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07050033 CITY OF CUPERTINO BUILDING DIVISION PERMIT +Cfi��`►rtJttC" (?R ' BUILDT61M1E%ASCOIGNE DR KELLY WILSON P07050033 OWNER'S NAME: PERMIT ISSUE DATE KELLY WILSON 10751 GASCOIGNE DR 05/04/2007 INE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH !0 p LICENSED CONTRACTOR'S DECLARATION Job Description W p I hereby affirm that I am licensed under provisions of Chapter 9(commencing z W with Section 7000)of Division 3 of the Business and Professions Code.and my license is PANEL UPGRADE 200 AMP zoo, in full force and effect. )2? License Class Lic.A 3—w Date Contractor ARCHITECTS DECLARATION i a a I understand my plans shall be used as public records >yV U.y Licensed Professional H OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the C 0 O 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} prior to its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $300 Valuation aF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y 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 ofNumber Occupancy Type not more than five hundred dollars($500). 3 7 5 3 1 0 2 2 'l7 : ❑I,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 Required fired Ins eCt10IIS and Professions Code:The Contractor's License Law does not apply to an owner of q P 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 �) 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. Q I am a;e err Sec B&P C for this n Own Date D WO OMPENSA71ON DECLARATION I hereby affrm rider penalty of perjury one of the following declarations: ❑I have 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. ❑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 Workees Compensation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any mr as a wbject a the Workers'Compensation Laws of Calfform eL Applicam 'v 4 NOTICE TO AFPLICANT.If,ae maki g the Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Lahr Coda you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z'" CONSTRUCTION LENDING AGENCY HI hereby affirm that there is a construction lending agency for the performance of Ili > the work for which this permit is issued(Sec.3097,Civ.C.) WCs. A Lender's Name z Lenders Address U 0 1 certify that I have read this application and state that the above information is 4L correct.I agree to comply with all city and county ordinances and state laws relating to 0U building construction,and hereby authorize representatives of this city to enter upon the a above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against c,) liabilities,judgments•costs and expenses which may in any way accrue against said City ()z in consequence of the granting of this rmit. t"r APPLICANT UNDERSTAND A WILL 77—z- WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. y Re-roofs Signature of Applicant/Co or Date HAZARDOUS IRATERIAM DISCLOSURE Type of Loof Will the applicant or future building occupantstorc or handle hazardous material as defined by the Cupertino Mu 'cipal Code.Chapter 9.12,and the Health and Safety Cote,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. Q Yes No Will the applicant or future building occupant use equipment or devices which If a roof s installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes No I have read th hoz ms materials requirements under Chapter 6.95 of the Califor- nia Health&Safety ode,Sections 5505.25533 and 25534.I understand that if the building docs not currenti avc a c is my responsibility a notify the occupant of the rcq rem ts w ust fa' uance of a Certificate of 0�ctn cy. Signature of Applicant Date Owner r thorize a Date All roof coverings to be Class"B"or better CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT' RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: B1{: Lot: APN . . . . . . . . : 37531022 . 00 DATE ISSUED. . . . . . . : 05/04/2007 RECEIPT #. . . . . . . . . : BS300001211 REFERENCE ID # . . . : 0750033 SITE ADDRESS . . . . . : 10751 GASCOIGNE DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : KELLY WILSON ADDRESS . . . . . . . . . . : 10751 GASCOIGNE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : RE2EIPT INTERFACE CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : KELLY WILSON ADDRESS . . . . . . . . . . : 10751 GASCOIGNE DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 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 300 .00 0.50 0 .00 0.50 0. 00 EPERMITFEE FLAT RATE 1 .00 38.37 0 .00 38 .37 0. 00 - --------- ---------- ---------- ---------- TOTAL PERMIT 68.30 0 . 00 68 .30 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 68.30 VISA-KELLY WILSON --------------- TOTAL RECEIPT 68.30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform A. All the work autho rued by this permit B. — A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hirec L to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City —T—Phone # State License # Type of work to 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand.that I may be an employer(see reverse side). A Certificate of Insurance covering workers con ipensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City . Phone Number Type of work to be performed ..................................................................................................................................................................................... I declare under penalty of perjury that the ab ove is true and correct. I have read and understand the Owner-Builder Information(reverse s' e). f Property Owners Signature: c,L / Date: -S�� � Job Address: �6�S/r A-SC o/ E,Alie '� ' Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. ' CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO APN# Date: Building Address; Mailing Address (if different from building address): G .4c.p Owner's Name: Phone#: ` sa (4&Z -7 Z-$-- I q 3 Contractor: License#: /L Contact: Phone:402;. 7 j-S--i 4 3& Cupertino Business License#: V-�t�tj Fax: (aSO 4 o 4 2 SL Building Permit nfo: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: Residential ,�1ANS tr V P epi — 2 Commercial El Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: 306 OccupancyC�rup: Type of Construction: Please check this box if the project is a second-story addition. El Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Bc iler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Bol.er> 500K to 1M Btu MECHANICAL BBOILER4 Boilor> 1M to 1.75 M Btu MECHANICAL BBOILER5 Doiler> 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 Ccnstax—Resi/Mobile BUILDING BELEC 1000 E ec 600V<= l 000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING of 3 CITY OF (XPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO 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 13ldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Ga>Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Phan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE 3ewa a Dis osal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn Sprinkler/Backflo PLUMBING BPSTORM "torm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER V later Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT keins ection Fee BUILDING BREMACOVER A/(, Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY I:emodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Rc location of Furnace MECHANICAL BREMFURNOV Rel c) Furnace> 1 O btu MECHANICAL BREMHEAT Neater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pc le/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT R,-pair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY f CITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rnidl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Tl eatrical 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 7.em ora 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 Mechanical sq. foot MECHANICAL MPERMITFEE Much Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq-foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Plannin ,Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3