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05090166r3 CITY OF CUPERTINO BUILDING DIVISION PERMIT *t" ' �'', ��r'° '`�1, F5"'�ONr' BUILDING ADDRESS: PERMIT NO. CLIFFORD W COUEY 05090166 6hib"bAMNATERFORD DR FERMITISUEDATE CLIFFORD W MUM SANITARY N L N0. ARCHnEC IENGiNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 t� LICENSED CONTRACTOR'S DECLARATION Job Description P I hereby affirm M91 l ser 11¢nsed underpmvWon of Chapter D (commercial with Sendon 7").f Division 3 orthe Business and prefeasions Code, and my license is in fullfome,ad eBett. Lie.0 ic - ADD 187' (BEDRM/MS BATH) tr mr Data Contractor Dam ARCHITECTS DECLARATION I understood my plans Nall he used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby string that I am exempt from the Contractors License Law for BM following mason. (Section 7001.5, Busineas and Profession Cade: Any city at county which requires a permit in construct. alms, improve, demolish, or repair any structure prior m ILL Issuance, a1W ergot. the applicant for such permll to BIC a signed ruammeal Law 9 Sq. FL Floor Area Valu aflft that he is licensed personal mthe pm.mansofthe cantmcmrsuanse (Chapter (commencing with Section 7IX10) of Division 3 of the Bualncss end Preafesalnm Cada) or dust he is exempt therefrom and Bre basis fm the alleged Gumption. Any violation of p7�T 7�T ,,,g � yY4Y6+yr Occupancy Type Section 7031.5 by airy epplicam for a permit subjects to applicant to a civil penally of non mom Bob an hundred dollars (SSBB). 3�jA O i o v v a. 0 0 ❑Loteworof the properly ormYemptoyeuwithwguu.It soleroW.Businex Required Inspections sa rr dolhework, and Maswnureinonnhndedorote lin owner of Vw don not apply lf own and does and apply Cade: The Contractors Liccousand q P r is andwho does such work himselreddura{h his who who propertywhobullro of Impmvuch property WtsuhImprovementssernot tendedopleemA for ole. if. sure..themployees. improvements Wildingorimpmwmennismid within oro year of the K... Wilding Improedmn. purpose but a will Mw the burden of proving that W did not Wild a Improve for purpose of a ill 1). 1.as owner of do, property. ItceneC m roftedu rwise rmne. construct IM1e (gee. , Bnness and Cade:) Canlrhamrs U. Business and Proray es at nd sued Wdpurstmpmwa thereon rod, . La to . who wild. p covelawdollnotchp mjecu, id, aofproartY who contracts for such Dmjects with acanuromrtu) licenser pursue m the Conuattors License law. ❑lam B&PCfor Wu,,/ n crb Ownu Date,�—O WORKERS COMPE! ON DECLARATION I hereby &(lase under penalty of perjury ane of the fallowing deelarstioas: hrw and will maintain a CeNBao ofConanl to self -Wore for WorkersCompen- suian, as provided (tar by Sacdon 37M of the labor Code, for the performance of W work for which this permit is issued. ❑ 1 Mw and will maintain Workers Compensation Inunance, as acquired by Section 37M of the labor Coda, for the Krformance of the work forwhicb this permit is issued. My Workers Compensation insunnm carrier and Policy number art: Carrier'. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This saline need not W camplemd lithe permit is forme, hundred dollars (SIM) or less.) 1 cenify Out in the performance of the work for which MIs permit is issued, I shall nm employ any person in any mpineryp lg Ce= subject m the Workers' Compensation Lowe of CalifornlKDelar l7a Applicant 7 NOTICE TO IL afmr m Cealncue aq you should r Cnke, you mull Lb LAmr the Workers Compr don provisions of the bnromeSubjecth the meed forthwith comply with such provisions or this permit shall W deemed ranked. comp y CONSTRUCTION LENDING AGENCY 1 hereby alarm that them ill contnc0an lending agency in the amformence of the work for which this pereall Is issued (Sec. 3097, Civ. C.) Landers Name ' Lenders A ldrus I =try that l haw read Mls appllnglmn and sum that the show information is correct 1 tyres, to empty with all city and county ordinances and mm law totaling to Wilding construction, and hereby anthodse representatives or this city to anmr upon she atave-mentioned property for inspection purposing. (we) agree in ow, indemnify road keep bumless the City of Cupertino against Iiabilitiu,judgments, Com, and expansion which may In any way amuse agalnt mid City in coasegance of the {r.aliq of this pernall. APPLICANT yMNDEE��STANDS D WILL COMPLY WITH ALL NON -POINT SOURCEJj�GUlr3TQN5. Issued by: Date 'YJG Re -roofs �Z (GcLaV Signature of ApplieaH mr Dam HAZARDOUS MA AIS DISCLOSURE Type of Roof WIII die applicant or forum Wilding occupant or handle material Houdous e, ChChspmr 9.12. alta the HuIN and Surety o cleared by the Cupertino Mu ' Ipal Code, Cade. Secure 25532(a)? All roofs shall be inspected to any roofing material being installed. �Yu Nu prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or forum Wilding attupam use equipment or device which hanrdnus air conuminenµ a)(dcaned by the Bay Arca Air Quality Management all new materials for inspection. DisiricR [ajf/ ❑Yes Nu 1 haw goad the haraMms materials requirements under Chapmr 6.95 or the Califon nia Nixon & Safety Codi Saga= 23505,25533 sad! 25534.1 understand Net truth building does not curten11 ho a enanl, Mel it I y responsibility to wary Be occupant of the rcyvlrcmcnow' mooed repass ,roanarraCarunc.mararopuey. Signature of Applicant Dale All roof coverings to be Class "B" or better Owner or dmhodud a em ram r3 CITY OF CUPERTINO BUILDING DIVISION PERMIT *t" ' �'', ��r'° '`�1, F5"'�ONr' BUILDING ADDRESS: PERMIT NO. CLIFFORD W COUEY 05090166 6hib"bAMNATERFORD DR FERMITISUEDATE CLIFFORD W MUM SANITARY N L N0. ARCHnEC IENGiNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 t� LICENSED CONTRACTOR'S DECLARATION Job Description P I hereby affirm Net 1 am 11¢nsed underpmvWon of Chapter D (commercial with Sado. 7").f Division 3 orthe Business and prefeasions Code, and my license is in fullfome,ad elfen Licanrccl.er 0 - ADD 187' (BEDRM/MS BATH) Contractor Dam ti mr Data ARCHITECTS DECLARATION I understood my plans Nall he used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby string that I em exempt from the Contractors License Law for BM following mason. (Section 7001.5, Busineas and Profession Cade: Any city at county which requires a permit . construct. alms, improve, demolish, or repair my structure prior m ILL Issuance, a1W ergot. the applicant for such permll to BIC a signed ruammeal Law 9 Sq. FL Floor Area Valu aflft that he is licensed personal tothe pm.mansofthe cantmcmrruanse (Chapter (commencing with Section 7IX10) of Division 3 of the Bualness end Preafessinm Cada) or dust he is exempt therefrom and Bre basis fm the alleged exemption. Any violation of p7�T 7�T ,,,g � yY4Y6+yr Occupancy Type Section 7031.5 by airy epplicam for a permit subjects to applicant to a civil penally of non mom Bob an hundred dollars (SSBB). 3�jA O i o v v a. 0 0 ❑ L ot the property, mY emptoyeu with wgu u sole ampeea Required Inspections e worof rr r .It ionex aelapply dolhework, sae thaswCoretsnonmm�dedorote owner of ininown Vw don not apply lf end does and Cade: The Contractors Liccousand q P r is propertywhobullro of Impmvuthereon,andwho areaouchwork himselreddura{h his property who who employees. Wtsuhimprovements usenet tendedopleerW for ole. if. iprovided K... time Wildingorimp.wmennismid within oroyear ofImproedmn.the owner. K bui a will Mw the burden of proving that W did not Wild or Improve for purpose of a 1). 1.as owner of do, property. anteduar wise:)ceased m ec.704, Bnness andclusively rmne. eo ale (gee. Business and Cade:) Canlrhamrs U. es at nd sued Wdpurstmpmwa thereon and, La to . ray who p covelawdollnotchp mjecu, id, aofproany who contracts for such D.jects with acanuacmrtO licenser pursuer m the Conlrattors Liuue law. ❑lam B&PCfor Ws,,/ n crb Owner Date,�—O WORKERS COMPE! ON DECLARATION I hereby &(lase under penalty of perjury ane of the fallowing deelarstioas: hrw and will maintain a CeNBao ofConuant to self -Wore for WorkersCompen- suian, as p.vided (tar by Sacdon 37M of the labor Code, for the performance of W work for which this permit is issued. ❑ 1 Mw and will maintain Workers Compensation Inurance, as acquired by Section 37M of the labor Code, for the Krformance of the work forwhicb this permit is issued. My Workers Compensation insunnx carrier and Policy number art: Cerner'. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This saline need not W camplemd lithe permit is forme, hundred dollars (SIM) or less.) 1 cenify Out in the performance of the work for which MI& permit is issued, I shall nm employ any person in any mp;eryp lg Ce= subject m the Workers' Compensation Laws of Calffor De l Applicant s� NOTICE ro ANT: If. After mCenIR,AIe or Exemption, you should 11=010 subject to the Workeh Compr don..visions or uta LAWr Cc&, ynu mull forthwith amply with such provision or this permit shall be deemed ranked CONSTRUCTION LENDING AGENCY 1 hereby al0rm that them ill const.c0an lending agency in time amformence of the work for which this pereall Is issued (Sec. 3097, Civ. C.) Landers Name ' Lenders A ldrus I =try that l haw read this appllwtmn and sum that the show information is correct 1 gree to empty with all city and county ordinances and mm law totaling to Wilding construction. and hereby anthodse representatives or this city to anmr upon she atave-mentioned property for inspection purposes (we) agree in ow, indemnify road kap bumless the City of Cupertino against Iiabilitiu,judgments, costa and expansion which may In any way amuse galeal mid City in cmm.qumnee of the {raadg of this peaah. APPLICANT yMNDEE��STANDS D WILL COMPLY WITH ALL NON -POINT SOURCEJj�GUlr3TQN5. Issued by: Date 'YJG Re -roofs �Z (GcLaV Siymuvrc of ApplieaH mr Dam HAZARDOUS MA AIS DISCLOSURE Type of Roof WIII die a forum or handle material ost Co e, Chapter Houdoua o dcRnca by time Cupertino Mu ' :pal Code, Chapmr 9.12. alta the HuIN and Safety a Cupertino Cade. Secure 25532(e)7 All roofs shall be inspected to any roofing material being installed. �Yu Nu prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or forum Wilding aaupsm use equipment or device which hanrdnus air conuminenµ a)(dcaned by the Bay Arca Air Quality Management all new materials for inspection. DinricR [ajf/ ❑Yes Nu 1 haw read the harardlms materials requirements under Chapmr 6.95 or the Califor- niaNixon & Safety Codi Saga= 23505,25533 sad! 25534.1 understand dot truth building does not eurten11 ho a mnanl, them it I y responsibility to wary Be occupant of the rcyvl.go" ' mooed mpno ,manarraCerdnc.maraapumy. Signature of Applicant Dale All roof coverings to be Class "B" or better Owner or dmhodud a em ram =ile Edit Actions Details Links. Favorites Help L g 6. yI I� a `i'p` k Ql-i rf sa 1001 L�ration fr�lormat�or�-• _-=7_�_ . r �.. .� . ., _......r. _.. Permit: Number 05090166 Address X761 08 WATERFORD DR� i= r k� . .Status CitylState/Zip ICUPER1'RJO �` €95014_:. MasterNumlier Notes 0 APN - 16616001 00 ¢ Prosect —_� — .? o Unit _ ; ._ �� -- A IDake'x 09/2612005 ppy �_Qperator _ canrnew 0�ner E��tit, lr�lormanor m -.¢ Permit Issue Date 103120/2006 — 0"peratorersaw =1 Owner NameCLIFFORD W COUEY Certificate Issued 07/25/2007 Operator-,, . )PALM - Use Default Certificate Type _ Add Address ;. _Certificate Number I i City/State/Zip iCUPERTINO CAa 95014 5244 Permit Property Zoning ,)Applicant 1 Contractor' Defined Fields w --Permit Details Conditions 4a Back t Contractors Fees° ;Plan Reviews' Inspections Print Permit Adjustments ii f Holds a Copy Permit Close Permit Overrides Supplemental Fields t Nates j ri-fl Attachments lermit issued 03j20j2006 . anter permit status CITY OF CUPERTINO BUILDING DIVISION PERMIT COiWTlaAtCT�iR;il vIA I(Il BUILDING ADDRESS: PERMIT NO. CLIFFORD W COUEY 05090166 O BFUdAtMATERFORD DR PERMIT ISSUE DATE PHONE: SANITARY N L NO. A RC H1TF.CT/ENCINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 o LICENSED CONTRACTOR'S DECLARATION Job Description � uJ I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is h in full force and effect Z License Class Uc. s ADD 1871 (B EDRM / MS BATH) p Date Contractor 1 ARCHITECT -S DECLARATION < I understand my plans shall he used as public records U Licensed Professional ,F,r < OWNER -BUILDER DECLARATION g I hereby affirm that 1 am exempt from the Contractor's License Law for the 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 r prior to its issuance, also requires the applicant for such permit to file a signed statement Contractor's Liccnsc Law 9 Sq. Ft. Floor Area Valva n e that he is licensed pursuant to the provisions of the (Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of�7h not more than five hundred dollars ($500). 361(� lr 0 0 Q 1, as owner of the property, or my employees with wages as their solo compensation, Required Inspections will do the work and the structure is not intended or offered for sale (Sec. 7D44, Business and Professions Code: The Contractor's License Law does not apply to an owner of 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 1.-,'..s or of the property, em exclusively contracting with licensed contactors 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 contacts for such projects with a contractor(s) licensed pursuant to the Contactors License Law. Q I am ezem/6der-S c. , B & P C for this tea/son _ Owner Date 1—O Q6 WORKER'S COMPENUATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: Q 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. Q 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 am: Carrier. Polity 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, 1 shall not employ any person in any m or so as 1p -h fine subject to the Workers' Compensation Laws of Cali' Da 42=00 Applicant NOTICE TO CANT: If, after m, is certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must Zforthwith comply with such provisions or this permit shall be deemed revoked. CONSIRUCT70N LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued (Sec. 3097, Civ. C.) aLender's Name , Lender's Address Z 1 certify that I have read this application and state that the above information is - '� correct. I agree to comply with all city and county ordinances and state laws relating to Jbuilding construction, and hereby suthorim representatives of this city to enter upon the fTa ahove-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against rj liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT D STANDS D WILL COMPLY WITH ALL NON -POINT SOURCE ,UL/t�NS. Issued by: Date Re -roofs ` L��/ Signature of Applicant/Contractor Date HAZARDOUS MAT ALS DISCLOSURE ' Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Mun ipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? All roofs shall be inspected to any roofing material being installed. Q Yes No prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminan defined by the Bay Area Air Quality Management all new materials for inspection. District? Q Yes Nu 1 have read the hazardous materials requirements under Chapicr6.95 of the Califor- nia Health & Safciy Code, Sections 25505, 25533 and 25534,1 understand that if the building docs not currently ha a tenant, that it is y responsibility to notify the occupant of the requirements w - must be ct prio ssaancc of certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class "B" or better Owner or authorized agent Date 11 N r A CITY OF CUPERTITA CITY OF PERMIT APPLICATION FORM CUPEVINO APN #�C � - � � ' � bl Date: Buildi1n�gCAAddress: �i Mailing Address (if different from building address): -Co4/ V Owner's Name: LAJ Phone #: BBOILERI Boiler <= 100,000 Btu Contractor: J License #: Contact-Phone::'-1'2rr "LO j ,( Cupertino Business License#: 1 • )' Fax: Boiler > 500K to 1M Btu Building Permit Info: Bldg Elect COY PlumbL� Mech Job Description-/ ' Residential LJ rl�` r'� Commercial El Sq.Ft. Floor Area: ��„�`.�. / VVI c,-� �, $/Sq.Ft.: , Cost of Project: a Occupancy Group: J� 2-3 Type of Construction: Please check this box if the project is a t-/ second -story addition: ❑ Project Size: Standard R Large ❑ Major ❑ BUILDING Quantity Fee ID Fee Description Fee Grou 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 BELEC 1000 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 1 of 3 • Community Development 10300 Tone Avenue Cupertino CA 95014 Telephone (408) 777-3228 100 OF Fax (408) 777-3333 CUPEI�TINO Building Department I am not using any subcontractors: (�tJ Signature Date Please check applicable subcontractors and complete the following information: JOB ADDRESS: PERMIT # BUSINESS NAME OWNER'S NAME: Cf. l i j e �.P . PHONE # 0 S -- "GENERAL Cabinets & Millwork GENERAL CONTRACTOR FAX # I am not using any subcontractors: (�tJ Signature Date Please check applicable subcontractors and complete the following information: Owner/ Contractor SigAature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass % Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor SigAature Date