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CITY OF CUPERTINO
PER
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT N®410 012 0
0265 TANTAU AVE
W NER'S NAA1L
PERMIT ISSUE DATE
MARY WILLSON
10/18/2004
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description1
hereby and that 1 am licensed under provisions of Chapter 9 (commencing
with Section ]IXMp of Division 3 of the Business and Professions Code. and my license is
MONe ertecl.
in full
REPLACE WINDOW (EGROSS�� I�I )
Cham
Clas3 LIC.N
FRAt
Dam Contractor
tl
EU
ARCHITECTS DECLARATION
! l understand my plans shall W used as public records
JAI11 (T— 9005[
Licensed Professional
i OWNER -BUILDER DECLARATION
L
I hereby affirm that 1 am exempt from the Contractor's License Law for IW
i following reason. si,cuun 1031.5. Businexs and Peofenions CWC: Any city or county
1 which mquires a permit at construct, alter, improve, Jcmnllsh, or mpair any,strucmre
'
$ 3 8 0 0
prior to its issuance. also requires the applicant fmiuch permit to file asigncd Statement
t he Contractor's uccnm Law (Chapter 9
Sq. Ft. Floor Area tion
that he is rccnxd pursuant o the provisions Of
s
(commencing with Section 700Q) of Division 3 of the Business and Professions Cook)or
S
chat he is exempt therefrom and the basis for on, alleged exemption, Any violation of
Occupancy Type
Section ]031.5 by any applicant for a Permit subjects the applicant to a civil penally of
not more than fim hundred dollars ($SW).
!D 1, as owner of the property, or my employees with wages as Ncir.role eompensalimn,
Required Inspections
will do Ne work, and the souaum is not intended or offered for sale (Sm.7 d , Business
Rod Professions Code: The COmnctor's License Law does not apply to an owner of
properly who build, or ine,oves thereon, and who does such work himself or thmugh his
employees, provided that inch improv cuts are not intended or offered for Cale. If.
however. in, building or improvement is sold within nor year of completion. she owner -
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
.[j h as owner of the property, am exclusively contracting with licensed contractors to
construct the pmjecc (Sec. ]Odd, Business and Professions Code:) The Contractor's Li.
cense law docs not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(a) licensed pursuant to Bar Contractor's
License Law.
❑ l am cx�c/m r under 5ec. . B & P C for this mason
r10e
.
rk-/11'$'Lki Dam C
c
Own \ -"CCC W9 ER'S COMPENSATION DECLARATQ?A%
�I hereby affirm under penalty of a jury one of the following declarations:
1 have and will maintain a Ceo fieam of Can scat to self -insure for WorkersCumpen-
sation, as provided for by Section 37W of the tabor Code, for perfomance of the
work for which this pf.mit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, u required by Section
37W or NC Labor Code, for Be performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not brcomplemd if the Permit is for one hundred dollars ($181)
nr less.)
1 ecnify Nat in the performance of the work for which this Permit is owned, I shall not
employ any person in any manner Stn as to became subject to the Workeri Compensation
Laws of California. Date
APOicant
NOTICE TO APPLICANT: If. after making this CCniOcate Of Exemption, you should
become suEjcn to the Worker's Compensation previsions or the Labor Code. you must
' forthwi lh comply with such provisions or this permi t shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 heathy scarce that is lending agency for the perlurmance of
nitdrimi
s ed (Sett. 30
' the work for which this permit is issued (Sec JfN], Civ. CJ
Lender's Name
1<ndcr's Address
I ecnify that l have read this application and sate that the above infom oun i3
correct. I agree to comply with all city and county ordinances and state laws misting to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned
d pronU. c for purposes.
(We) agree to smx, inderemfy and keep harmless Use City of Cupertino against
jvdg costs
tsind of this carousel which may in any way accrvc against said City
carousel
j inconseaenceo the Starting
consequence of the graining of this Permit.
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dale
SOURCE REGULATIONS.
f
,/-.r
Re -roofs
Type of Roof
gwwrc o Ap 1 'HAZARDOUS MATERIALS DISCLOSURE oam
Willy applicant or (mune building store m handle
t
as defined by the Cupeninn Municipal Code. Chapter 9.12. and the Health and Safny
e. Chapter Health and
cWe. ea 111111a'7[DYea [9 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
Will thea applicant building Occupant or devices which
pP 6 pa
g remove
emit a Air Qu
ons air contaminants as JcfincU by the Bay Arca Air Quality Management
all new materials for inspection.
Dixtria?
District'
❑Yes qNu
I have real Be ha aNnusmamrials requirements under Chapter 6.95 of the Califon
nix Health & 5afety Code, Seniuns 355(15.25511Iced 2553d. I undcrxand tha if the huild'mg
docs nal eunently harm s ¢rant. Nat it is my respum ibilicy te notify t c ¢cupanl of the
requirements which must be met poorer issuance of a Ccmfiaama r'
g Applicant
Signature ofA locant Date
_oSi J,C(�L-• r�--.--� /::'
All roof coverings to be Class "B" or better
owneori d as nl Date
29(n
•
City of Cupertino
'- Plan Check Transmittal
Permit#
Project
Address
Owner
04100120
Control#
Plancheck# 1
FileDate 10/18/2004
WINDOW UPGRADE/EG
10265 TANTAU
AVENUE
MARY WILSON
Description
WINDOW UPGRADE
Plan Check Status (attach comments and return to Building with plan set)
Plan r'
Deot check#.. -Date , Due Date Staff
Comment Date Approval?
10/18/2004 D
Building 1 1
0/18/200
31/1/2004
I POH
Assessor 1
0/18/200
11/1/2004
SENT
10/18/2004
Additional Plan Check F.ee. .H Hours
Planning Fees
Housing Mitigation Fee Amount
Heart of the City Specific Plan Fee Amount
:)ATE
SIGNED
This set of n specifications MUS
be kept on t e job at all times and it ie un
Lawful to make any changes or alteration
on some without. written permission iron.
the building Dept., City of Cupertino.
The stamping of this plan and epeciflceNon+
SHALL NOT be held to permit or to be ar
approval of the violation of any prowsiom
•� r anv City Oromance or brace law
.1 Ea -
CITY OF
CUPEkTINO
WITY OF CUPERTINO*
PERMIT APPLICATION FORM
J
APN # 37- "- D,F v
Date:
D
BAPPLOTHER
Building Address: Mailing Address (if diff from bui ing address):
fent
oJLs Ste. T-4NT 'kv .
Owner's Name:
Phone #:
." & Y%v;IIsd1J
4 n,5 is 7 -38b0
Contractor: n `
License #:
Contact: Phone:
Cupertino Business License#:
Fax:
BBOILER4
Building Permit Info:
Bld Elect ❑ Plumb ❑ Mech ❑
Job Description:
��
Residential Q� o rct i
Sq.Ft. Floor Area:
$/Sq.Ft.:
Cost of Project:
Occupancy Group: r
BCONSTAX
Ind/Off/Comm/Quasi
Type of Construct n: /
Please check this box if t ect is a
Con. Tax for BQ Zone
second -story addition: ❑
Pro'ect Size: Standard ❑ Laze ❑ Major ❑
Hotel and Motel
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 > 1 M 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
Elee 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENE
Ener
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
A.
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