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07050163 CITY OF CUPERTINO BUILDING DIVUION PERMIT RMATIQN• BUILDING ADDRESS: PERMIT NO. 10803 BROOKWELL DR TBD - TO .3E DETERMINED 07050163 OWNER'S NAME: PERMIT ISSUE DATE ROWE DOUGLAS G AND CONNIE R 05/17/2007 ZONE: SANITARY NO. CONTROL NO. ARCHTTECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 00Z LICENSED CONTRACTOR'S DECLARATION U p 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description z UUJ with Section z. of D�ivision 3 of the Business an d Professions ofessions Cade,and my license is in full force and offeSERVICE U_?GRADE TO 200 AM P S-C ONTRAC TOR'PAC I F I Cw 1cense Class V p Date cOn,= `OAST ELECTRIC PD FOR BL. � ARCHITECTS DECLARATION ECL R ON w I understand my plans shall be used as public records aV Oy Licensed Professional y 15 OWNER-BUILDER DECLARATION 7 1 hereby affirm that 1 am exempt from the Contractor's License Law for the 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure z�y prior to its issuance,also requires the applicant for such permit to file a signed statement =o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1850 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy not more than five hundred dollars($500). 36921017 . anC()U p y Type 0 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). 0 I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and, who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. 0 1 am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: �sve and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foronc hundred dollars($100) or less.) I cenifv that in the p rmance of the work for which this permit is issued,I shall not employ any person a y manner so as to become suJIjectt yn W Compensation Laws of Califomi, c Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must O forthwith comply with such provisions or this permit shall be deemed revoked. s CONSTRUCTION LENDING AGENCY -- I hereby affirm that there is a construction lending agency for the performance of 4> the work for which this permit is issued(Sec.3097,Civ.C.) G7 Q Lender's Name Z Lender's Address Q 1 certify that I have read this application and state that the above information is L r—' correct.I agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorise representatives of this city to enter upon the .r W above-mentioned property for inspection purposes. y L1 (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,casts and expenses which may in any way accrue against said City Z in consequcn f the granting of this permit. �— APPLIC NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: s Date S'l SOUR R L NSI ' i Re-roofs e/7 Signatthlfbf Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type,Of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. 0 Yes WIC 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 emit hazardous air contaminants as fined by the Bay Area Air Quality Management all new materials for inspection. District? ^ 0 Yes u j 1 have read the hazardous materials requirements under Chapter 6.95 of thc Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.I understand that if the building �-- does not curer ve a tenant,that it is my responsibility to notify the occupant of the requircmcnts must be met prior to issuance of a certificate of Occupancy. Signa of Applicant Date Owner or ari-zed agent Dam All roof coverings to be Class"B"or better CITY OF CI'PERTINO 4 ITEMS OF 4 PERMIT FECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 36921017. 00 DATE ISSUED. . . . . . . : 05/17/2007 RECEIPT #. . . . . . . . . : BS000001362 REFERENCE ID # . . . : 07050163 SITE ADDRESS 10803 BROOKWELL DR SUBDIVISION . . . . . . : CITY CUPERTINO IMPACT AREA . . . . . . OWNER ROWE DOUGLAS G AND CONNIE R ADDRESS . . . . . . . . . . CITY/STATE/ZIP CUPERTINO CA, 95014-4608 RECEIVED FROM . . . . : CHRISTOPHER KIESMAN CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - ------------- ---------- ----------- ---------- ---------- ---------- BELEC200 METERS 1. 00 29.43 0. 00 29.43 0. 00 BSEISMICRE VALUATION 1, 850 .00 0.50 0 .00 0 .50 0.00 BUSLIC FLAT RATE 1.00 _.07. 00 0 . 00 107. 00 0. 00 EPERMITFEE FLAT RATE 1. 00 38 .37 0 .00 38 .37 0. 00 ----------- ---------- ---------- ---------- TOTAL PERMIT -.75. 30 0. 00 175 .30 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -- ------------------ CHECK 175.30 2_49 --------------- TOTAL RECEIPT 175.30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL . CITY OF CUPERTINO CSF PERMIT APPLICATION FORM CUPEkTINO PN # Date: �0 s-/7- a7 Building Address: Mailing Address (if different from building address): f Owner's Name: Phone#: flu S -Ls3 y° License#: Phone: o$ ' `6 Cupertino usine s License 44- Contact-160 Fax:449 -oWVIA C Building Permit Info: C-)- 0�0 Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential L� Commercial E-1Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: 3 Type of Construction: Please check this box if the project is a second-story addition: El i Project Size: Standard ❑ Large ❑ Major [] Quan_fity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> l M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Con:.truction Tax BUILDING BCONSTAX Ind/Of f/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotcl and Motel BUILDING BCONSTAXR Consta,:—Resi/Mobile BUILDING BELEC 1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Ener;;y Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 CITY OF CUPERTINO 0 OF PERMIT APPLICATION FORM CUPERTINO Fee ID Fee D:scri tion Fee Group Quantit Miscellaneous Fee BUILDING BMISCELL BMITIGATC Comm. He using Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspectbn Overtime BUILDING BPBACKFLOWAtmos l-enc Vacuurn PLUMBING _-- ---- Cesspool PLUMBING --- --- ---- - - BPCESSPOOL pooi BPERMFEE Bld IP ermit Fees BUILDING BPFIXTURE PbIg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK7 Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Repi e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER S ewers PLUMBING BPSPRINK Lawn Sp inklerBackflo PLUMBING BPSTORM Storm 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 NJater Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remo iel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> IOK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc;Apparatus ELECTRICAL gREMNRApp Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl,Svitch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT RepairlAlter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 - . CITY OF CUPLRTINO cl, F PERMIT APPLICATION FORM C U PENT lN0 _ Fee ID Fee Df�scri tion Fee Group quantity ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch 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 BSEISM11C01 lit; Sc �H re oirt ,rnei ct T BUII,D'II�T --- -- --- -- --- -- ----- - --- - BUILDING BSEISMICRE Seism_c Fee Res BSPECIAL Special Inspection BUILDING BSWIM Swim ning Pool BUILDING BTEMP Tempo rary Power ELECTRICAL BTEMPPERM Temporary Bld Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL / BUSLIC Business License BUILDING ELECTRIC Electr cal sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing; Permit Issue PLUMBING PPLBG Plumbir.g Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Lont;Ran a Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3