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07020103 - PUB � f LL" CL vt 4) ti �` `i' �v` 4) HCl' °p SY m U Li` �` +� 4 ` a tet , 4J, U, [a' u z7J A Q" rarF/ ror rr! ii, r -,rii/, 4 l i l I cu CD LU t CD o t a ro r F Z cc C:LZJ _ r- ; f, a M "cc � 'C=ON ',' N ., 8z ,o � z f t1 p CC . W o a o C:) q , w, „W, ' m is � �c v � v ' G 8 %Q :� I iD io g W }� 1 CL CL ... ,Qr Q O Cti O o fes- ¢ g i CD m 'E v C) <f CL W to foLLJ r W '® tri " W Qo 01 �1�� j m 41 z z W ClW fa rn p��, G CIL UO- 64 0 o ui KJ QII of a �y 18 4 N p a) 0) x 3 cu t m J3 aD wx u� ° y a o yo ry LL a E a N f s CD LL- ar tms ti E 01a tai E c , :. _ w ,: as 4" n 4`a v ei C Q or U n a o t`L „I , OL CITY OF CUPERTINO ; BUILDING DIVISION PERMIT CdJ 'RCTO INFOktIVIATIf)1�1` BUILDING ADDRESS: PERMrr NO. OWN A PHoRMM BATES 411IYAP&N 0 0 7 CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH j p LICENSED CONTRACTOR'S DECLARATION Job Description dC I hereby affirm that I am licensed under provisions of Chapter 9(commencing to with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force License Class d effect- Lic.a ADDITION: 397 ' MASTER BEDROOM SUITE C1 Date Contractor ARCHITECT'S DECLARATION < I understand my plans shall he used as public records , U L H Licensed Professional n OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the 0 following reason.(Section 7(131.5,Business and Professions Code:Any city or county o which requires a permit to construct,alter.improve,demolish,or repair any structure L y prior to ils issuance,also requires the applicant for such permit to flea signed statement _< that he is licensedpursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area Valuation (commencing with Section 70I)0)of Division 3 of the Business and Professions Code)or t that he is exempt therefromand the basis for the alleged exemption.Any violation of Section 7031.3 by any applicant for a permit subjecu the applicant to a civil penalty of .APN Number CCUpancy Type not more than five hundred dollars(5500). ❑1,as owner of the property,or my employees with wages as their sole compensation, 36933051 00 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 wort 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.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profusions Code:)The Contractor's G- cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projccls with a contractor(s)licensed pursuant to the Contractor's License Law. ❑I am exyetptec, "' .B&P C for this reason Owner YY Date /—/6-07 WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Workers 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 Workers Compensation Insurance carrier and Policy number are: Carrier. Polity No.; CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION 114SURANCE (Thu section need not be completed if the permit is foronc hundred dollars(EI00) or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person Tn any manner W em;suhio o the Workers'Compensation Laws of Califoraia_A�ajo L7 Applicant 4 aCl;21 1 S r Yl<!4-) NOTICE TOA PLICAM:If,atter making this Cenificatc of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must z forthwith comply with such provisions or this permit shall be deemed revoked. 0 CONSTRUCTION LENDING AGENCY �--� 1 hereby affirm that there is z construction lending agency for the performance of jthe work for which this permit is issued(Sec.3097,Civ,C.) Q Lender's Name , z Lender's Address 0 1 certify that I have read this application and stale that the above information is �—' correct.I agree to comply with all city and county ordinances and state laws relating to Ubuilding construction.and hereby authorim representatives of this city to enter upon the U above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against r/I liabilities,judgments,costs and expenses which may in any way accrue against said City Z in consequence of t e ranting of this permit. .� APPLIC� STANDS AND WILL MPL WITH ALL NON-POINT Issued by: Date SOURfZ ATIONS. / � jz� Re-roofs Signa(m of Applicant/Con Tactor 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,Chaptcr 9.12,and the Health and Safety Code,SE3Yes 25532(a)? 1z< All roofs shall be inspected prior to any roofing material being installed. 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 defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes o 1 have read the hazardous materials requiremcnLs under Chapter 6.95 of the Califor- nia Health&Safct ,Sections 25505,25533 and 25534.1 understand that if the building docs not furze y vc a tenant,that it is my respo ili y to notify the occupant of the roquim,ne tchmustbeme rt ' � nificatcorOccup Signature of Applicant Date 6 d Owner or authoriz;.d agent Date All roof coverings to be Class"B"or better CITY OF CUPERTINO .P o 702.0 03 CUPEIkTINO PERMIT APPLICATION FORM APN# 5 ((" 7 3 ,�-> c) 5-I Date: i Building Address: o �a� � D v Mailing Address (if different from building address): � �� Owner's Name: Q/Vj Phone#: Contractor: i License#: Contact: Phone: t1ob T-33 74Fk Cupertino Business License#: (� 1L4P C4v AS Fax: c3 � 433 -4�3` I Building Permit Info: Bldg 2�/ Elect L/ Plumb Z/ Mech �2 Job Description- Residential til ;14 56(K- Mil3f��— Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: Type,of Construction: Y rd Please check this box if the project is a second-story addition: (❑ Project Size: Standard Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERl 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 I of 3 S Ary OF CUPERTINO cuPERT iNo 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 I 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 rinklerBackflo PLUMBING BPSTORM StormfRain Water PLUMBING BPTRAP Kitchen Tra PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER_ Ins fil/Altef-Wafer Pi_& PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAHMAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY 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 BREMMISC Mise Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platfon-n Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Re air/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 Community Development 10300 Torre Avenue ' Cupertino CA 95014 AltTelephone(408) 777-3228 CITY OF Fax(408) 777-3333 CUPEkTINO Building Department JOB ADDRESS: PERMIT# c7 -7--1 �Sc���-V� �� C)I, OWNER'S NAME: `ThM A-� PHONE # GENERAL CONTRACTOR: !3(� FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and com lete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Ll VE s 6 Cement Finishing ' Electrical A�i � G � 2&7Y4(7 Excavation Z-f-V n/ N&i2c:,,f� Fencing til Vfz ;L, Z (u Flooring: Carpeting -t (9 PE--- Linoleum / Wood Heating Insulation L;L 13 Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving V Plastering Plumbing L �,� P(—L)Mdbl� f$3 Roofing 13 Z 6G Septic Tank Sheet Metal Sheet Rock 2-11 (, File _...... caner/Contractor Signature date