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03100101 (2) ITY OF CUPERTINO . els ta;sr•'n + BUILDING DIVISIONPERMIT CONTRACTnR INFORMATIQN ,,, II :• ;roe. .:mak . s ,�. u m JLDING ADDRESS: GROUND FLOOR LANDSCAPING I elrr N003100101 l ')S STAFFORD DR OWNER'S NAME: 443 LASWELL AVE PERMITMUEDATE 3NE: (408) 295-5225 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH �op LICENSED CONTRACTOR'S DECLARATION li 1 hereby of Orm that 1 am licensed under,provisions of Chapter 9(commmling Job Description .,��y wish Scction7WPW fDiAlum3of Ne rB,"u�pnexamd Paressionf and mylicenscis ; i °} (an°`rf` �Lk.a E3 00 ADD 1 CIRCUIT TO BACKYARD Da@��\ /// Cumracy - JEd all W use a Punic RATION tU // °p� LlaFnsed Professional I 3 OWNER-BUILDER DECLARATION 1�f I hereby affirm that I am exempt from the Convenor's License law for too :00 following moon.(Section 11131.5,Business and Profession Code:Anycily or County which requires a permit to Construct.Aller,improve,demolish,ar repair any 3B"elurt .ti poor In its issuance.also mquires the applicant for such permit to rile a signed statement —� that he is Rttnsed Forunuo Ne pmvisiaas a(the Contractor's License law(Chapter 9 Sq. Ft.Floor Area Valuation 2 (commencing with Section 7")of Division 3 of the Business and Frolicsome Call or $ Nat he Is exempt therefrom and the basis for the alleged exemption.Any violation of 3 6206012 . 00 Section 1031.5 by any applicant fon permit subject the applicant o A Civil penalty of APN Number Occupancy Type not more Nen five hundred della.(5500). ❑I,avhe..,Land .,L the pro structure o my employm with wags u their sok compensation, t+r ander Newark,endo: suamueix notintended (Crash,nrapply.70".Business - ROUGH IWaaf � nS and Pnfeuiobu CMC:The mwaora and law does not apply tom owner of ---'s ownpropeny who crox,pmdcd thavu Nertprownehe daresuch work ratit menet intended imsalfarNrotrgh nes 501 - FINAL ELECT AL ENERGY f. howemploycea,ping or i pmwmat each rot is semwithin mtmu of mofferalltion.forthe ow.r, 505 — FINAL �Ri AL however.the building or improvement is said within one yes of completion,the owner, builder will hove the burden of proving Net he roti not Wild or improv for purysme of sale.) . ❑1,As owner of the property,am exclusively contracting with licensed convenors to convect the project(Sec.7044,Business and Profession Code:)The Commuter's Li. cense Law docs not apply he an owner of property who Wilds or improvu Merton i who counters for such projects with a convector(O licensed pursuant to the Comrac da- Lice=law, ❑lam exempt under gee, ,Ceti PCfanhis Owner Due WORKER'S COMPENSATION DECLARATION 1 hereby affnm under penny of perjury ane of the following declaration: - I ban and will maintain a Cerdhems of Consent to¢If-insure for Workots Compce scion,an provided for by Section 31110 of the Labor Code,fm the performance of the work for which this permit is issued, ❑1 have and will maintain Workers Compensation Insumnce,as required by Section 3100 of the Labor Cow,for the performance of the work for which this permit is Issued. my Mes Compensation Insurance caner and Policy number art: r;WI`/rpofY T.uS Balnie No,:wy(OOI CSL C RTIFICATE OF E% FROM WOR KERS' COMPENSATION INSURANCE mosecetion need not W completed iftk Permit Is foronc hundred dollars(SWO) kis) I certify that In the performance of the work far which Nts permit is Issued,I Nell net employ any prison In my mannose se re Woame subject to the Workers Compemation Laws of California.Data Applicant NOTICE TO APPLICANT:If.after making this Cenifl aw of Exemption,you should become subject to the Walker'.Compensation provisions of the law,CMC,you mum Oforthwith comply with such provisions or this Fermi shall W deemed revoked. Z ti CONSTRUCTION LENDING AGENCY 1 warty affirm that them is construction lending agency lar the Performance or Si> the work far which this worrit is iasoed(Sec.3091,Civ,C.) 1 p Lender's Name 7 z Lcadces Address Q 1 certify that I haus read this application anal sum Nu Ne Own information is f" Cromer.I agree to comply with all city and county ordinances and suit laws relating to 7 V building construction,and hereby authmie repruematins of Nis city to color upon to a shave-mention.prop-,-,fe inspection purpoaes ti (We)agrte to ave,indcmni fy and keep harmless the City of Cupcninn aSainu TA liabilities,judgments,coma and expenses which may In any way accrue against mid City Z in conxquence of the granting of this permit. ^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCER U T s. /O-l3 U Re-roofs e of APpIiaMConruer Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will be a C.Pm ror mfuture Wilding e.Chmt store Or lunette bar ida anmaterial as de.Sa a. 25 Cupertinoyfut.0"67miding Code.Chapter 9.11,and tW Health roti Safety Code.Sayan nsl2ar All roofs shall be inspected prior to any roofing material being installed. ❑Yes VIr-dg 1If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant oupant use equipment or devices which n he,nou s air conamhc Bay Area Air Quality Management all new materials for inspection. sassier? ------El Yes ❑No I hew lea°the hnardnus maknal.rtyvimmcnrs unticr Chapter 6.95 or de Califon T nia Health At Safety Code,Sections 256!15,25533 and 25534.1 understand than if NC Wilding does not currently haw a enmL than it u my responihility in mod fy the eaupmt of the equirtmcnt.whuse W mm pd.,missuance of.C.mfic Oce mcy. Sign ure fApplicant Date f0-13-o ow ormthonedagent Date All roof coverings to be Class "B" or better • aoTr CITY OF CUPERTINOU3oCUI� PERMIT APPLICATION FORM IN APN# 36 z 06 0 (2, Date: 03 Building Address: I LS S FEQr D bt. Owner's Name: Phone#: runty k- D-5-3 -53 ?-5 Contractor:r �L ��� License#: ©00H43 Contact: v Cupertino Business License#: 57— Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: mn� (� Residential r �� o a1 ❑ � Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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/OMComm/ uasi 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 BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of �� ��• CITY OF CUPERTINO CITY PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMiJLTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING 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 eOfFixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMA U-IAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace 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 2 of 3 za CITY OF CUPERTINO PERMIT APPLICATION FORM CUPEkTINO uanti Fee ID Fee Description Fee Grou • BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Sin le 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 MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3