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03100060CI'rY OF CUPEWFINOsea r� ' BUILDING DIVISION PERMIT' R CO({NTRACTOR INFORMATION BUILDING ADDRESS: SIMON JULIUS S AND MICHELL ERMITNO.03100060 ERSNAME: PERMIT ISSUE DATE PHONE: SANITARY NO. CONTROL N0. ARCHITECDENGINEER: BUILDING PERMIT INFO ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hcrcby affirm that 1 am li¢mod under provisions of Chapter 9 (commencing with Scnion7D)0)h Division Jof NC Business and Professions Code. and my license is Trp CO in mnmaanderr«t. CONVERT DEN TO BEDROOM Z�04 License Cllus Lin. N DateContractorDELL ARCHITECTS DECLARATION r� 1J[(II TNa,B 1 understand my plana shall he used as public re<rnJa he used 1 kkJ L�J aIIa1W1 Y11 .gg`!, yG Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city ar county which requires a permit in construct. alter, improve. demolish, or repair any structure prior m its issuance, also requires the applicant for such permit to rile a signed statement that he is licensed pursuant to the previsions,,( the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Codolor 35618070.00 that he is exempt therefrom and the basis for that alleged exemption. Any violation of APN Number Occupancy Type Section 703 L5 by any applicant for a permit subjects the applicant o a civil penalty of not more than five hundred dollars ($50)). Q I, as owner of the Pmpeny, or my employees with wages u their sale compensation, 101 — FOUND@4d Inspections will do the work, and the structure is not intended or offered for sale (See. 70PI. Business and Professions Code: The Contractor's License Law does not apply b in owner of property who builds or improves tbefcon, and who does such work himself or through his 102 — PIERS ownemployaes. provided thnuuch improvements creno mandedaroffercd forsale. If. 103 — UFER however the building or improvement is sold within one year of completion, the owner- builder will ban the burden of proving door he did not build or improve for purpose of 1 04 — REBAR "I`')' Q 1, a owner of the property, am exclusively contracting with licensed convenors to 105 — ANCHOR BOLTS construct the ptnjecr Soc. 7W. Bu:meas and Professions Code:) The Contractor's Li. 106 — SEWER & WATER cease Taw does not apply to an owner of propeny who builds or improves thereon,and 202 - UNDERFLOOR PLUMBING who contracts for such projects with a comeactor(s) licensed pursuanuo the Contractors e L. I em cum w See. s B h P C Orth' reason 203 - UNDERFLOOR MECHANICAL VVLV Datel'"103 204 - UNDERFLOOR FRAME o RSCOMPENSATIONDECLA�t 205 - UNDERFLOOR INSULATION /7pN I hereby Tom under penalty of perjury am of the ThTfowing declarations: 301 — ROUGH PLUMBING ❑[have and will maintain aCertificate ofConsent toselNotion, for Worker aCumber. 302 — TUB & OR SHOWER aadoa, as provided for by Section 3700 of doe Leon Cede. far the pertomuna of the 3 03 - ROUGH MECHANICAL work for which this permit is Issued. 3 04 - ROUGH ELECTRICAL 1 have and will maintain Workers Compensation Insurance, as required by Section 37M of the tabor Code. for Ne porfurmanec of the work for which this pemtit is issued. 3 05 — FRAME My Worker's Compensation lnsunnee carrier and Policy number are: 306 — HOLDOWN.S, Cartier. Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 — SHEETROCK ' meissu6nn re ad not be completed if pe. it a to,.. hundred dollars ISIBOB 309 — EXTERIOR LATH trlcss.) 310 INTERIOR LATH 1 certify OUR in the performance of the work for which this Permit is issued, I shall not - employ any personany manner an n m becoe msubject to the Workers' Compensation 311 - SCRATCH COAT Laws of California! Date Applicant 313 - 501 - ROOF NAIL FINAL ELECTRICAL ENERGY NOTICE TO APPLICANT: If. after making this Cenifcave of Exemption, you should become subject to the Worker's Compensation provisions of the UNIT Cole, you most rental tocnmplywith aain rciviriur,orthis permitshall IN, diamrdrevoked. 502 - FINAL PLUMBING ENERGY CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY Ihereby affirm that there isa construction lendiagagenry for the virfamark. of _ 504 FINAL BUILDING ENERGY ' Ncworkforwhichthispermitisissued(Sec.Jvi7,Ciy.C.) i Lendc%sNino 505 — FINAL ELECTRICAL IndersAddor. 506 — GAS TEST i 1 carry that I have read this application and state doorthc above information is FINAL PLUMBING correct. 1 agree to earn ply ply with all city and county nor nances no sulaws relating to 507 - building eoremacrion, and hereby authorim representatives of this citym tear upon the ahove.mentioned probarty for inspection purpose (We) egret to save, indemnify and keep harmless that City of Cupertino against 0 9 AL FI FIN MECAWORKS j liabilidev,judgments. costs and expenses which may in any way sector against said City r in eonsecucnc of Ing of tau Permit. 5 i APPLIC{� NT U ERSTANDS AND WILL COMPLY WITH ALL IN P NT Issued by: 5 Date SOURC�1I'Rr: LA DITI IO Re-roofs SIU.uco Applicro ontracmr ?to HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle ha'rarduus material }s Ecfned by dx CuWnino Municipal Code. Chapter 9. 12. and the Health and Safety a'SpYCS zssJ2(a)+No All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building =upon[ esu cyuipmcm or Jcvims which emit ha ardous air contaminants as defned by the Bay Area Air Quality Management all new materials for inspection. District? Q Yes gin. 1 have read the haoutbrus materials myuimments under Chapter 6.95 of We Catfor nia Heelthfk Safety Smai 25515,35533and2553q.lundersundthuifth, building does nn conudlya ten ethm it is my Tesponsighty m hour he ate ant or the requimocou wmrn u Mm rt ay qs ante ofa CerufC'c catenf \rip Signature of Applicant Date All roof coverings to be Class "B" or better Owner uf auttthonmd agent Date CITY OF CUPEWI'INO +* "'' * s*`�W r,..o 9+CONTUMN'QR�>INFORMA N" BUILDING DivIsloN PERM BUILDING ADDRESS: _ SIMON JULIUS S AND MICHELL ERMIT ND.O310OO6O OWNER'S NAME: PERMIT ISSUE DATE NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am limned under provisions of Chapter 9 (commencing p with Section 7M)) of Division 3 of Ne Burincss end Prof..!.. Code, and my license is L License Class Liccnm Clms CONVERT DEN TO BEDROOM Dam Contractor DECLARATION TSD ARCHITECTS be e I undcrrsenJ my plans shell W umJ u coheir, rtmrsE Limosed Poor csstrust DECLARATION Oe I hereby ,f0rm !heat 11. ,Bump! from Nc Comncmfs Law for the I Am % : Any c 703 Business and oli Code: Any city Of County v whInwingmason. Permit ere. do which its i res n e..l. hs c�n the alter. improve, h Permit t or repair od atructum construct. prior m its i atm requires the applicant for tech ractor's L f lc Law( staamcnt Ft. Floor Area Valuation se licensed of Contractor's License law(Chcpmr9 Ihotnomminwition lathe pursuant Sq. or Diviso Code) or (commencingwith Section?ODD)And or Division3 oft he Businessandcim. 35618070.00 Any Net he is exempt Ncm(rom and me basis for the all,{cd emmption. Any violation of Section 7031.5 by airy applicant for a Permit Subjects the applicant o A civil penalty of APN Number Occupancy Type not more than five hundred delta. (5500). ❑ 1, As no, of the property, or my employees with w,, u their tole compemNon, D @gd Inspections will do the work, end the atrublum is not Intended or offered for sale 706x, Business and Profesaions Code: The Co bat Uccrsm law does not apply m an owner of p lfor rough his property who build, mimpmves Nemon,and who does such work himmth 10 2 - PIERS own employees. provided that such improvsmenu ere not intended or offered for Sale. If. 103 — UFER however. the building or improvement is sold within one year or completion, the owner builder will Nve Bre burden of proving that he did not Wild or improve for purynm of 104 - REBAR 105 - ANCHOR BOLTS ❑ 1, a owner Of da property, exclusively contracting with )m onan ton i. mnnmcnne project (Sec. 70d4,, Business and Processions Caee:)MCantnclorr u. 106 — SEWER & WATER mue Law docs not pply An in owner of property who WBdsor improver thereon. and, 202 — UNDERFLOOR PLUMBING who contracts for Such pmjecu with a comiector(A) licensed pursuant in the Com.cto's taw. em axe m to rSeb. N ,B&PC o,th remora 203 - UNDERFLOOR MECHANICAL 'R'ICt �l/��i>� '03 204 - UNDERFLOOR FRAME ov1, Dauw 205 - UNDERFLOOR INSULATION JrI 0 A'S COMPENSATION DECIA71,1 I hcrchy AMM under penalty of perjury one of NeTalfowmg deciarniona: 301 — ROUGH PLUMBING haveand will maintain a Cenificue of Consent m self -insure for Worker's Compen. 302 — TUB & OR SHOWER ton, As provided for by Section 3700 of she Labor code. for me performance of the 303 — ROUGH MECHANICAL wart for which this permit Is issued. 304 - ROUGH ELECTRICAL ❑ 1 haw And will maintain Winker's Compensation Insurance, u mqui.d by Scion 3700 of Ne labor Code, for Ne performance of Ne work far which this permit is Issued. 305 — FRAME My Worker's Compensation Insurance carrier and Policy number ate: 306 — HOLDOWNS Caller. CERTIFICATE OFEXEMPTION MOM WORKERS 307 - INSULATION COMPENSATION INSURANCE 308 - SHEETROCK (Tills section need not he completed if the permit B for one hundred dollars (51 Off 309 - EXTERIORLATH - or Mas.) 310 INTERIOR LATH 1 molly that in the performance of the work ror which this permit IS Issued, I Alin[ nut employ any parson in any manvrm As m become subject to the Wmkeri Compensation - 311 — SCRATCH COAT ff Celifornia.Oe a 313 - 501 - ROOF NAIL FINAL ELECTRICAL ENERGY Applicant NOTICE TO APPLICANT, if. after making this CeniOcam of EmMPOW, you Ahou[d become subject to the Worker's Compensation provisions of tW labor Code. you most forthwith comply with such provisions or this Permit than be dmtom revoked. 502 — FINAL PLUMBING ENERGY CONSTRUCTION LENDING AGENCY 3 503 - FINAL MECHANICAL ENERGY lhemeyaffirm that Drum I$aconstruction lending sganayfor the performance of 504 - FINAL BUILDING ENERGY ' the work fur which Nu permit is issued (Sm. 3097, Civ. C.) 4ndcr'I Name 505 - FINAL ELECTRICAL LanderA Add. 506 - GAS TEST Ieegreeoclhaw foodthismamas ane salveinforming[s 507 - FINAL PLUMBING and county ordinances building I agree l9 comply with all airy and county ordinucef pod Sum taws reining to nercbyamhodmrcorerenmiry of this dtymmmr upon Ne FI&aNW`j CL AWK-gmv0ucslnnand ahovememioned property forivpcction purposes. ( (WA) agree to save, indemnify and keep harmless the City of Cupertino against 0 9 FI . j liabilities judgments. costs and expenses which may In any way mane against mid City a in ton quend err .mmg Onhisrnoul. U ERSTANDS AND WILL COMPLY WITH ALL NP NT 5 Issued by; 5 / UT RKS Date SOURC RE LA iV ' Re -roofs Sipiruma ApplicarritContractor Yam' HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant car future building Occupant store or handle hasardov material As thorned by the Cupertino Municipal, Code, Chapter 9.11, and the Hcabb and Safety Code, S All roofs shall be inspected to any roofing material being installed. ymzss3z(.)7 ❑ Nu Yes prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant orrWurcbuilding aaupnnlumequipment ordcvicorwhich II havardous air contaminants As donned by she Bay Are, Air Quality Management all new materials for inspection. mict7 ❑Ya OJNu I have mail the ha.Nnua materials mqulmmmis under Chapter 6.95 of the Califon oaRoddr&S 1 Pat, 15505.15533md25534.1undcnna tiff Wilding 'lily Vas not cunenlly h w an a mat it is my rcipomi m and Max tot of the requirements ich 9 xof a arac�cmRdaaar`ap ' ItI V Signature of Applicant Date (� I All roof coverings to be Class "B" or better Owner%authhorized agent Data OWER -BUILDER VERIFICATW 1. (Check one) I or my immediate family (parent, spouse or child) will perform: • A. All the work authorized 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 hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to be performed 3. _ mil I will utilize unlicensed person(s) other than my immediate fay 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' compensation must be on file at the City of Cupertino Building Department office. Type of work to I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner -Builder Information (reverse Ade). , Property Owner's Job Address: s21 Any changes to 0 Department. r1 U Date: /b U 3 Permit # Q 0 CITY OF CUPEkTINO Dear Property Owner: 40 City of Cupertino Building Department 10300 Torre Avenull Phone: (4081777-3 An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner -builder you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding, federal social security taxes, workers' compensation insurance, disability insurance costs, and unemployment compensation • contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers compensation insurance. For more specific information about your obligations under federal law, contact the Internal Revenue Service (and, if you wish, the US. Small Business Administration). For more specific information about your obligations under state law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner -builder building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino • Printed on Recycled Paper �!Q. CIT O CUPEkTINO VITY OF CUPERTINO PERMIT APPLICATION FORM r N 'BUJ Date: /4605 Building Address: f ^^ CJLv C -A I i - Owner's Name: I f �( I u S� L �n /!� Phon 4(,,, 4,_ ^ �5�C7 t Contractor:( ^ Licensed#: Contact. BBLDGFEE Cupertino Business License#: Buil ng Permit Info: " B d Elect Plumb 0 Mech (;Z� J bes tion: %�� R ide al El`�� er ial� Sq -Ft. Floor Area: $/Sq.Ft.: Cost of Project: 2 Occupancy Group: Type of Construction BBOILER3 #z3z� 1 of S 19 Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILER1 Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to IM Btu MECHANICAL BBOILER4 Boiler> IM 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 > IOOOA 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 #z3z� 1 of S 19 CUPEkTINO a 14. 1 &TY OF CUPERTINO 0 PERMIT APPLICATION FORM 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 BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTME 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 Repipe Of Fixtures 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 cfm MECHANICAL BREMAiRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 �l . Cl 0 CUPERTINO 4kITY OF CUPERTINOO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Group 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 Single Duct MECHANICAL BREMVENSYS Ventilation System 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 I BUILDING • 3 of 3 11 QQ 1/n r t G 1. r V I/ G rt j Z �c�,i � � '„ �n •7, r� CJr j. "`9ir.. s^,+ �t,,yas�f. IA Gv-e.alyd,(I -riY �n Trsen _ - 0C ' 0 g ILI CL y < - - N 4 CEI -:PR ^LAD. STAG ! .... y -1,J - � i- -�. ':.... . _.-.._- .... � 1 •--_ - I♦- t- ��iYTT7 �L-3�i�-'fit it _ Elr1 zo 00 010 - rn>�'�.�&uer hal_.. • ,.. 'S,,.T_ >_r. * c: ii �,'�` >alClST77 �n ._.... - - ...N\ ,�. � tc_ �� _ .,.. I � �� I 7 '. M�`.,T•i"_L-t`£?-t -�i '.t-- i�� aso f a _ ; -i -� 'o- ( T _:wszs�ta._CtlS.`+�6Nc NEC 1`� ; f; . _ Ex. :r J g 7'B 1 ; ANCU,E W-TH T ' �.. 1 T;YD CDD } ND Oi �AI�C 49 Den arg. r' . ,canons UST / I _ of .nett -b ata 1!imes and it s un: ,t/ t I f ►y �� yPZSfli Ulje a y changes or alter tions I V t --L. Y without w..,- Gelmissioo ttom '' U in l f" building Dept., City of Cupertino r tl taggQf ttilspl I an and sperm as — o _— LL f4DT be field to' permit r $eoar. - ; ' U,� �' vvon;.'i a SEL215 - occp !a"�?_ _ a royal of the violation of any provisioftt " .y 5T r.2_r %o C>�, 6 _ . .... i i — ---- if any pity Ordinance of ate UYL -• � 15 I -- � � I ! i � '- I I i�� -_ _- tC% -- #I •Y �tl -- -"`--_:._ haw.__..,,,•_._... -t-..... _._`_ � - ... ,r_ _.� '{ lin A.STS .-ZEUi1,G2X! n-: ttt`I4 f-! T F ycr t t L ATI Or\ + 'r':_ ; T' SE N G a 11. W4I-L- ..F.. - Cl. Y" ad 1p L00fZ. dYCb . Z55'^ ,r •, }pra _...1(2dil;i f3,G,:_r - -- 5 a , r