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04120018CITY OFCUPERTINO'*s='4!Sye,srw^ BUILDING DIVISION PERMITr;CONT U 11 ,0R BOILDING ADDRESS: MICCICHI MASONRY PERMIT"004120018 940 PROVIDENCE CT OWNER'S NAME:. PERMIT ISSUE DATE TED TSUCHIDA 180 CHERIS DR 12/02/2004 ONE" SANITARY NO. CONTROL NO. (408)219-5964 ARCHITEC (ENGINEER: BUILDING PERMIT INFO ' BLDO PLUMS MECH O O LICENSED EONTRACTORi DECLARATION I IMthat I liven Chapter 9 Job Description - Am u mvlxiow of (commencing with5ecdon of DlHdonJWdb B)cfr SPM Pmfesdoes Code.andmylice�4 nfu°` a"0 LA, Lc CHIMNEY REPAIR Licenst umcm, d' 2 Date L Con _ ARCallbeU SDECLARATION DECLARATION I ticaunti my plane shall M u tl�hlic records - Licensed professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors Uedcse Law for the - fallowing reason. (Seeman 713 1.5, Business, and Pmfessionet Code: Any city or county which remained; a Permit to construct, slide, Improve. demolish, Or repair any structure prior to its umance. Also requires the applicant for such Permit to file a signed auu nom that he is licensed pursuant to the pmvisiom of the Contractor's License Law(Cluper 9 Sq. Ft. Floor Area Valuation - • - (commencing with Sutton 700M of Division J of the Business and Professions Code) or that he is exemptWerefrom and 0m bass for he alleged eumptim. Any violation of B Occupancy Type SeNan 7031.5 by any applicant for a permit subjects the sppllunt To a civil penalty of am more Nu five hundred dolmas (53007. . - ❑ 1. uowem of the properly, m mY wPloybes wW wages u the'msem compewtion, %.J •- l s Required Inspections. wllldo thew.h..dthemunuremnminmM mafremd for.le(Sac. 7E01,11eeirms, and PmfeWam Cade: The Communes License tow dl b am na apply An M. of property who Wildsmimprows thereon, andwhadusauch work himselfortluaugh her .k�y, II// owncmployme, pmvidedthatswhimpmwmenuarenotlmmndedaraffeToo forasle. If,. however, the building or mprovement is sold within ane year ofcomplemon, Ne owner. - Y4,,h builder will low the burden of proving that he did not build Or Improve fm purpose of sale.). 0 1. as owner of the property, am exclusively contracting with licensed comusum an construct the prejem (Sec. 7014, Bulruv and Professions Cotler) The Cmuano's U- O �On✓ _ came Law does; r ownuafprenory who dmreomand, sedpmimprowv suchplytem who concocts for such projects wiNernntraclor(s)Ilcerned punwmm Ne Conuactora C✓L ma Law. p ATexempt under Sea .B&PC (m thio moon _ (�/J/%� (� Owner Deb L i WORKER'S COMPENSATION DECLARATION I bereby affirm Yoder penalty of perjury ane of the following decimmom: I haw and will malnuin ACoNBun, of Consent to self -laude for Worker, Compact. .tied, as pmvided for by Section 370E of the Isber Code, fm the perfnrmenca of dm work for which tris permit is lasucd. ❑ 1 hew and will maintain Workers Compensation Instance, As inquired by Section - - 370D of the Labe, Code, for the perfmmanee of Ne work fm which Chia permit is laved. My Workers Compensation Insurance carmen eM Polley number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE from secure need not becompleted If IK permll Is faro chundred dollars (SIM) or less.) - 1 unify tha performance of PO war for which this permit is issued. I shall not employ ypZfjgn in try ma1127sstbclamasaElecl to lite Warken'Compenudon - alif//CC//dditl9,W Ap N TOIAPPUCANf: If. after making Nymm d Exemption. you should b-ri sohjcen b Ne Workers Cempewtion provisions of the Lahr CMA, you msec foMwilh comply with such pmvitinm Or (his Permit Nell be MemM rewked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that then is a construction lending agency for the performance of the work fm which this Permit is issued (Sm. 3097, Civ. Cd Lenders No" Lender's Address 1 unify that 1 have read Nis application and sate dent the above InfmmW end is ' CotmeL 1 agree an comply with all city aM county ordinances and are laws relating in building communion. and hereby sutbadu represe isfim of Nis city in enter upon the abovomentioned property for impecdon purposes (We) agree to saw, indemnify And amp harmlw the City of Cupenim Against liabilities. judg nla. casts and expenses which may In my way accrue against to City _ In consequent f the grunting of this permit. APPLICANT ND STANDS AND WILL COMPLY WITH A NPN -POINT Issued by: Date SOURCE R Re -roofs Type of Roof t 2 �� signapof,.fApPlicmWCbd,.mrlOwin HAZARDOUS MATERIALS DISCLOSURE Will the applicant or An"m Wilding occupmtamm or handle harudous material As defined by the CuY.pertino Momcipel Code. Chapter 9.11, and the Health and Safety CMA, Section 2553I(a)7 Soma All roofs shall be inspected prior to any roofing material being installed. LWill rare If a roof is installed without first obtaining an inspection, I agree to remove the applicantor f building Occupant use equipment or devices which it husrdow air canumi u u defined by you Bay Ards Air Quality Management all rte materials for inspection. Dmuict7 ❑Yin ITT I hsw mad the hauNattaaartaterials mqulrements under Chapter 6.95 of the Califor. ala Health & Sarcty CpOc, Sccmom 25505.25533 and 25534.1 understand that lfthe building Jou nal currently 0 w A uaank that it u my responsibility m notify the uputmf the oxmiremcn sour met priormissuanaofacoaifsauaf m - Sign tureofApplicant Date b T`— All roof coverings to be Class "B" or better ___T_ Owner msotnorimtl agent Dc I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry tCCc,�}5cvu Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Til Owner/ Contractor Signature Date r CUPERTINO Iwo ME CITY OF CUPERTINO PERMIT APPLICATION FORM Z U PFA PN # r Date: Fee'Group Building Address: �r �© 7 Mailing Address (if -different from building address): Other Appliances Owner's Name, .�' \ - i1 J Phone : r I C _, � %D� lit 7 � Contractor: / -ltLf_tC License #: L-\2_� c+C b BBOILER3• Contact: Phone: Cupertino Business Licenseg: v �G Fax: Boiler> 1M to 1.75 M Btu Building Permit Info: Bld Elect ❑ Plumb ❑ Mech ❑ Job Descrip 'on: Q 4-, Residential Commercial ❑ /� 1 Sq.Ft. Floor Area: $/Sq.Ft.:- .- BUILDING BCONSTAX Cost of Project: Occupancy roup:' r Type of Construction: Please check this box if the project is a --- --- "- = second-sto addition:' ❑ ' Hotel and Motel BUILDING Project Size:-- Stand Laze ❑ Major ❑ Constax - Resi/Mobile Quantity Fee ID Fee Description Fee'Group BAPPLOTHER Other Appliances MECHANICAL " " . 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 BBOILERS Boiler>1.75MBtu 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 CUPERTINO CITY OF CUPERTINO - PERMIT APPLICATION FORM uanti 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 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 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 Furnace MECHANICAL BREMFURNOV Relo Furnace > IOK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMIvIISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc ti Switch &Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res A liance ELECTRICAL 2 of 3 F-4 i m tnrnriki� CITY OF CUPERTINO PERMIT APPLICATION FORM 3 of 3 Quantity Fee ID Fee Description . Fee Group BREMSIGNAD Rmdl Signs 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 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 Change .=" --' -•- BUILDING 3 of 3