PERMIT LSSUR DATE ONE: SANITARY N0, CONTROL NO. ARCHITECTIENGINEER:BUILDING PERMIT INFO RLDG ELECT. PLUMB MECH t� � 0 l� LICENSED CONTRACT'OR'S DECLARATION Job Description nvons of chapter 9 (commcneing 1 hereby affirm Thal 1 am licensed Took, proisi P with Swlbn)BIX))of Din3ofde '(o(P B.none Om1P.ATsxoM Code. enda,Iiccm=is mmur aerreet 'j KITCHEN REMODEL Z Licen as L Ca I CONTRACTOR: J H LEWIS GENERAL CONTRACTOR H ATLON ,l y II use public postords U To ud Pmrcssionsl OWNER-BUILDER DECLARATION 1 hereby affirm em exempt from the Contractors License Low the o on 71 em o fallowing rmxon. (Sacha,,? Business and Prnfmsin Colo: Any city or county 0 which cont; demolish. firapaigany ,,nidus to construct, alcor,imprnvc.i I0, io itryirunAdmit permit prion„iBcensed pursuan-qui teaahovisio so for suchp-rmiunice a, Law(Cned atemem Lha that wit pursuant in the of The Co Law(Chapter9 Sq. FI. FloorArea Val u@ C 0 0 � ; $ Dianna me cing Business and (commencing Sectionfrom )th Division ]or Business and Professon. lation y oan That he is excmpl Therefrom and the bazis for The allege) exemption. Any violation of andthc al Any f Seitlon 7031.5 by any applican,for a permit subjects The applicant to a civil penalty of APN Number Occupancy Type not moa Than five hundred delta,, (1500). P Y YP ❑ 1, as owner of the property, or my employees with wages az their sole compensation, 34213014.00 will do TIM work, andthaamantaail.otmendcdconrrm eted.aam(See.]D0.1,Businw Professions Cad-: The Cont License Required Inspections p grid moon law Joys not apply m an owner of propertywho buildsorImproveschimprve who his areninchworkhimselfedThrough own employees, provided din such improvements are not intended o for however pled n, ovmrIt. din of youbuild of compicuan, Thc owner- or den q ill how do: of proving Thasolt builder will have de burden of proving Net he did not build or improv for purpose of he sal-.). ❑ I, as owner of , exclusively conTnaing with ITcensetl / coned the project (Sec. ]p ct Seen momma, b . Basin. and Professions Cade:) The Contractor's cense Law does to an owner or property who Wilds i thereon, and n wnof fid _ - rnot such for such projects with a contrector(s) licensed pu,,uem to The ConOedor's poll no to Th Li en.acu W env law. I em exempt under Sec. , B h P C far This maze,, Owner Data WORKER'S COMPENSATION DECLARATION ' I hereby affirm under penalty of perjury case of the lollawing decle,,tions: I have and will maintain a Cenincem Consent or Conseno self-insum for Worker's Ccmpco. u on, as provided for by Section 3100 of the labor Cade, far The Performance of the ' work for which this peit is issued. permit ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3]W of do labor Code, for The performance of The work for which Niapeamil is issued L. My Worker's Compensation insuantt carrier and Policy number am: _ an: No.: CERTIFICATE OF EXE�''OM WORKERS' COMPEIt�ifT10 NS ANCE "fhb we(' red not M1e co Jifl rmilb Porone ndretld ars($100) on less) I ccnify d , i the crfnrm ce a(d rl fm w 'ah i rssucd, 1 shall net employanyp rs ny T esu cWorkc 'Compcnswlon Lawsof Calif m , App item NO A LICAN'T: If, after making is Certificate of Exemption, you should W', a fhje to the Workeh Compnwtion provisions of the 1a o, Code, you as, , Ofgrthwi co Ply with such provisions or Permit shall be deemed revoked h CONSTRUCTION LENDING AGENCY ., 1 hereby affirm Nal dere is a constmctinn lending agency for the Performance of ti do work for which this permit is issued (S.. 3097, Civ. C.) Lenders Name Q Lenders Andreas z /1 Q I ccnify That 1 have read This application and state that the shove infannatiun is bonen. l agree m comply with all city and -aunty ordinances and state lows relining to Uabove rcprescmetisxs of Nis city to enter upon da hemhyaction +' W ahavo- mennsuudiommd p pwpaws for emn (We) . M to saw,mKrty ify an (We) a to env-, indemnify end kcc the City of Cu against T4 cnu,c fid fists ch ma in any way eccac against said City n an agents, car, Z of grao of this mil. ^� E W COMPLY WI ALL NON-POINT' Issued by: Dale 0 G-0 WHAZARDOUS Re-roofs licmUCon cmr Oate HAZARDOUS MATERIALS DISCLOSURE Type of Roof epplicant or future building occupant amen or handle hanardous material az defined by the Cupeniva Municipal, Code. Chapter 9.12, and the Health and Safety Codc, Section 25532(,)? ]Yes W”. All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to W! the applicant or future building Occupant use equipment or devices which remove i, hazardous air contaminants as define) by the Bay Arca Air Quality Managcmcm all new materials for inspection. District? eKu ❑Yes Ihov real The v aTdialsre .-menu ppier Chpparb.95elde Califon fila Heald SaldyC u 25N)5, 533md2557J.1 ande"Tmd That ifde building �e dins n I d cntly n k t'�s m rc p ability tennury,hc occupmt omit require - whi tp rmusumcearacc career ' ucy6� Signature of Applicant Date All roof coverings to be Class "B" or better 4W 52F.rnamnri'red ag-cal Dm- — --- — 17 r ry ✓-! .�-- --- — - - 194 --- - -- ----� h; r�-3p4 UVTG eTS 571 � I I 1171 j II I 35 257' W30 42 -- I FXlfmug S�oGpRt j9R 1 Tube FkroreseNr r�x,srr,u9 42L f --- 76 PENINSULA: COVER BACK WITH PANEL. APPLY OUTSIDE CORNER MOLDING TO COVER CORNER EDGE. APPLY OGP8 AT FLOOR BASE d 8PPS24 TO TRIM BASEIFLOOR LINE. CROWN: SIPS( 8 RANGE WALL-SCM8, RIF WALL•OGP8, CMS STD. SEE SECTION DETAIL DRAWING. WOC2436: APPLY REPLACEMENT DOOR TO LEFT SIDE. TMs m an ongwial desO and must AN dinznsOns d size deson*MM nE 0w;,,,, °" HOME -DEPOT II ,�be,e ae°WWPaa « oa COW_ j older paced • 8�' � � �,`C• p` Sryp /aoSa�atiy�o4P QoG Qeitp\ p\Q til`e\ ao�' y4�� p'� aoa .Yoe C�oSe� al�r� 0 c\0y�tiv��e\a\o�,O�otig e�p�.ao py`?� OFFICE COP� d (S I Mche#e Kaplan 23030.SloneW4p, Cupedino, rA Dw9 no, Desgr, tNG5iO3 Scam:m anwn DMP 11/06.103 DesVw n278 m • nz78 &;�nzthzl, CITY OF CUPERTINO *CITY OF CUPERTINO* PERMIT APPLICATION FORM 03jz0Cn APN # Date: /Z _/G ' 0 3 Building Address: ;?3030 57`oti d rad ,� lir. Owner's Na,r Phone #: Contractor: f? / AJ�� `, License Contacts Cupertino Business License#: Building Permit Info: . Bldg I Elect Plumb ,® Mech A Job Description: /rjreA env Pll-Brrzria&2 Residential X Commercial ❑ Sq.Ft. Floor Area: r�( / S 7",( yJ I $/Sq.Ft.: 1 Boiler> 500K to 1M Btu Cost of Project: 000_, Occupancy Group: 2, Type of Construction: -�v I 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 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 4--2- � ,-,-7 - 1of3 # l D7/ 6 iarlan� CITY OF CUPERTINO { 16ITY OF CUPERTINO PERMIT APPLICATION FORM ISQuantity 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 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 cfrri MECHANICAL BREMAIRHAN A/C Units <= 10,000 cf n 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 BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL v 2 of 3 QITY OF CUPERTINO 4i CUPEYOF PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL t Cb BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Seb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection 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 r� • CITY OF CUPEWFINO CONTRACTOR INFORMATION: BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMITN003120090 7 OWNER'5 NAME: PERMIT LSSUEDATE NE: SANITARY NO. - CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECt. PLUMB MECH 0 LICENSED CONTRACTORS DECLARATION escrlP Job Description r 9 (commencing 1 hereby arm that I am lilicensedd undertrnJcr Provisions of Chapter with Scm�iory70th).(Digyi nJof the Ousinc, arW Prufestiuu_cnda.od my license is infell fel{ °`ff"' 3 (o(o KITCHEN REMODEL - Lifullrcen u L' a s ,p%� C.Wktw Z CONTRACTOR: J H LEWIS GENERA&.JWT�A�CTO l^ HI ATIPM 1 y use public n PP��ryry��. �.I O 200�t FEBr scJ Pmfeuianal OWNER -BUILDER DECLARATION 1 hereby .('firm License Law for the 1 em aurin from me fessions ClJ LUU9 C's mason. (Seed". 703 Any tiny or courtly on alter, and Professions whicfolloh m h. or which oyuims a pctmil re cnmvum, alley, improve, demolish, Or repair any tatemum con'", t. pr10fal,lcensecc,.. a, in resthe pro inion Of for such Contactor 1Lfies Uw(ChOp col that he incmn¢cd punuam to ln)ofDiaronsn lzmr9 Sq. Ft. Floor Area -000' othe r Business=ucenx Cod (commencing with Section 917th) Division J of the exeandmpt ProfessionsAnviCode) or Out u exempt Therefrom and the basis forme alleged ez Any violation Of the alleged b any dollarfor apertnil subjtta me epPlicanlmecivil penally of Section liclaR to APN Number Occupancy Type .at...t71.5by Bol more man Eve hundred dollars [!00(1). P Y YP 0 1, as owner of the proPcny, or my employees with wages u their sale compensation, 34213014.00 will do the work and the awcture la not intended or offered fouale (Sec. 7044, Business Required Inspections and Professions Cock: The Comm�ors License Law does not apply m an owner of propeny who buildsorimprov"thereon, and who does such work himselfor domain his own employees, provided Nan such improvements are not intended oroBerW forsale. IL however, the building or improvement is sold within can year of completion. the Owner. builder will have the burden of moving that he did non build or improv for purpose of sale.). 0 L u owner of she property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- . cense taw does not apply to an owner of p.Peny who builds me improves thereon, and who contracts for such projects with a co oractor(s) licensed pursuant to the Comnctor's li ensa Law. Iam exempt under See. Bk P C for His mason , Owner Due WORKERS COMPENSATION DECLARATION he 1 reby of on,under penalty of perjury ooe of me fallowing declarations: I have and will maintain a Certificate of Consent to salf-inure for Worter'sCompen- sa on, u provided for by Section 3700 of me labor Code, for ma e pe formncc of the work for which this Permit is issued. 0 1 have and will maintain Wri terk Compensation Insurance, u required by Section 77th of the tabor Code. for the performance of On work Im which this permit is issued. My Workefx Compensation luunnce carrier and Policy number arc: er. ��'�V1®No.: CERTIFICATEOF EXT, yOM WORKERS' COMPfIB IO NS ANCE (Thu sect ecd.wheco dift nonhisforene ndmdd .($ifp) nr leu.) I certify Nati me r(mm ca of r for w ''h r mucd, 1 shell nut employ any by Wartc 'ComPcnsation Laws of Calif I App can, � NOTtI A LICA NT: IL after making is CeniOcate of Exemption, you should bttoTne ad a to the Worker's Compensation provisions of the fahnr Code, you must form i c ply with such provisions or this permit &hall be deemed revolted. CONSTRUCTION LENDING AGENCY I hereby aMrm that mere is a construction lending agency for me Performance of the work fur which this permit is issued (Sec. 3097, Cih, C.7 Lender's Name Leti rs Agree 1 certify that 1 have end this application and sant mal me above information is emoccfs t concis 1 agree to comply with all city and county ordinances and Cale laws miming building constructiand hereby authodre rssemelive¢of this to enter upon the ie city dhOVgre propertyfor inspection purposes. (We) agree saw, indemnify IeaimCCity oflne against labilities c ad Li1 cAma inanywayaccruc.lairslsaOCity nin ui ca.fth gr. of mil. APP CA U E W COMPLY WI ALL NON -POINT Issued by: Date SOU EG 0 Re -roofs Type of Roof 't% to of ApplicaburCompicuir Oam HAZARDOUS MATERIALS DISCLOSURE Willmeapplicant OrFuture building occupant stow or handle maxi us ma4rial as defined by to, Cupertino Municipal Code. Charm, 9.12. and the Health and Safety Code. Section 25532(a)? ❑Yea �u All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant saw equipment or devices which W...do., air contaminants u dcfncd by the Bay Area Air Quality M...lea int I,n all new materials for inspection. Oyes �u Ihnv readtheh r m aterialsm mmcnts der. Chapler6.95ofine Califon dish caM SafclyC d 25505 SJJ anJ2r .IunJcrsmrb thuifmc beilJing Jars I c Indy vo n 4 1'Yu en r hili1y m no ily de oce, of me require whi Ip'rluO$mmo..f.Ccni¢amof _<y6� Signature of Applicant Date - All roof coverings to be Class "B" or better Cow Lir aumorbed agent Da1c