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03050021 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION. , BDILDINGADDRESS: SHEPHERD SERVICES PLUMB IN "O'g "°03050021 OWNER'S NAME: 10121 IMPERIAL AVE "'W756/2003 CK & BETTY NE: 4085597160 SANITARY NO. CONTROL NO. ARCNITECf/ENGINEER: BUILDING PERMIT INFO PLUM MWH Bloc D l� t� �o Zp LICENSED CONTRACTOR'S DECLARATION Job Description 16 1 hereby same that I am Ikve ed under provisions of Chepur o 9(commencing p with Sadon7000).f Di,iA..3.fthe Businw P fessiom Code,and my licemc is on y� in roti roans and o y INSTALL HOOD, GAS COOKTOP/CAP ELECTRICAL Z Lkenm Clan -2o�'7t' LIc.N _ 2�i Date - rsund CaylCiS HrMC RATION mym FINALE® ir. 3 Licensed Pmfevtional 3 =� OWNER-BUnDeRm CLARATION MAY O H 2OOJ a 0 I hereby maso eBOfn that 1 1. exempt from Ute CantectCo License law for the 0 o which re moan.(Saito 7 continues, Bmineu and lir.d oiodi Code:Any oily or county $ which requires•permit a cnruuuct.a3tec Imf for demMkh,or repair t cement H Z'y poor Nits issuance. ensedpatmmquime Ne inion enlfor mch muntlNceseLnedwtemenl ggF< (c mmealkgwiLhstuantbNeprDislovofthcConusiu .ndProcuionCh )car Sq.Ft. Floor Area g � (commencing with Satiumandth bast%n3 the alleged lege axe pion.AninnsCndc)of �a Nal he 4 sumps IherUrom and the beak for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit=ejects Ne applicant to a civil penally of 3 1A&%n 1&bet0 0 Occupancy Type not more Nen fiw Intuited dollen(SSM). ❑I,u awns of W prrpaty.or my employcu with wegu u Nek ante compemWon. will de,the work,and themuch reknotintended oro@rtd fee oak(Sec.7011,Business J.J1 - dInspections and Profeenums cads:The cmuume ult i hi Law dorm Man apply N an owner of 102 - PIERS property who builds ori mpmves Nmon e ,and who doessuch work humin f orthrough his awn employes,provided Nal such Improvements are not intended mortared for cal.E. 103 - UFER however,the building or improvement is sold within am yeu of complexion,to ownm. Wilder will hoe the burden of proving that he did not build or imports for purpose of 104 — REBAR ank.1. 105 - ANCHOR BOLTS ❑1.as ower of the property,am exclusively contracting with licensed contreeun N 10 6 - SEWER & WATER commret the project(Sec.704/.Business and Professions Cade:)The Contrmur's Li ams Law does not apply m an owner ofpmpeny who buil"or improv lhemon,tool — UNDERFLOOR PLUMBING who contrasts for such pmjecta with a contruNr(0 licensed pe som,in the CanmactaM1 txmasLaw. 203 - UNDERFLOOR MECHANICAL ❑I am exempt under See .B&P C for Nis reason 204 - UNDERFLOOR FRAME OwnerDate 205 - UNDERFLOOR INSULATION WORKER'S COMPeNsZosi DECLARATION I hereby air=under penalty of perjury am of Ne following declaretiam: .301 - ROUGH PLUMBING I lura andwlllmainWn aCeNOeauof Conuntmml6inumfm WorL-e$Campen, 302 - TUB & OR SHOWER sedan,as provided for by Section 3700 of the Labor Code.for the performance of the 303 - ROUGH MECHANICAL work for whish this permit is issued. 304 - ROUGH ELECTRICAL ❑1 have and will msimain Worker's Compensation Insurance,as required by Section 3700 of the Labor Cade.for the performance of the wort for which this permit is Issued. 305 - FRAME My woo fs Compenutiov lnmrsnce command Poll umber are: 306 — HOLDOWNS Carri S7Y1-ls f's�a✓� PoliryNa.. IS'}SSO?-Mo3 307 - INSULATION CERTIFlG7E OF e%EMPnON FROM WORKERS' COMPENSATION INSURANCE 308 - SHEETROCK mussectlen need not he completed ifdm permit is formic hundred dollars(SIM) 309 - EXTERIOR LATH inlets) 310 - INTERIOR LATH I artily that In the performance of the work for which this Permit is issued,)shell not 311 - SCRATCH COAT employ any person in my manm u m ncrbecame subject to the Workers'Canpenutian Laws of California.Date 313 - ROOF NAIL Appecant NOTICE TO APPLICANM If.slier making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY become subject N tits Wookels Compensation pfrvision of the tabor Code,you most .JZ forthwith comply with such provisions or this permit shall be deemed mutrd. 502 — FINAL PLUMBING ENERGY z o CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY [-xM Ihereby"Rumdeal them isaconstruction lending agency for the performanceof 504 - FINAL BUILDING ENERGY ai;> Nc work for which this permit is issued(Six.3097,Civ.C.) 505 - FINAL ELECTRICAL IA Q Lender's Name 7Z IondesAdd= 506 - GAS TEST U O I cenify Out I hive read this application and Nu Nm the shave Infe m iuon Is 507 - FINAL PLUMBING F correct.I agree N comply with all city and county eminences and sur law"testing N 0 U building<omwctian.and hereby emhodm mpmaenuNwa of Nis city manor upon the FINA MECHAN CAL W ahem-no ndoned property for Inspection purposes %09 F I N(Wo)Inu u cave,indemnify and keep hay In m tit y sy of Copeman igumt Uy IiebilWa,jndgmenu.costsandnpemN whish mayor anY way accre gsin"tuid coy GUz in 0rICA=n of Nis permlLAPPLICANT U D AND WILL COMPLY WITN ALL NONPOINT Issued byWORKS Date s W. /c y�1�/ - �6 "a3 Re-roofs SI u f plican o forDau HAZARDOUS MATERIALS DISCLOSUR Type of Roof Will the applicant in future building Occupant store or handle hanardam material u defined by the Cupertino Municipal Cade,Chapter 9.13.and the Hca1N and Safety ,9111111I.cane.Seetion zss33(.)7 �No All roofs shall be inspected prior to any roofing material being installed. ❑Yen Will the applicant of future evading Occupant ora equipment or detimt which If a roof is installed without first obtaining an inspection,I agree to remove mil harardouf air munitions u defined by the Bey Area Air Quality Management all new materials for inspection. District? ❑Yes (A No I have mad dlM)usrials requirements under Chapter 6.95ofNeCalife- nialicaW&Safexyc5,355]7 ane 3553d.lundersand NUlfNc Wiling �snotcuommlyfa1k my responsibility to noul'y Nc oecupml of Burircrom ltMmhou..f.CertificateafGe m Signature of Applicant Date owns ori.. �.D o All roof coverings to be Class"B"or better t 11 S(I CITY OF CUPERTINO o o S- ,, Z/ CITY OF PERMIT APPLICATION FORM CUPERTINO APN # / /, O D / Date: Building AµWess�00 2 S I CEDAR£DAR TRf£ CN Owner's Name` T Phone#: %� ISblikt}wR IS�, 1 )O7 Q yOg SS9 �/60 Contractor: n License#: �NU41ECW ScavIcf s '60?t 3 c zo�3c Contact: Cupertino Business License#: L'J(L��R.+-r �£P fan Building Permit Info: Bldg ❑ ]ect Ph4b Mec Job Description: Residential ❑ G� r Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Constructi : Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERl 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/Con m/ uasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elee 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 lof3 Z (ly , 5 1�ilp] CITY OF CUPERTINO CITY PERMIT APPLICATION FORM CUPEf?;TINO 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 BNUSFD New Single Family Res BUILDING BOVERTINM Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g 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 Repipe 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 Pipe PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2 of 3 alTYV CITY OF CUPERTINO CUPEkTI PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rcptl, Switch& Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 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 BUIL G BSEISMICRE Seismic Fee Res BUIL NG BSPECIAL Special Inection 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 PPERMITFlumbin Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3