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04100016 (2) CITY OF CUPERTINO " "" °'#7``q '"'' '§' BUILDING DIVISION PERMIT CONT=I2"P,.CTC)RINEORVIA.'TIO 4, BUILDING ADDRESS: - ""'%4100016 "NO.4100016 OWNER'SNAME: tts PERMIT LSEUEDATB ED TOM & TERRY PHONE: MAN SANITARY N0. CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO P fy BLDG ELECT PLUMB MECH LJ = 0 = Q aCp LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I sm Iiceesd under provWom of Cooper 9(commencing - with Section 70f111)of Division 3 oftic Business and Profusimu Code.and my liconc is in full(ortxand t. BATHROOM REMODEL (GUEST & HALL) j n Z� Licence Clue Lk.A E mm — — Conn lar CONTRACTOR: ROCKY LOWELL CONSTRUCTION 3 A CHITECPS DI TION 3` 1 understand my plans shall he used as public records i cad Licensed Pro(essienal M1 OWNER-BUILDER DECLARATION 40I I Wrtte affirm Nat I em cumpt s an the Contractor's License Law for Ne I o o following mason.(Section 711313,Brise,.and improve. de oli Code:Any city Or county $ which I%uims a permit re cnmbueL alter.Impmw,demolish.m repair ed structure prior incensed c.pursuant to be provision of farthe Contrach ctor's Lic nm Lamed statement Val ll#�%no 0 0 < thmhsiscing With pursuant mOW.f Diainu of the Gomorrah Li cense Law(Chapter9 Sq.F[.Floor Area 4 V z❑$ (commencing wit Scstion7 and Divisiofr the Businexempton.AnlnnaCdc)of 3.- Nn io u exempt any applicant li and or beck far Ne alleged exemption.n.Any violation of Section 7031,3 by ocy eppliantlmapertnit subjecu Ne applicant acivll penalty of APN Number Occupancy Type not mart than five hundred dollars(5300). 31646001 . 00 0 1,u owner of the pmpmy,or my employees with wges as;Neu sole mmpematim, will do Om work and one stratum is not intended or offered fommki(Set.7044,1I.Shus Required Inspections and Professions Code:The Concracuer's License Law does not apply m an owner of q P propenywho builds orlmproves thereon,and who does suchwork himself or through his own employees,provided that such impromm ms sm notinteded oroffered for sale.if, �9 however.the building or Improvement is mid within one year of completion.the owner builder will have Ne burden of proving that he did not Wild or Improve for purpose of sate.). 0 I,u owner of dm properly,am eacludvely contracting wide licensed coni anors he coasroct the project(Sec.7004,Business and Professions Cade:)The Contnnm's Li- =law es enot apply man ownu of property who Wilds or imProws demure.and, who ssfor such pmjcc%with a conuactor(s)licensed pursuant to Ne Centraeters Lk Lew. em uempt under Eee. ,B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby ofind under pcally of perjury oro of use following declaratives: 0 I hsw and will mainuln a CWrium of Conant m calf-insure rwwoftes Compere _ salon,u provided for by Section 3700 of the labor Cade,for Ne performance of the work for which this permit is broad [:11 hoc and will maintain Worker's Compensation luumnm,as required by Section . 3700 of the IaWr o de,for Ne porforrnmce of dm work for which this permit is issued. My Worker's Compensation Ins..artier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE This;section need not W completed If the Permit is fnronchundred dollen($100) nr less.) I cantly Not in Neperformance 9rum work for which this Permit is iuwd.I shell not 'iruploy any person in any mann tyha�imc tubi to Ne Workxn'CompenseYon Laws of CalifpTrtja.Dam V Applicant iC NOTICE To APP CANC flaalEftilkh,this Ccnifiate of Exemption.you should "Sesame subject to the Workers ComPauation provisions of the Labor Code,you in= .JO Tonhwiih comply with such provisions or this permit shalt be deemed revoked. Z y CONSTRUCTION LENDING AGENCY [ti I hemhysffrtm that deert Ba construction kndinPgency or tW perrurmanaof G' the work for which this permit Is issued(See.3097,Civ,C.) W m Lcrdcr's Name 15. Lenders Addmas V I comfy that 1 haw mad this application and some Net Ne above information is W eonem I arce to comply with all city and county eminences and sus laws mlating he p buildingconstruction,1.and w,indehereby amhomeepharmiwsof this or in Cupnmupnntd W ah.ve-amol ma property for inspection purposes. (We)agree ,caw,indemnify and keep harmless the City of Cupertino against itZ iiin consequne of the grassing expenses mit. may in any way aamc against said City V^z' APPLIICCANTaUNDERSTANDSof this AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale SOURCE REGULATIONS. Re-roofs Signature of ApplicanUContncmr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Nc applicant or futufc buil ' g m Occupant or handle hasaous material u defined by the CupinihmMunic' 1 Cook,Chapter 9.12.and the Health and Safety Code.Section 25532(e)7 All roofs shall be inspected prior to any roofing material being installed. [3 Y. Na Will the applicant Or mtem Wu 'ng necapans use equlymem or devious which If a roof is installed without first obtaining an inspection,I agree to remove amu hmsmnus air annmiomis a recd by Nc Bay Ana Air Quality Management all new materials for inspection. District Owl I have mad the h amdnus materials requirements under Chapter 6.95 of the cairn to H IN&Safety de,5cdune 25505,25533 am125534.[understand doss fdhe Wilding (, ✓ L4 L9 4 dqo Currently v oa mnmt.Nat it u m in Ofy dm occupsns of Ne y trt nts which v W m t prior m iguana of a Cc Oate of Occupmcy. Date e���O RSigture of is nt Da¢ All roof coverings to be Class"B" or better CITY OF CUPERTINO CUPER,TINO PERMIT APPLICATION FORM ( l APN# 31 c / b/ d Date: U m Q Building Address: S Mailing Address (i different frbuil ng address): a VA et c e Owner's Name: v Phone#: n w. — 22 l � I O"� 7 23 o tractor: l.J Licen�G#: ) D o act: L ` Phone: 4 O 0 Cupertino Business License#: ©C., Fax: Q BOding Pe Info: / BldgElect � Plumb 2- Mech Job Description: i Residential ❑ Com�cia -Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: ] Occupancy Gro Type of Constructi - Please check this is a second-story addition:; LJ Project Size: Standard ❑ Large ❑ Major❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other'Appliances MECHANICAL 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 272, 7 1of3 CIPY OF CUPERTINO 40 IT 0 cuPE�riNo PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME 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 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 Stonn/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM3USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 BREPOWER Power Device/Apparatus aratus . ELECTRICAL M BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT R air/Alter HeatingMECHANICAL BREMRESAPP Remodel Res Ap liance ELECTRICAL 2of3 CITY OF CUPERTRO CUPEI�TINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL BREMSIGNS Remodel Sips, 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 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 I MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue _ _ PLUMBING PPLBG Plumbing Fee sq foot _ PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 Y 1 1 16 P.PF ROVED" TY qF IN ACCORDA r IT ' i 91 CUPERTI T J DATE -- — SIGNED This set of plans ' F scifiand is ul;T be ����� all t' as and it is ui It wful kepi on the \\� to make gas or alterations on : ama _ without den eomi ion from the E u ding . Department, City f, pertino. The stam `' ^` s plan and specifl ions $HALL N( ' sr .Id to permit or to C r an f any provis o approval c t+e vic ation os of ...�..,.n. ^-^^ .'ra a Law. 04 ZU�9 S�3 CITY oF �'SP�RYIN4 T gtJtl.Oi�IG DEPA�i�n 14 1 `evr� ek £o-, r t v\g dtv f`00 w- :V�3 el6x� s I°n3 FixTureS ToW. awl Tca�Y Fu.rry Ioi56 wva SWar . SJ\�e' yA 259 262-3 � 43 n N , s Q1 i � N gn I VED OCT 04 2054 CI IY OF UPFRYIN® ST LMNG C)EPAW[Mr.NT S7rr�A:07u�0..� �-�" ` U Q � � X1Tn5 ' U 7v ar��ebR� FuP-Ry 1025(9 Swcw Com, eeT��o� C0 4a8 2s7 2 62�