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0307020730F0F �eW s�— s yyU [ r so� yoo <m� a—„ zFc 4 :./ 2 Z 0 i CITY OF CUPEWHNO '^ gwi+'3w "rr' `�s • : �'- BUILDING DIVISION PERMIT CONTRACTOR INFORMATION BUILDING ADDRESS: SOUTHWEST ELECTRIC PERMIT NOO 3 O 70207 OWNER'SNAME: 14510 BIG BASIN WAY PERMIT ISSUE DATE- ATEHALL HALLSHIRLEY ONE' (408) 999-8721 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG E ELECT' PLUMB MECH O O 0 LICENSED CONTRACTOR'S DECLARATION 1 heseny affirm Inas lam licensed under provisions of Chaper 9 (commencing Job Description p with Sceum70r0)af0ivision 3ofdae Beinessand ProfessionsCode,andin,imcnx is ' in a a LECT SERVICE UPGRADE 0=00MA-•.LER3 ed Class License Class ti• _Lick ARCHITECTS DECLARATION I understand my shall be used u records 1 JUL L 2 9 2003 P9ns public Licensed Professional OWNER -BUILDER DECLARATION Licence Lata the 1 Weeny .mem that 1 son exempt ane one Cantons BUILDING Cos inns Code: Any city or county co fallowing retina (Section ID3str Business andnve. which demolish, repair any de requires a pmmil a construct, arms.applicant rot per its such file PHOT to its issuance. also mquims the applicant rar such permit m Glc s signed natemcm statement the sadPnselaw(Chapter9 Inas Weis licensedpursuant70NR Sq. Ft. Floor Area Valuation (commencing with Section7and of Division3 oftCnmeeuti ofprevisions sion Inc Rosinessapim.An vi Cndo)or the that he u emmp therefrom and the best for Inc alleged cmmption. Any violation of 35923001.00 Section 7031.5 by any applicant for a permit subjects the applicant to a civil porosity of - APN Number - Occupancy Type no, no, ... tbnfive hundred dollars (SM. I. as owner of the pepeny. Or my employees with wages as their sole compensation, .Ulelo dmwmk.and Neatrvenorcu ainwstdedmoReed I ... ic(Sec. 7061, Business — and Pwfcssion: GwC: The Cantnclar'a Liana Law docs not apply to an owner of ❑ P.pltywhobuildsorimpfawethemon,and who does such Work himself or Olmugh his 501 - FINAL NERGY awn employees, provided that such improvements are not intended oroffered forsake. If. SOS — FINAL ELECTRICAL however, lie building or imprawmem N is sold within one year of completion, e owner - builder will bare the Widen of proving Nat he did not build or improve forgmpose of sale.). ❑ I. as owner of Ne pmpeny, am exclusively containing with licensed contractors to construct the pmjecl (Sec. 7064, Business and Professions Code:) The Contractors Li. ,I. law dors not apply to an owner of property who Wild, or improve daemon, and . who contra er for such pmjeets with a contracwr(s) licensed pursuant to the Contractors License Law. I am esempl on&, Sec. B & P C for his rtuon Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury ane of dao following declarations: 1 have and will maintain a Certifies. of Consent to Sel6insue for Workeh Compet auxin, u provided for by Section 3700 of the tabor Code. for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as "cited by Section 37M of the Labor Code, for the performance of dni work for which this permit is issued. My Work e`rs `anntt coin and Policy number art: sCn—mpcwlion�l Canicr 1/�%Y TNN ii Policy No.: z7-- CERTIFICATE OFEXEMPTION MOM WORKERS• COMPENSATION INSURANCE This section need not becompincd ifthe permit is intone hundred dollars (Sip)) or less) 1 anify that in the perrosmenee of the work for which this xrmil is issued. I shall not employ any,arson in any manner an u to become subject o be Workers Compensation Laws of California. Date , Applicant NOTICE TO APPLICANT: If, after making this Ceniacate or Exemption, you should become subject to the Worker's Compensation provisions of be Labor Code, you must fofdawllh comply with such provisions or this Permits shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that then is a cunstructinn Lending agenry lot IM performance of the work for which this patmit is issued (Sate 3017. Civ. C.) Lenders Name Iander's Address 1 anify that I nave read this application and as. that the shove information is conch. I agree to comply with all city and county ordinances and sate laws relating Io buildingcoimical roand hereby authanpeprcxnatisu of this city racoma upon Inc ahovcmemioned property for inspection . (We) agree to save• indemnify and keep harmless the City of Cupcnino against which m expenses Which may in any way accmc against aid City in enceo doe granting in conuyucnce of the granting til this permit. SOURCE E UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT fya7fs Issued by: Date 7,1p,'`4 Re -roofs Sig a of ApplicanVConvazwr Dan, HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant of fa.. building occupant store or handle hazafdous material as defined by (be Cupenion Municipal Code, Chapter 9.13• and the Health and Safety ewes Section 25532N)?v ❑ Ye V. All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use c equipment of when If a roof is installed without first obtaining an inspection, I agree to remove g p tis hazardous air contaminants u defined by the Bay Arta Air Quality Management Qu Mara istrin7 all new materials for inspection. p Yes �o I have mail one handouus\\ma trials equirtmems under Chapter6.95 of the Califno- nice Health &Safety Codd.Sections251)5.25533 and 25534.1undermand loan ifdm building dors not currently It.w a .nano that it u my responsibility to notiky the wc,am of dao mqullnn ms Which must he mel our iauana ora L•CNacam Of Oscar., f�wV Signature of Applicant 72f 07 Dale All roof coverines to be Class "R" nr hf•nPr ownee ar authorized agent 1-i- CRY OF CUPER,TINO Ak CITY OF CUPERTINO PERMIT APPLICATION FORM 6 3O 7 U z--67 PN # / V (/ Date: Building Address:. Mailing Address (if diff e f 4/�/ ,Cat et/A", C�9 t from ilding address): Owner's Name: ,ed p A/l / /Jy oO yr' Phone #16 : Contractor: / , >dz4r A es { r/G� • License #: / <Q� Contact: Phone: Fax: Cupertino Business License#: ' Building Permit Info: BldWZ El4�2 Plumb ❑ Mech ❑ Job e cription: Residential ❑ f / Sq.Ft. Floor Area: /Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this b ct is a second-sto addffi Itoon- Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > I OOK to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to I M 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 <= I OOOA ELECTRICAL BELEC1001 Elec 600V >I OOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Ener BUILDING BENERGYADD Ener Add Multi BUILDING BINVESTIGA Investi ation fee BUILDING BMITIGATC Comm. Housin Mit. Fee BUILDING 1 of �v617 27 7 CITY OF CUPEI,TINO CITY OF CUPERTINO PERMIT APPLICATION FORM 2of3 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 BOVERTEN4E 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 BPINI'ERCEP 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 Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER WaterHeater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cf n MECHANICAL BREMAIRHAN A/C Units <= 10,000 cf n MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Ligbting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Fumace > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMMHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL 2of3 salffll-� CITY OF CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmd] Sips Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM BSEISMICRE Seismic Commercial Seismic Fee Res BUILDING 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 •