04110004 (2) CITY OF CUPERTINO
BUILDING DIVISION PERA mac„♦9¢,/'. ++�` T "'�'a;"is"'a-z�.
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BUILDING ADDRESS: PERMIT N0.
LOVELACE CONST. 04110004
OWNER'S NAME: PERMIT Tess rE DATE
MW PHONE: SANITARY OL NO.
ARCHI7ECT/ENGINEER; BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
uOo LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I em Ilanutl under p Inions of Chapter Y(commencing Cr rap
with Secti ] )ref Oivklan3of the Bminos}and Professions Code.endmylicenuis L
n- in full fang O fine"ayzq oases Clava Llc.x �� REMODEL KITCHEN & B
y7 Dem_f/— i - oy Contractor L /Arv
W7 ARCHITECrS DECL-A ION MM
�i rsMail plows Ilhusa apuhli recauk .7 M a100C
D�U L I
i C t; Li coed Proficied
3
OWNER-BUILDER DECLARATION
Contr ,ON
BUILDING®'
1 herehy o firm that 11. exempt from the Cosi..Ce License Law for thefoll ®y L
p�0�•
which requires
PermitSacdcm]omourt5.Buaineasandno,demolish.
eoli Co de:Any city U,county
which rtquims a permit m cnown,elite improve,ticmolL h.or repair any amnum
a prior In its issuance.also regulons the applicant for such permit to file a signed statement
F4
£ Nal he is licensed pursuant re Law w(Chapter9 Sq.Ft.Floor Area Valu non
y $ (commencing with Section]00o)of Divlsion3 of the Business and Profeselont Coda)or
� .. Nat he Is exempt thrtfrom and the basis for the Wcgcd exemption.Any violation of
Section 7031.5 by say appliunl for a permit subjects due applicant to a civil penalty of 3ye4Tdit*er00 Occupancy Type
not mote Nan five hundred dollars($500).
0 I,aownerofthaproperly.ormyincid yin witharat.astheir sok compensation,
will do thework,and the swclurt is nalintandedaraRLRd foraala(See.7044,Business Required Inspections
and Profusion Code:The Convector's License Law does net apply to an owner of - q p _.
property who buildsorimpm momon,endwho doessuch wakhimalforthrough his
own employees,provided that such improvements art not intended compered forsale.if.
however,the building or improvement la old within one year a(complelion,the owner.
builder will have tis burden of proving that he did not Wild Or Improve fm puryme of
W.J.
0 I,a Owner of the property,em exclusively contracting with licensed conumemrs in
construct the project(Sec.7049,Business and Professoriat Cade:)Ilse Contractor's Li-
sense law dans not apply to an mann of property who Wilda or improves daemon.and.
who convects for such projeca with a contrutor(A licensed pecounl to lh ConautoYa
Livain Law.
I an exam t under B k P C for dila mason
Owner Data '0r'
WO Kgaa'S COMP ATION DECLARATION
I hereby affirm under penalty of perjury one of the following deciandons:
0 I have and will maintain a Certificate of Consent loaelf USUSSOfarWarkefeCompen-
Sudan,as provided(m by Sutton 3700 of the Labor Code,for the virfarmu ce of the
work for which Nis permit is isswd.
0 1 have and will maintain Worker's Compensation Insurance,as acquired by Section
37W of the labor Cade.for the performance of the work forwhkh this permit is issued.
My Worker's Compensation Insurance carries and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed If rah permit is forme hundred dnlla s(6100)
,it lass)
I Mo i(y that in the Performance of the work for which this permit IS issued.I shall not
employ any 55_z
n' y manner su as M became subject to lW Wrb ra amentyUs
Law%of Califo as "-
N�yyUy�E TOO APPLICANT.If. fail a:mg this Curd tc W of Esempuon,you should
to polome subject m the Works r'f c 21 roalan provisions of the labor Cade%you must w
OZ
forthwith comply with such ponvisions or Nis Permit shall be deemed invoked.
„zi a2 CONSTRUCTION LENDING AGENCY
f~ I hcrcby apirre that them is a construction lending agenryfor Ne Performance of
a.>, the work for which this permit is issued(Sec.3097,Cin Q
WMA Lender's Name a
a z Lender's Addmas
C.)Q I ar i(y Nat i have rtad this epplietian and sate that the above information is
Irr F norma I agree to comply with all city and county ordinances and state laws relining to
0 building convection,end heteby.tolmdre uprtsenutimof this city memo upon the
W above-mentioned pmperty for inspection purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupertino against
liabilitiesjudgments,costs and expenses which may in any way accrue against Said City J
U In consequence of the granting of this permit. ll
APPLICANT UNDERSTANDS NO WILL COMPLY WITH ALL NON-POINT Issued by: Date «l
s0 RCE GULAT ONS. X/0
Re-roofs
u¢ofAppliw Tomo Date
A ARDOUSMATERIALSDISCLOSURE Type of Roof
Will Bic ap]!nest or future building Occupant Store or handle h(iySNsus mearul
as defined by the Cupi nines Municipal Cade.Chapar 9.12.and tha with and Safety
Code.Scutari 255320)] / All roofs shall be inspected prior to any roofing material being installed.
❑Yes mil.
Will 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
cmll haraadnus air contaminants a fined by the Bay Arta Air Quality Management all new materials for inspection.
District]
0 yes ffN
[have mad the hanaNaws matelots te,pu tsmsm under Chap or 6.95 of the CAW.
.I.Health&SafctyCode.Suction 25505,25533 and 25534.1 understand thuifdte Wilding
dura non currently have a tenant.Ne It u my mspousiihiliry to ato0fy d¢acupul of the
mgair�- hieh mu met pn ,luisse o IcoNfiwa or Oceupansy./�t . Signature of Applicant Date
.awn6raraamorivm .. / Data All roof coverings to be Class "B"or better
OCITY OF CUPERTINOO
•CUPER
PERMIT APPLICATION FORM
TINO
APN# 3 / qi / / Date: r{/
( 6 (> d h
Building Address: G� li lin ddress (i f building address):
Owner' Ne:�C Phone#:
Contracto • p,,[,� G4�11� License#:
Contact:// (�Dy //^ Phone: Cupertino Business License#:
.1 / Fax: Q'// �[
Building Pe -Info: f
Bld Elec MechcCJ
Job Description:
Residential ElComm rci —, .-
Sq.Ft. Floor-Area: $/Sq.Ft.: .
r
Cost of Project: �- v Occupancy Group:
Type of Construction: / Please check this boxif the project is a
/
second-story addition: ❑
Project Size: Stand Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Efiergy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
27 (J
1 of 3 r 7 7.
CITY OF CUPERTINOO
CUPEkTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMIvIE New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum , PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
44— 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 Water HeaterNent 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
BREM3USWAY 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
BREMNvIISC Misc Apparatus ELECTRICAL
BREMNRAPP 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 Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res App liance ELECTRICAL
2 of 3
aF
WITY OF CUPERTINO*
CUPEI� PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
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 Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL S eciOInspection 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
3 of 3
' CITY OF CUPER'fINO . '- 's^ ermxa/.rFlft��"' y' "��a'w�'s ?/' A - - - -
BUILDINGDIVISION ^PERT CONT,9ACTOW1�Nl'0111YlA IVNv C
BUILDING ADDRESS: PERMIT NO.
LOVELACE CONST. 04110004
OWNER'S NAME: PERIATISUB DATE
E: - - _TA SANRARY OL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
?.rGp LICENSED CONTRACTOR'S DECLARATION Job Description
1 Mmby afOnn(hal 1 Am Iittucd under prrwyvyybbns of Chapar 9(mmmencin{ -
with Sao 7 )of Dlv
In( Z R iAPfiL'adjaM mlimnse is
REMODEL KITCHEN & BATHRMJOE License Class U.:Nz
p
one ARCHDELTSDECf; ION - - -
1�f Ci X7
; 7W< ' J YPlanss the use napes ranns
n U ��A
Li enaJ Pnsfessian -
OWNER-BUILDER DECLARATION /i
I I hereby al ec on 70 1. exempt from the Convector's License taw for(M / (q _ -
p o following mason.(Section ED L5,Business and Nofesdana Cale:Any city or 4 ry'1
1$� which requiresa permit to construct.since,improve.demolish,or repair.my structure
.. . .. .. U
prim in to issuance,also requires theapplitut for such permit to file C signed statement Q a
< than islimruedpursuanl(o Nepmvisiounfthe Corridor$Lan=Uw(Chapm9 Sq.Ft. Floor AZ %` � }l Valu tion ,
-
G (commencing with Section 7000)of Division 3 ofuw Businessland Professma Cade)ar t ' / v
$ Nal lien,exempt therefrom and Am Audi for the alleged eumption.Any violation of.
Section 703"by any applicant for a permit subjects the applicant in a civil penalty of 3I*er00 Occupancy Type -
act mom Nm five hundred dollars($500). -
❑Lu awnmof ilii manaiyar,myemploym landed oroffinekuthevple mm,Bud.
-
will=Newark Code: he Connotes
s shares, a w do fs Act apply IDN, a n of n
' and Profession cam:The ConvacmM1 License Law dons rot apply m an Dana a( � —,. .-_. ... �%1R0gIll/led.InapeCtlODs
pmpertywhobubldwrimproves thereon,endwhodoessuchworkhimulfmNmogh his
own a
however,
the uiPmvimd thnaah tmprovemenu are mt c mplMon.fm pie.if, v
however,the building orimprovementdid oneyearofmmoveforNeowar-
alWilder will Nve Ne boom or proving that he did m(Wild m Improve(m purpose of
ole.).
D I,as caner of nate property Am excheo ely.."meeting with demand mnvuwrs to
conduct the project(See.70611,Bminm and Professions Com:)The Contrsmors Lt-
cense taw dad at apply an an ewar of property who builds or I.M.income.dna,
who contracts for such projects with a contramor(O licensed pursuant to ft Convectors
4eflas,Law.
1. Lem eaem funder ec. .Bk PC fm Nis mason
Owner Data
WOK 'S COMPENSATIONsDECLARATION
I hereby&Bunn under penalty of perjury ane or the following declaradom:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- .-. _ ... -
sstion,u provided for by Section 3700 of the Labor Com,for Ne per(onnum of Ne
work for which this permit is istued.
D 1 have And will maintain warkmR Compensation Insurance,u required by Sccrlon
3700 of Ne labor Code,fm Ne performance of the work far which this permit is issued.
My Workers Carepedation Inmrarce caries and Policy number are:
Cartier: Polley Na,: - ..
CERTIFICATE OF EXEMPTION FROM WORKERS' *COMPENSATION INSURANCE -
(Ibisamimllecd net becompkwi done permit barroom:hundmdm0ara(SIM)
or leas.) - -
1 cenfy that in tare performance of the work for which this permit as issued,l shall not
employ any nymurorwudbemn wbjecuo thetad i ons an
Laws of Calif as
�
1TO A PLICANT.If a�er ting Nv Gem Team Exemption.you should'
me eubjm w the Worker' Cori pcmation provisions of f Lehr Code.you must
,JO forthwith comply with such provisions or this permit ahall In Accrued mmked.
ti CONSIRUCDON LENDING AGENCY
[--I I herby afRrm that Nem Is amnstmctin t lending agency for the performance of
a> the work for which Nu permit is based(Ses.3097,Civ,C.)
CQ LeMce.Name ,
.7. Z lancers Addreas
U Q 1 minify Nal I have and this appliudon and ma than the above information is
F
comm.l agree to comply with all city and county enhances and sate laws readmit to
OU building construction,and hereby authorize representatives of this city w enter upon Ore
above-mentioned property for inspection purposes.
Ly, (We)agree Inc an.indemnify sed keep Warren f City of Cupmano against
s,y Ibabilides,judgmenv,cuts and expenses which may In my my ems,against pad City
U Z en consequence of the 6.Itng of Ni.permd.. /-
"" APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by:9
Date 111 1
SO RCE CULAT Ons.
Re-roofs
armat roof Applin mere Date
ARDOUS MATERIALS DISCLOSURE\/ Type of Roof
Will Neap Iicam ser fuuuc building=upanutam or hunk hp)pjnou metend
u de0ned by the Cupertino Municipal Code.Chapter 9.13,and a calm and Safety
Code,Section 853]4)? / All roofs shall be inspected prior to any roofing material being installed.
❑Yea 0<5
Will the applicant or future building occupant sex equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I
t haled..air con mananu As ilpfined by the Bay Area Air Quality Management all new materials for inspection.
Di him?
Dyes Na
Ihavemad theh 7ArdousmowdahrequlmmenuunderChapmr6.95of the Calife,
ala FknithB SafctyCode,Sec6.25315,8533 md85311.1 underMnd Nm aids Wilding
Jens Inst curendy have a amara.N h is my respensthBity in notary tax=.Pant or Nc
mqut Inch ran me( missesor cmriicain foccu cy.'� SignatureofApplicant Date
wait a,amhadzeu 441 Danc All roof coverings to be Class "B"or better