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03040080 (3) CITY OF CUPERTINO '�"'• � BUILDING DIVISIONPERMIT CONTRACTOWINFORMATION , I�YJI ADD"'A CAMINO CT LENTZ CONSTRUCTION INC, J PERMFFNO.03040080 E7IGARWAL 5087 MAITLAND DR pEpM""6a"J"15/2003 NE: (408) 264-0555 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 ±oo LICENSEDCONTRACTOR'S under DECLARATION Job Description U 1 hereby affirm that 1 em licenced under and Professions of Chapter 9(commencing p 1 z�W wilb Section 7IXM))of Diviaion3of NC Business and Pmfcssium Calc,and my license is s n in full frame vnd eff i � License Class `� Lk.a SJ6SIb INSTALL SKYLIGHT (DINING EN�iLl�'® Date ^/-v A' Conmaclor 3�,4 L&71T1 X57- ' tl 11 f$- ARCHITECTS DECLARATION 34"X34 " ' 1 ai1 understand my p1am,N11 be used a public records ) U APR 2 8 2003 W U.t; Licensed Professional 3 OWNER-BUILDER DECLARATION y 1 herchy affirm that 1 em exempt from the Contractor's License Law for the BUILDING OO fallowing mason.(Section 7031.5,Business and Professors;Cade:Any city or county - 3§ which requires a permit to construct,airs.Improve,demmis M1,or repair any structure .zi prior to is issuance.also mquims the applicant for such Permit file a signed statement 21F0 ttm the,he in licensedpursuanotheprovisionftheContractoriLiccoseLw(Chapter9 Sq. Ft. Floor Area Valuation `C$ team mencing with Section 7WO)of Division 3 of the B mens and Profession,Cale)ar 3 that he i,exempt therefrom and the buts Ne for alleged exemption.Any vialadnn of 82400 Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of APN Number Occupancy riot mom man flue hundred delta.(SSW). ParaC Y Type ❑I.as owner.(the property,re mycmployus with wega as their mlc compcnuties, 32646012 . 00 will d.the work,and the awctwe i,nal intended w offered for ale(Sec.7061,Business and Predications Code:The Canlracmr',Lt.Law doe nal apply in an owrre,of Required Inspections property,who build,or improve thereon,and whodaa such work himselfor through his 101 - FOUNDATION own employee,provided that such improvements ac not intended muttered for sale.If, 102 — PIERS, however,the building or improvement Is mid within one year of completion,the Owner- builder will have the burden of proving that he did not build or improve for purpose of 103 - OF ER sale.). ❑I,as owner of the properly,am exclusively contracting with licensed contactora te 104 - REBAR construct the project(See.7044,Business and Professions Cade:)The Contractor's Li. 105 — ANCHOR BOLTS came Law docs not apply to an owner of property who builds or improves thereon,and, who contracts for such projects with v contractor(s)licensed pursent to the Contractor, 106 - SEWER & WATER L"`sonexe ❑e se Law. under Scc. ,B At P C for Ni,moon 202 - UNDERFLOOR PLUMBING caner Data 203 UNDERFLOOR MECHANICAL WORKER'S COMPENSATIONDECLARATION 204 — UNDERFLOOR FRAME d , Ihereby afErmunder pcnaltyofperjury one ofthe following occlueti.e: 205 — UNDERFLOOR INSULATION I have and will maintain i Certificate of Consent selGinsum for warker',C.mpcn- 30.1 — ROUGH PLUMBING station,a provided for by Section 37W of the Labor Code.for the performance of the 302 - TUB & OR SHOWER work for which this permit is issued. ' ❑I have and will maintain Worker's Compensation Insuana,u required by Section 3 03 - ROUGH MECHANICAL 37W of die Labor Crude,for the performance of the work for which this permiti,issued. 304 — ROUGH ELECTRICAL My WorkeM1 Compensation Insurance carrier and Policy number me: 305 — FRAME Cartier, S ffMt'C I C.A/ 'N Policy No,: �yO�,j a� CERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HOLDOWNS COMPENSATION INSURANCE 307 - INSULATION or lea?rbts rsection need not W competed ifthe Permia,forone hundred dollars(31W) 308 — SHEETROCK 1 certify thin in the performance or the work rat which this Permit is issued,1 shalt not 3 09 — EXTERIOR LATH employ any rcomm in any manner so as to become subject to the Workers Compensation 31O — INTERIOR LATH Law,of California.Date Applicant 311 - SCRATCH COAT NOTICE TO APPLICANT:IL after making this Ccnificate of Exemption.you should 313 - ROOF NAIL become subject in Ne Worker's Compensation provision,of me Lahnr Count,YOU must zz fonhwithcomplywithsuchprovisionsnnhisPermitshallbedecmedrevoked. 501 — FINAL ELECTRICAL ENERGY fin CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY ? I hereby affirm that diem its construction lending agency for the performance of Y, 503 - FINAL MECHANICAL ENERGY the work for which this permit is issued(See (197 3 ,Civ.C.1 ^q Lender's Address 504 - FINAL BUILDING ENERGY �z Lcntler's Addmas _ C) rtify that 1 have reed this application and,tam that Be above information is 505 — FINAL ELECTRICAL Fcorrcn.I agree to comply with all city and county ordinances and sum laws relating t. 506 - GAS TEST �U building construction,and hereby autborim mpresentativu of this city to enter upon the — FINAL PLUMB NG N d 31mvnmentioned pmpeny for inspection Purposes rN ti (We)agree to ave,indemnify and keep Mrmless the City of Cupertino against Q$ F I AL y liabilities,judgments,costs and expenses which may in my way seems,against and City SM J z in APPLICAeNTANDSN- eUNDERof the STtng of tAND WILL COMPLY WITH ALL NON-POINT Issued by:his permit. 5 ENG Date SOURCE REGULATIONS. SigpA �� a"' - 4-/J OJ Re-roofs 514 NAL PUBLIC WORKS Signemre of Appl Meracontractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or forum building occupant stem or handle haardou material as deflred by the Copeo Municipal Code,Charter 9.13,and he Health and Safety Code,.Yee 25532(x7? N. All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future Wilding occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove he Mo.air con anuu defined by the Bay Arta Air Quality Management all new materials for inspection. 1 nricR ❑Ys,, Nn ' I have read the herardnus materials requirements under Chapter 6.95 of the Califon nixHealth&Safoy CuM,Sections 25505,35533 and 25534.1 undersand the ifthc building docs nm currently hove a mnen,Not it is my responsibility m nntily the occupant of Ne requirements which must M met ped m iaamce of,cenirteme of accapaney. Signature of Applicant Date 'e�— � t� �3^ All roof coverings to be Class "B"or better Owner uthanycd cram Date g X(,�il % CITY OF CUPERTINO OFCUP Ty6F O PERMIT APPLICATION FORM AP # y/ a 7� Date: 7� Building Address Owner's Name: Phone#: Contractor: License M. Contact: f Cupertino Business License#: Building Permit Info: Bldg ❑ lec Plumb ❑ Mech ❑ Job Description: Residential ❑ *`"' (5717 TComa ercFal E l ' J Sq.Ft. Floor Area: $/Sq.Ft.: / Cost Of Project: c�,� / Occupancy Group: —127 Type of Construction: / di 1p —:Au­an—tity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERl Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL BBOILERS 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 Ah BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 7, 17v /' 1of3 C�3 i PER, CITY OF CUPERTINO C'7Y OF PERMIT APPLICATION FORM CUPEkTINO uanti 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 InstalUAlter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 din 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 Fumace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res App liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2of3 1. i CITY OF CUPERTINO CITY OF 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 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 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 .r i, CITY OF CUPERTINO m 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32646012 . 00 DATE ISSUED. . . . . . . : 04/25/2003 RECEIPT #. . . . . . . . . : 21701 REFERENCE ID # . . . : 03040080 SITE ADDRESS . . . . . :22175 VIA CAMINO CT SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : ASHOK AGARWAL ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1031 RECEIVED FROM . . . . : JERRY LENTZ CONTRACTOR . . . . . . . : LENTZ, JERRY LIC # 15763 COMPANY . . . . . . . . . . : LENTZ CONSTRUCTION INC, J ADDRESS . . . . . . . . . . : 5087 MAITLAND DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95124 TELEPHONE . (408) 264-0555 REE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- --- ------- BPERMFEE VALUATION 2 , 950 . 00 77 . 00 77 . 00 0 . 00 0 . 00 BENERGY PERMIT FEE 77 . 00 23 . 10 23 . 10 0 . 00 0 . 00 BPLANCHK PERMIT FEE 77 . 00 65 . 45 65 . 45 0 . 00 0 . 00 EPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00 BREMFIXT NO. FIXTURES 1 . 00 1 . 11 0 . 00 1 . 11 0 . 00 BSEISMICRE VALUATION 2 , 950 . 00 0 . 50 0 . 50 0 . 00 0 . 00 ---------- ---------- ----- ----- -- - ------- TOTAL PERMIT 202 . 68 166 . 05 36 . 63 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ----------- ------- OT14ER 36 . 63 M/C TOTAL RECEIPT 36 . 63