04030222 RZ
CITY OF CUPERTINO CONT12ACTaR INFORMAT�I
BUILDING DIVISION PERMI�
BUILDING ADDRESS: TIMOTHY MCAULIFF CONSTI . CO PERMITNcb403O222
PERABT L4UEDATE
OWNER'S NAME:
SERGIO CAMERL
SANRARY NO. CONTROL NO.
NE:
(408) 879-0790
BUILDING PL PER INFO
A0.CHITEC7/ENGTNEER: BLDG ELECT PLUMB MECH
0 0 0 0
zi
LICENSED CONTRACTOR'S DECLARATION Job Description
C1 hereby-Mon WI I am IimnrA un er pmvixions of Ch to 9(commencing
b wiNSccuon]OIIO�of Division Sof NCB WPro(rssioruC ridmyfccnxis
« imm�rp�kydtrec Lcs 7 i (�jy REMODEL-7 NEW WINDOWS/2 BATHRM
2 Liccmej a
Co
£v� ARCHITECTS RATION
n� 1 understand my plaru shall he used as public records
sU
G Licensed Professl
iona
OWNER-BUILDER DECLARATION
to I hereby from Nal I am cumpn from Ne Conmcmrs License law for the,
'C following reason.(Section 71013.Business and Prefeatinos Code:Any City Or county
$1 which requima a pem,(t.to conswe4 alarimprove.demolish,lir repair any sumture
o prior m is issuance,&he mquims the applicant for such permit to rile a signed sammenl �Ft.Floor Area Valuation
�<
that he is licensed pursuant m the remotions Of the Connector's License Law(ChaPmr 9 Sq.
r$
(commencing with Section Division 3 of the Business and Profmssi.m COdc)ur
(c '
Nu he u exempt Nemfroor and the bests for use alleged exemption.My violation of
Section]031.5 by arry+ppbam for a pewit subjects the applicant m a civil pcmlty Of 5 ' eTo 0 Occupancy Type
'bin mem Nan live hundred dO1Ws(5500).
FI 1.as Owner Of the property.Cr my employees with wages a their sole compensation,
will do the.,it.and Ne."comm ts not intended Or.Rcred(.ream(Sec.7061,Business Required Inspections
and Professions Code:The Coopmeurs License Law dna nm apply to an Owers Of
propenywho builds mimprnws drreon,endwhodaesauchwmkM1imaelf.r Wough his J
own employees.buipuviOriNalsato impm old wits in om intended mortared fins I-
hwweor, e building or improwmem u cold within ono year ofd m ortare.He owrof, /�(—'A'•](v
builder will have the burden of proving that he did not build or improve for purpose of
ale.). —y
1,as Owner of ate botany.am exclusively contracting with licensed contractors So
comwet Ne Pusan(See.7061.Business and Professions Code:)The Coutraebrk Li.
c.law dins not apply on an owner of progeny who builds or impOs a Hereon,and V
who connotes for such projects with a eomnmor(s)licensed pursuant In the Connecticut /
License Taw.
E3 1 am exempt under Sec. .B d:P C for this mason
I Das
WORKER 5 COMPENSATION OECIARATION
I hCmby affirm under Nastily of perjury One Of Ne following declantioss:
❑1 haw sed will for by
Section
37W of the Labor
fm eroors ice of me
work(as provided pe by Ss list 7]00 or the labor Code.(m the per(omame of Ne
work for which His permit is issued.
1 bow and will maintain Wmk eS Compensation Insurance,u mquimd by Section
3]W of the Labor Code.for the Perfomana of the wok fmwhich this Permit is issue.
My Wmk,,s Compensation Insurance cannot and Policy number art:
Cartier. Policy NO.:
CERTIFICATE OF UEMPf ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need non M completed lips,Ixrtnit IS fm.nc hundred dollaot($lop)
or lossJti
I ceNfy Nal in me perf.rmanco of He wart for which this Pemit is issued,l shal not
employ any pCtson yfany mpOjmrs�aslpLccv suhjauo NC Worteri Compensation
Laws of Cabins.Dare �rj
Apple ant
CE TO APPLICANT:If,after making Nis CeniEcam of Exemption,you should
me subject to the Worker's Compensation Provisions of He labor Crude.you most
Z foMwiN comply wish umh provisions;m this Permit shall W ticemed mvctr6
Z 2 CONSTRUCTION LENDING AGENCY .
I hereby aRrm that Nem is a construction lending agency for the pmfumence of
]� > the werk for which Nis permit is issued(Sec.304E Civ.C.)
31 r, Lender's Name
Lenders Address
;)O T comfy shut I haw read His application and sur the c-boor in(omati.n u
LL r- crucck I agree to comply with all city and county ondirunas and state laws reading w
mpr
net
p V Wilding construction,etosinebereby demniy and eep himlustof this City merton aupon
m,
r shove-mentioned propmny for inspection purposes. A
a
(WO)agree a,save,indemnify+lid hich ay is an w yCity of against S against ._�l`7
,Fat fn liabiliva.judgmcnu costo aid eapcnscs which may in any way same against Said City
U Z in consequence of the granting of His Permit. Date
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR ATIDNS.�.
Re-roofs
gig m sir App HAZARRDCOUS ALS DISCLOSURE Dar Type Of Roof
she appit.,or future di upannsummbaralc Namom materia
ss defmW by she Cupertino Mumnpal Code.Chains,9.12.and the Health and Safety
CWc.Section 25532(-)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
wu He.ppbwnt.r mwm building=upon,use egmpment.rdewfea which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrums air conumimns ss dcl ned by He Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yu KN.
1 have mad one ha ardmrsmanoudgmquici ents under Clupmr6.95 of Ne Califor-
ninHalHjeBaelyCedc.Sections 25505.25533 and 25536.1 understand Noif Ne building
dors Iron cummly haw a tenant.Nat it is my mspomihilily to unity tM occupant of the
m' uimnr .a mm Peine n,iuL n .raapu¢y. Signature of Applicant Date
`f 31 All roof coverings to be Class"B"or better
owner or eon 'ase Date
WITY OF CUPERTINO*
CITY OF PERMIT APPLICATION FORM Z" Z Z
CUPEP,TINO
APN# Date:
Building Address: Mailing Address (if different from building address):
Owner's Name: -X Phone #:
Se � , SgOg
Contractor: iLicense #:
-,110c ff 739364
Contact: _ Phone: 9 3 I N1 Cupertino Business License#:
—1,,/h? Fax: 3 G L L
Building Permit Info:
Bldg ® Elect Plumb Mech ❑
Job Description: -7 "4cw w /vdobtld
Residential 0 r /'E C L Commercial [I
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Pro] j a d Occupancy Group:
Type of CkQLtructi Please check this box if the project is a
U O L second-story addition: ❑
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/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
BMITIGATC Comm. Housing Mit. Fee BUILDING
1 of 71, S /
r Q40TY OF CUPERTINO
cITM 0 PERMIT APPLICATION FORM
CUPEI�TINO
Quantity Fee ID Fee Description Fee Group
BNUCOMA E 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 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 Re eatFee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit > 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT ✓ Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREND RAP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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 Rmd] Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
2 of 3
t� CITY OF CUPERTINL
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMTHEATR Theatrical 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 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
•
3 of 3
�fl/I;G U C 6 GGct j4dg.IV WX .
" Uc�a
"ZA
ZZA
y / S
rn
} PEKE COPY
of
MAR 25 2004
CIV ING DEPARTMENT
APPROVED BUILD
M ACCORDANCE WITH THE OR
CUPERTI 0 pp
,, NA
)ATE
IGNED
This setfo pl s a ecifi. tions MUST
be kept on at all times and it is un
lawful to make any changes or alteration,
nn same without written permission from
he building Dept., City of Cupertino.
• The staNDTmping of this plan and specifications
SHALL be held to permit or to be ar
approval of the violation of any Provision,
Citv Ordinance or State Law
A
CITY OF CUPERTINO +� ''' 'z '"'- "' •
BUILDING DIVISION PERMIT CONTRAC�TOR�INFO.RM TION
BUILDING ADDRESS: TIMOTHY MCAULIFF CONSTI . CO PEaMITN904030222
49ER'S NAME: PERMIT ISSUE DATE
SERGIO CAMERLO 14850
PHONE: SANITARY NO. CONTROL NO.
(408) 879-0790
ARCHITECIENGINEER: BUILDING PERMIT INFO
BLDG EIFCT PLUMB MECH
0 t 0 0
X00 LICENSED CONTRACTOR'S DECLARATION Job Descri twn��
ZC 1 hereby firm that 1 am lianutl un9�cr provisions of chapter 4(commencing P (�tt p �®
i with Scom.7000 of Division3of lhcfivai ,errd PrA earn C and my Hearne is e Y� 161
;; ,.x mono. art. ✓✓ j r� REMODEL-7 NEW WINDOWS/2 BATHRM
D viz Linc/ns�c Clas Lica
e g D`�� 1 understand
ARCHITECTS
d u P hliRATION MAY 5 2004
�wU
05 Licensed protest ontl BUILDING
OWNER-BUILDER DECLARATION QD
1 hemhy affirm that 1 am exempt from the Contractor's License Law for the
a0 following Mason, M1.5,Business and ProGssiuns Cale:Any city m county
K a r which.quires a permit.to iMmarucs at.,.improve.dcmnlim.o,.pair any avucture
FZ< prior to its issuance.alio reci the applicant for Such permit to file a tigMd sumnocro
that he is license)pursuonuo the pmvisinna of the Comranor's License law(Chapmr9 Sq. FL Floor Area Valuation
(commencing with Section 7")of Division 3 ArlM Buseresa and Professions Code)or
— that he is comp,therefrom and the buffs for to alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicuuo a civil penalty of 3 5 iln"bet0 0 Occupancy
not more than firs hundred donors(5500). P Y Type
❑I.Asowncr of Ne progeny,or my employee with wage As Nen sol.compensation.
will do the work and the structure is not Intended or offered rot sale(See.7014,Busircss
and Professions Cade:The Connor's License Law does Am apply to in owner of Required Inspections
proper who builds mimproms thereon,and who doessuch work himself orthrough his
Own employees,pmvidcd that such improvements are not intended oroffered for mile.If,
however.Ne building or improvement is sold within one rat of mmpmtion,the owner,
builder will have Ne burden of pmving tut he did not build or improve for purpose of
sale.).
❑1,as owner of the proper,am eaelumvely,contracting with licensed convenors to
co..,the pmjen(Sec.7014.Business and Professions Cad)Tu Conuacmri U.
cense law dos not apply to an owner of prapeny who Wi1N or improves tu.on,sed.
who contacts for such projects with a cumractoKs)hemiscd pursuant in the Contractor's
License raw.
1 Am exempt under Sec. B h P C for MA neason
Dale
WORKER'S COMPENSATION DECLARATION
I thereby affirm under penalty of perjury,a=of Ne following declarations:
❑1 have and will maintain a CenlGcam of Consenuo self-insure ra Water's Compen-
e pion,u pmviMd for by Section 3700 of the labor Codc,for the performance of be
work for which this permit is issued.
❑1 have and will maintain Worker's Comperuauon Insurance.az mluired by Section
37W of the labor Code.for the performance of the work forwhich this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed KIM permit is rorone hundred dollars(Sli()
or less.),
1 cenify that in%e peHamancc of the work for which this permit is issued,l shall out
employany dcgohyfany MuTcrsy,az comcsu ect to the W.,lams'Compensation
Laws of Califo D.,A S'iaS� ['l
Appli ant
CE TO APPLICANT:IL at.,making Nis Ccnificas,of Exemption,you should
omc subject m the Worker's Compcammon provisions of the labor Code,you must
.,z. fmnhwith comply with Allen provisions or this permit shall be deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
Ihendr,dlirtn Nat Mum I,,construction lending agency to,the pctformance of
tY th,work for which this permit is issued(Sec.3097.Civ.C.)
(y Lender's Name
�• lender's Address
U O 1 certify that r have read this application and state Nat the above information is
ly (•' correct.l agree to comply with all city and county ordinances and sum laws relating In
pU building construction.and hemby amnorimr.presenmtims of this city to enter upon the
r{gl ansae-mentioned property for inspection pugwses
(We)agree to save,indemnify and kxp harmless to City of Cupertino against t�
Fr/j liabilities,judgments.cam and expenses which may in Any way aecme against said City \7
U in consequence of the granting of this permit.
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR ATI NS.
Re-roofs
ig rcafApp O'O FIDOUS ALS DISCLOSURE De. Type of Roof
tueColiseumMurt di uhaptuarco undkh Health And Safety
deRSed by to Cupertino Municipal Code.Chapter 9.12.and to Health and Safety
0 es zss3xan All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardnus air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
D.hie'?
O Yes 9No
1 have mail to hanNnus materials requi.mcnu under Chapter 6.95 or Me Califor-
nia Health A,Safety Co .Secuom 25X15,25533 And 25534.1 untkrstand tha,ifthe building
docs not cumendy have a imam,Nat it is my reiponamility m notify to Occupant of the
gmrem> as mnpdormimiu R of Occupancy. Signature of Applicant Date
5'O
owner or an ,.d Date All roof coverings to be Class "B" or better