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04090248 CITY OF CUPERTINO BUILDING DIVISION PER CONT�°A.G�`TOR�INT+ORMN BUILDING ADDRESS: MAM DESIGN CENTER INC PERMITN%4090248 NER'S NAME: PERMITISSUE DATE DO PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH 0 0 0 0 2000 LICENSED CONTRACTOR'S DECLARATION u F I Thereby of ima Nm I am Bmvcd under provisions of Chapter 9(commencing Job Description no`o. d with Section?qnD)of Division 3 of the 13:�o and Profccsinm Code.and my licence is offinct.¢¢ �yej REMODEL LIVING RM & KITCHEN Liccnac rni /J Lic.M rW Dam —7'A"/ Costs �— Wy ARCHITECTS LARATION � l understand my Plans shall M used u Public records ;,,v 4/+r-r ik U ''a G Licensed Professional 3 OWNER-BUILDER DECLARATION Contractor ON E 20 1 hereby affirm that 1 ach1. .Bumps from the Cantmeroe :Any C Law for the E20 O following dm3 a(Section 701.5.Business and improve, derons Code:Any city m county K m which its un a Permit m constrma,slur,impmm,demolish,or repair any suunum +t-m Prior miu ceased purse mqn the lMvisionamfos such Permit micensm asigned atsmmcnt Fi0 NatMisliccvcdPursuammthcpmvisionsnfthcCommcmr'sLiccnelaw(ChaPur9 Sq. Ft. Floor Area Valuation rot-$ (commencing with Section T000)of Division 3 of he Basion and Pmfeniom Code)or Net he is Col Nerefmm and the basis for Ne alleged Caunption.Any violation of c,�1]P.� aS��r�s_xvv.. Schon 703 L5 by any applicant for a permit subjects the applicant to a civil penally of 3 ayyye�le/"cio 0 Occupancy Type normnm0.fi<hundreddollam(ssBo1. P Y YP ;]I,asownerofinepmpenyormyemployceswithwaguas NcGsolecompensadon, will do mwmk.and the suuaurc is notinmMed uroRered forst(Sec.7014.Business and Professions Cunt The Contractor's Limmc law doer not apply to an owner of1 Re ' e spections property who buildsorimproms themon,end whodecssuchwork himself orthmugh his [`�DI,l/,,/y,, own employees,provided Nat such imprommenuam morin nded mattered for sale IL however,Ne building or improvement is sold within orc)ear of oonspicumt,the owner �y Wwill have IM burden of proving that he did not build or improve for purpose of /� -V salt.). n !i 1,ea no,of du propert,am exclusively convening with licensed contractors to Chaumont the pordw(Sec,7014.Business and Professions Code:)The Coatrxmrs ti- cense law docs not apply to an owner of property who Milds or improves Ormon,and who contracts for such projects with a conuacwro)licensed pursuant an the Contractors Licence law. ❑I am exempt under Sec .B At P C for this mason er Dam WORKER'S COMPENSATION DECLARATION 1 hereby aRtm under penalty of pc jury one of On following declarations: Than and will maintain a Certifiexu of Consent to self-insum for WorkcrsCompen- sadon,as provided fm by Section 3700 of dm Labor Code.for the performance of the wort for which this permit is issued. 0 1 have and will maintain Workers Comperio tion Insurance,as myuimd by Section 3700 of the Labor Cede,for dm performance of the work for which this permit is issued. My Waders Compensation Insunnec cam.and Policy numMr au: C 'er. s f2*-wry Policy No..'a CERTIFICATE OF EXEMPTION FRO BEERS' COMPENSATION INSURANCE - ohusection recd not weemplcud iNM permit is for one hundred dollars(k10D) or leas.) I rtetify that in the perfarmenc,of the work for which this Permit is issued.l shall not employ any person in any manner so u to become subject o the Worktrs Compensation Laws of California Dam Applicant NOTICE TO APPLICANT:IL after making this CcniOcam of Exmnption,you should Mime subject m be Worker's Compensation previsions of the labor Code,you must .JO (nnoith comply with such provisions m this permit shall M domed revoked. Z M CONSTRUCTION LENDING AGENCY [-n r I berehy affirm that them is a cormmcdon lending agency far the performance of fYs Ne wart fur which this .it is issued(Sec.3097,Civ,C.) WLanders Name Z)z Lenders Address ()p 1 entity that I hast mad this y and coup aur sou Net the surto infomlating is 0 F' coned 1 ague m comply with all city and county madws of and sou laws relating m V ahow-gconswctian.and rotimaoNon urpoeunudms of this city mentorupon lM acry W ahbilit.mianed u.cost rot impaction which an (y (We)agree to sato,indemnify and keep humlew the City of Cupertino against T4 Ii mrsnajudgmf the oar and expmseeonit. any in my way acerae ageinv said City V z in conuquenm of the granting of this permiL ^t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURC RWULATIONS. �� •sir y3 "y Re-roofs Signamm of ApplicanUComracmr Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant sir future building occupant smm oa handle ha,,aadous material or defined by IM Cupertino Municipal Cock,Chapter 9.12,and Ne Health and Safely .ode Section 25532(a)7 pyran All roofs shall be inspected prior[o any roofing material eing installed. 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 ha-tardoos air contaminants as dc0ncd by the Bay Area Air Quality Management all new materials for inspection. District, Ely. 1 have mad Ne hauardtw maurialsmquimments underCMpur6.95 of thc Califon nia Hcalthdc Sa(elyCode,Secdnns255(15,25533md25534.1undersund thmifthe building doed not cunliy ham a noun,that it is my responsibility m notify IM occupant of the �E/ R r K regaire m �ich ma pn;nrmiamanee nr,cestificamnr(ktapmry. Signature Of Applicant Date �;.�� z3-a%Y neraraathmi.<d. enl Dam All roof coverings to be Class"B"or better • CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp : Rng : Sub: Blk: Lot : APN . . . . . . . . : 36217063 . 00 DATE ISSUED. . . . . . . : 09/23/2004 RECEIPT # . . . . . . . . . : 27156 REFERENCE ID # . . . : 04090248 SITE ADDRESS . . . . . : 1099 NOVEMBER DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : DOUGLAS CULLUM ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4129 RECEIVED FROM . . . . : MAM DESIGN CENTER CONTRACTOR . . . . . . . : GIBSON, ROBERT LIC # 21422 COMPANY MAM DESIGN CENTER INC ADDRESS 1676 MONTEREY HIGHWAY CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 • TELEPHONE . . . . . . . . : (408) 298-8668 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - --------- ------------ - ---------- ---------- ---------- - - -- ------ - - -------- BPERMFEE VALUATION 30, 000 . 00 367 . 20 0 . 00 367 . 20 0 . 00 BPFIXTURE UNITS 3 ..00 27 . 00 0 . 00 27 . 00 0 . 00 BPGAS OULETS 1 . 00 5 . 40 0 . 00 5 . 40 0 . 00 BPLANCHK PERMIT FEE 367 . 20 490 . 03 0 . 00 490 . 03 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00 BPTRAP NO OF TRAPS 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BREMAPPLI NO OFAPPLIANC 3 . 00 21 . 06 0 . 00 21 . 06 0 . 00 BEA?ERGY PERMIT FEE 367 . 20 176 . 26 0 . 00 176 . 26 0 . 00 BREMFIXT NO. FIXTURES 8 . 00 9 . 60 0 . 00 9 . 60 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BREMINHOOD NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00 13REMPOLE NO. FIXTURES 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00 13REMPOWER POWER UNITS 1 . 00 47 . 96 0 . 00 47 . 96 0 . 00 BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00 BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00 BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00 BSEISMICRE VALUATION 30, 000 . 00 3 . 00 0 . 00 3 . 00 0 . 00 BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 ---------- ---------- ------ - --- of AL PERMIT 1481 . 30 0 . 00 1481 . 30 0 . 00 METHOD OF PAYMENT AMOUNT ' NUMBER ----------------- ----- ------- ---------- -------- CHECK 1481 . 30 22599 44fiT;0F *CITY OF CUPERTIND•CUPEI� PERMIT APPLICATION FORM APN#5/ 2 1 D t� Date: — Z_9 – O y Building (Address: Mailing Address (if different from building address): /D 1f . Owner's Name: Phone #: Contractor: License #: /V � z Contact: Phone: Z¢9r. g66g' Cupertino Business License#: /at� ey SDti/ Fax: Building Permit Info: / Bldg ❑ Elect def P1 bk7 N16ch Job Description: L Residential / C ercVia l Sq.Ft. Floor Area: q.Ft.. 3� Cost of P je Occupancy Grou Type of Construction: Please check this box ► Ject is a 119 second-sto addition: ❑ Project Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Descri tion Fee Grou BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK 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/Off1Comm/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 2,7 I of 3 4 WITY OF CUPERTINC* CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME 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 BPF TURF Pbl Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Cbeck 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 Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAMHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY 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 — l BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT R air/Alter Heatin MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 a�omwb�--�, WITY OF CUPERTINOO CITY OF PERMIT APPLICATION FORM CUPEI,TINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL 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 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 EPERNUTFEE 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 Change BUILDING • 3of3 J an; K.- E-10YEWSHE A L g, RR MMIM -13- L�- 6 NOR% MA M1111 IEO UPE ,Wall, IN (37 0 C RTINO IN Assessor's Parcel Number: Name ofowner. 1-)nU(— Project address. /0 ppeePILL Contactperson. Ke-AbMft6ft Net square footage of lot. Existin Proposed Square footage: First floor: Second floor: 4ze! Garage: /1//r TOTAL: 414 RIEC�E- - D Are there at least two 10 foot by 20 foot clear spaces inside the age N 0 arage? 3 20041 Is privacy protection planting required for the project? Y Y • BYE On what floor(s) is work being done? /57 Brief description of work. H17tl(49� GU OE Code editions:2001 CBC (Y - N)2001 CFC (Y-N)2001 CMC (Y- N) 2001 CPC (Y -N)2001 NEC (Y - N) Effective 11/1/02 Z73 • Plan Review Process Work Book Page-8-Revised 4/28/04 Cfl �Ei- 1a� (� 7E��7cPS < iLIZ ZG i C{-P,TIC� e K 5 s � �S€�R vel UIJt r . UtIv-T E .4-7 'z;p LC C, nj twcolzn/Ai-C,�7 wCIA A 11Z tADiL'r / tFSS 6L � fIPVrCov�✓� APPt t � F CuNut�Tr`vL ,� SraAti 3E I ,C-TP-— Ftp UNiIc,rJ Gam! N Tc. 1�POi 1tc1V c 7 � 2Ut L L 1,4-N 4 � � 2 i= CE2ivz+C.A Com, , NTt� �Ci-:rte G2- u-I ' DE'2 . o-`( fit=7S Si�- Z� !v'-7{v'Z 7W��9-(.,t l 2.. w nr{,�. I S 14 G„� -7 AL ON C- '7/tel ( G(Zca.M j ✓r�Z.l-i� %.'t'C 1 V c' ;:><i. C'S lLlSii'el� ��c: iZo/ ( A-1c �u-7Lc f !,v 1Fac S ?hCe' CJ_Y u 1 L-r� k4)C(L 51 IJS7RC�7-0 ti—k. Sv4v,� ('uJ !C 2L�_ r'IC) 0I:. ;:�':( yr i,viljLi C� Ci ()' �tE 5 �+J �Ci� SiOC c� fLw'o SrNt� MSL (A,'-Ce LirZcS • `,I �v v DL c2E�.-rGZir/tC C 2w v7 flvi7 Com (� :;J ft trZ fl ' .'� r 1ti5'tJrC � N��t^; %� Vtly-t /i WD D2lir T tv l 3nY i�E'Lach7� t� STtw'c tiIA1� IAje C iC'. ttT /�j s-1 � 4_-G- S : l7T CO —f Ci ISC.fI.I-''.:� COPY !;1 SPARK ARRESTER REQUIRE® SEP 2 3 20 BY: • Nw-�,z G = o � copy CU CL i' z STER UIIL — U I - - SEP 4 E I U 0 3 APPROVE® IN ACCORDANrE WITH T E CITY ON i ————— C!lPFFRT 0 E qN I ES � i SIGNED U I I I This se+ and spar, ications Mu Z m maKe any cnanga uorJaiterahords W QI on same without written permission frog. F-- the building Dept., City of Cupertino. — W The stamping of this plan and sppgficationrs, SHALL NOT be held to permit or to be U N • approval of the violation of any prow, Z>�o ,f anv City Ordinance of AM LAW ;a o s: (nx5 z Wxo�m Z'v QOyo 0 °v CITY OF CUPERTINO BUILDING DIVISION PERMIT f;E�NTRACTQR INFORMATION BUILDING ADDRESS: MAM DESIGN CENTER INC 1111,11 N'64090248 OWNER'S NAME: PERMIT ISSUE DATE DOUGLAS E: SANITARY NO. CONTROL NO. (408) 29R-R668 I ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH sap LICENSED CONTRACTOR'S DECLARATION O O O O wF 1 he.by airrm that I me limned under previsions of Chapter 9(commcwmg Job Description i t`$ with Scnion)q1u)ofDivision SoftheB arWP f=ioe Code.and myliccne is �° in teat rrRge bd mrreaQ '7y$2 REMt„�ID� NEE) KITCHEN ��'a Liccnx c <J Lte.p o ARCNITECrg� I.aRAT10N -r IurMnrsLLnJmyplansshallWusedaspublicmmrds w4� FEB ?� 2005 Z.0 w Lkcnsed Professional Ap3 OWNER-BUILDER DECLARATION .i I hereby aRre that 1 am nxempt Item the Convacto's License Law for the ��l no following mason.(Smuun 7031.5.Business and Profession Cade:Any city or county m reqt��`�7�� which requires a permit m m consumer.alter.improve,demolish,or someone any somere prior ha its issuance,also aqui=the applicant for smh permit no rile a signed statement that Jud is licensed pursuant to the provisions of me Cuumournh Limns law(Chapte,9 q. Ft. Floor Area Valuation p�$ (commencing with Section 7")of Division 3 of the Business and Professions Com)or that he is exempt therefrom and the basis far the a1pged eemption.Any violation of Section 7031.5 by arty applicant for a Permit subjects the applicant to a civil penalty of 3 C,rPPF1/I31fr>;�3e0 0 Occupancy not marc than rive hundred dollen(5500). P Y Type 1,as owner of Ne property,or my employ=with wage as their sole compensation, will do to work,and theswctuse Isnot intended or offemtl formic(Sec.7014,Biomes and Prommau Code:The Conlncio's Liana law d=not apply to an owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his awn employ=.provided that such impmamcnLLare not intended or offered furaale If. however.the building or imprevement i,mld within ore year of completion.Ne owner. builder will have We burden of proving Me he did not build or improve for purpose of sale.). ❑1,as owner of Ne pmpeny am exclusively contracting with liancd contractors to consumer the Project(Sec.7014,Business and Professions Cade:)The Creamier's U. cane law d=not apply in an owner of property who builds or improves Neem,am, who concocts for such projects with a eontncmr(s)licensed pursuant to the Contractor's License law. ❑1 am caempt under Sec .B k P C for this rcssoa Owner Date WORKERS COMPENSATION DECLARATION 1 hereby affirm under parity of perjury ore of the fallowing declarations: have and will maintain a Certificate of Consent to elf-insure for Workd's Comber- thin, Provided far by Section 3700 of the labor Codc,for the too fmmana of Ne woras for which this permit is issued. ❑1 have and will maintain Workers Compensation Ina muco,as rnquimU by Section 37W of the tabor Code,for that pedorm.of Me wart far which rho permit is issued. My Worker's Compensation Insurance carrrrriier and Policy number am: C 'ser. 522Tela.- A;« 40' Policy No..% / Itl i7L�� _ CERTIFICATE OF EXEMPTION FRO RKERS' COMPENSATION INSURANCE (hpseclion need nm be compleed if the permit is forane hundteddollars($1 W) or less.) I modify that in the Performance of the work for which this Permit is issued.)Mail not employ any person in any manner n as to become subject to the Workers''Compensation Laws of Caliromim.Date Applicant NOTICE TO APPLICANT:If,after making this Ccrorima of Exemption,you should Immune subject in the Worker's Compensation provisions of the labor Code.you most .J z forthwith comply with such provision or this Permit shall be deemed mvomd. z O CONSTRUCTION LENDING AGENCY 1--r I heathy affirm that Uea iso construction lending agency l'nr Ne performance o! Nim the work far which this permil is issued(Sm.3W7,Civ.C.) CQ lamber's Name - z lcndcr's Address V p I certify Nat I have with Nisty and county and sua Net the shoo iws relauun is V. building l agree to comply with all city end county oNinan=and sure hums resting in e O V 0ovengcmumed property mU hemnspecby ton pisrfamsenuuvxs of this city to boar upon the (Zl above-(We)Agree to save for inspection mnify a keep k,4 (~cat (We)agree to save,indemnify and keep hay in Ila City m Copan no ,City Z in fftcesmiles,.Of MIS may in maty way eccmc ageinlseid City L)z A APPLICANT of the granting of this Permit.WI � ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURC�RLAnONS. S4401 OP Z3'�" Re-roofs Signature of ApplicanUContracmr Den HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII the applicant or future building Occupant Rorc or handle havallous maarial as&food by the Cupertino Municipal Cade.Chapar 9.12.and that Hcallh and Safety Com.se Yea All All roofs shall be inspected prior to any roofing material being installed. ❑Yes mNu Will thea applicant or future Wilding If a roof is installed without first obtainingan inspection,I agree to remove pp g occupant sex equipment or devices which P it hazardous air contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection. wrict? ❑Yes leNo I have mad the mommus..do]$ne,piremcros under Chapter 6.95 of the Cahror- / nia Health 6 SafetyCode,Section 25505,15533 and 75534.1 understood that ifrhe building d=not currently have I arrant,that it u my aapmuih bty he notify tbe me.,.,of the ayviamcnhmu brwissuana ora Ccruecaa arampandyQQ. Signature Of Applicant Date nor nr,trthnn,ed esdnt D,te I All roof coverings to be Class"B"or better * BUILDING DIVISION PERMIT 4CONTRACTQ;.��R�INFMA ORMATIONN BUILDING ADDRESS: WOODS ROOFING PERMIT NGO 5050126 OW HER'S NAME: PERMITL4UE DATE ROB ONE: SANITARY NO. CONTROL NO. (R-11) 637-qS7F ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH uOp LICENSED CONRACTOR'S DECLARATION 1 hereby affirm Out 1 am licensed undo,provisions of Chapter 9(commencing Job Description ,<i with Section7")of Division 3 ofthe Business;and Professions Code.and my license is ^�„ in sen rome ane errs 7qz LicenseC% C39 Lk. 2 f31 REROOF W/ DURALITE SHAKETILE A_�o Dam L Contracts, ARCHTfECTS ED RATIO" Y w< I understood my plans shall W used as puhli0 records 7y ;8t; Licensed Professional 5 OWNER-BUILDER DECLARATION a 1 hereby a�Em that I am exempt from the Comreaors License Law for the 20UC no fallowing mason.(Secuun 7131.5,Business and Pmfesslnas Cade:Any city or county L dd S e which requires a permit w conn=,.aloin impmm,demolish.or mpair any stmoum prior o its issuance.also mquims the applicant for such permit to file a signed statement xNat W is licensed pursuant w Rim provision of the Contactors Umnac Law(Chapter 9 Sq. Ft. Floor Area tion .0 (commencing with Section 7")of Division 3 of NC Business and Professions once)or 5.- Nat he u exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 GATV lfi ftr0 0 Occupancy Type not mom Nan five hundred dollars(S500). p Y YP I,as owner of the property,or my employees with wages as their sole compensation, will On the woh,and the structure 6 not intended or offered fo...I.(Sec.70sd,Business and Professions Cods:The Contacwes License Law does not apply w an owner of Required Inspections property who builds or improves Nemon.and who doea such work himself or through his Own employees,provided Nat such improvements art not intended croBered fosale.If, however,the Wilding or improvement is sold within one year of complcuon,the owner- builder will have the burden of proving Nat he did not Wild or improve for purpose of sale.). ❑I.as owner or the property.am exclusively cmmaetiog its licensed contractors to construct Ne project(Sec.7Uad,Business and Professions Code:)The Conuacu is U. come law does not apply to an owner of property who builds or improves thereon,and who contracts for such projecu with a emtracwrts)licensed pursuant in the Conlsaemfa License law. ❑lameacmpiunder See ,Bk PCror Nlamaemn Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury,one of the following declarations: I ham and will maintain aCertiGate of Consent o selr-insure for Worker's Compcn. sation,as provided for by Section 3700 of the Labor Code,for Ne performance of the wok for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,as rtyuimd by Section 3 Wof Nc labor Codc,(orftp dominmof Ncwarkfmwhich Nis XmiEisissucd. My Worker's C pens tion lnsi7 camcr and Policy number am: Cartier. ti Policy No.:}g S'OS�J (, ' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This scctim need not tecompleted if the permit is forma,hundmol dollars(SIM) or has.) 1 unify Nat in the performance of the work for which this Permit is issued,l shall not employ any person in any manor an as in become subjecuo the Workers Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:IL aper making this Ccniricate of Exemption,you should become subject in the Worker's Compomatimn provisions of the LOW Code,you must wJ z roMwith comply with such provisions ser Nis permit shall be deemed rooked. 'Zh CONSTRUCTION LENDING AGENCY [—I 1 hereby affirm Nat there is a construction lending agency far the Performance of ai the work for which this pcmit is issued(Sec.3097,Civ.C.) Lcndces Norm z Lender's Address U0 1 unify that I haw read this application and stat:than the above information is Lg. P cornet.1 agree w comply with all city and county ordinances and sum laws relating to 0 U building construction.and hereby amommica mpresenuti.es of this city to enter upon use aWve-menudgm Property forinspen.purposes F y (We)agree to save,indemnify and keep harmless the City of Cupertino against rte couts expensesmit. may in any way eceme against said City U z in conscqucnco of the graining of this permit. " APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by: Date SOURCE U ATONS. Re-roofs Signature of Appbanu antrzmor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future Wilding occupant store or handle hmardous material as defined by Ne Cupenino Municipal Code.Chapter 9.11,and the Health and Safety Cah.Socumn 25533(x)+ ❑Yea 1?� All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtainingan inspection,I agree to remove Will the applicant or forum building Occupant use equipment or devices which p It Im ardous air comaminanu as dc0ncd by ted Bay Area Air Quality Management all new materials for inspection. Wl<1? ` � (]Yes B>� 1 have read the ho aMnusmaterials requirements under Chaphr6.95 of the Califor- nisHosh"safctyCodc.Secuos25505.15533 ao125534,l understood On lithe Wilding dors trot cumolly he.0 a umam.Nat it u my res,mo ihility w nntil'y Nc mcupant of the reyuiremcno which must be met p'or w issuance of a Corticate of Qcup Signature of Applic t Date S �o Owner or authonzed D,m All roof coverings to be Class"B"or better Community Development f 10300 Torre Avenue Cupertino CA 95014 1 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 �UPEI�TINO Building Department JOB ADDRESS: n PERMIT # 0 .— OSUS IZb OWNER'S NAME: PHONE # Q 6 /33 3 GENERAL CONTRACTOR: Z..tq pwQ s FAX#,�/oI � I am not using any subcontractors: '' '91gnature Date Please check applicable subcontractors and complete the followmi information: 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 , JJ Tile f�fa O er/Contrac or Signature Date Community Development Department ?' Building Division City of Cupertino 10300 Torre Avenue Telephone: (408)777-3228 OUPEkTINO CITY OF Fax: (408)777-3333 Building Department Subject: Re-roofing policy for the City of Cupertino 1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards and manufacturers specifications on re-roofing. 2. New roof coverings shall not be applied without first obtaining all inspection and written approval from the building inspector. A final inspection and approval shall_ be obtained from the building inspector when the re-roofing is completed. 3. All roofs shall be inspected prior to any roofing installation. 4. To receive a final sign off from the City, the following steps are required: 1) Pre-inspection and/or tear off approval. 2) In-progress inspection approval. • 3) Final inspection approval. „ a) Spark arrester installation. - 5. If plywood is installed, a plywood nail inspection is required. 6. Any roofing which is applied without first obtaining an inspection, will require the removal of all new material down to the sheathing, so a proper City inspection can be performed. IMPORTANT: 1. Flat roofs must have a minimum of 1/4 " per-foot slope and demonstrate that there is no ponding. '2. An I.C.B.O.report is required to be on the job site at the time on inspection. I understand and will comply with the above stated stated policy on re-roofing. Homeowners Name: Job Site Address: 8— n0/y Roofing Company Name: A plicant's Signature: Date: S.2315 Greg eel Building Official Revised 1/30/03 Printed an Recycled Paper CITY OF CUPERTINO � / (,I Zm�c,, � REROOF $CUPERTINO PERMIT APPLICATION FORM b 2 p 5 to Date: APN# 31- -2- Ic Building Address: Owner's Name: ) Phone#:�9 —13-3 __-3 Contractor: Phone #:L �� U�v3 License #: s 3;? 3/ Contact: VPhone #: S � Cupertino Business #: Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles ❑ Asphalt Shingles 'IL Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles Q 13 Other(Specify) '* Other(Specify) lM v/1.. Number of existing coverings / ❑ Provide I.C.B.O.Repo #1; ,2 G5 (o ,( To be Removed ❑ Provide Mfgr. Installation Specs. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: T Job Description: o as/3 Residential Commercial. ❑ _._. Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if there are any restrictions: LJ Cost of Project: ,� Type of Construction: Occupancy group: Qty, if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg Permit Fees BUILDING BENERGY Energy BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING c2,59 7Y