04090004 (2) CITY OF CUPERTINO + ,rro:ir> ;:' la na
BUILDING DIVISION PER la � CUNTYtAil,.i1nT�TNk'C31t�'TO
�f�W*zCe^�fla'7k.€ :
BUILDING ADDRESS: JEFF REY MILLER, GENERAL C N%4090004
l
NEWS NAME: PERMITISSUHDA7H
CAROLYN MIL
PHONE: SANITARY NO. CONTROL NO.
408 866-13
ARCHITECT/ENGINEER: BUILDING PERMITINFO
ee BLDG ELECT PLUMB MECH
n00 LICENSED CONTRACTOR'S DECLARATIONO O O O
K L hereby affirm that I am Ilanxd under provisions nrChapter 9(commencing Job Description
with Session 70(10)of Division 3.rda Bu9nev and Prafassiou Code.and roy licmuc is
�< n a.C) and effect. 3 SKYLITS�30 H4 ING FANS
infull
cl.n sic.x
Dam Continental
ARCHITECT'S DECLARATION
I understand my plans shall W used as public mead. s
n
APR 4n 2005
is G Licensed Professional rX .
OatNEm exempt
ER DECLARATION
q I hereby affirm on I em exempt(rum the Cmm�cwrs License Lew for the
Do followingmason.permit
IIDar Business and improve,
damuli Ca de:Any city mcounty
'$ which requires s a.also
ac cores the etre improve,demolish,area sim(udum
F Z< prior:aiu issuers...abu requires the applicant for such permit m semnsigned(Cha mem
that he h licensed puraumun the prevision of the contractor'sUmnu law(Chapmr9 Sq.Ft. Valuation
8 (commencing with Section 7000)of Division 3 of the Business and Professions Carol or
B ese
dust he mpl imminent and dm the basis for alleged exemption.Any vialadon of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3 24f14?0Anbet0 0 Occupancy Type
not mom than five hundred dollen($500).
r
wi 1.as owner of the property,army employers with wages r Nei(sole a0mpensat ass;
will do Newark,Code:swctureunm,Licarss Law
apply TO u,owner of Required Inspections
and pmufwh mu Code:The Comnmofs ndwho law does not apply m rt owner is q p
progenywhobuilds orimprovu thercpureve who da sauchwmkhimseeedthroughWe his
awn employees,provided thatimprovement
art not you
or offered for Owner.
however,the buildingar improvementisest be
not Weld or completion,the purpose
of
Wilda will have d¢burden of proving Nn W did net Wild m Improve for purywe ar
sale.),
wnet of rhe progeny,am exclusively contracting with licensed andsom en m
onstNeI the project(Sec.70".Business and Professions Code:)The Conuacmr'a Lh
cense law dam not apply to an owner of prepeny who Wilde or improved derew,and,
whocan for such pmjecls with•mnuactara i ued purmgml oted Contractors
Lice
oInse a BR PCIm this /n y
WORKER', OMPENSATION DEC R 3NNJ 7/�
1herebyaffirmunderpenaltyofperjuryaroof Nefolb ingdectuadou:
(:]I here ood will maintain aCcrdrrum ofCauenm m sel6imum fm Worhb Compere
station,as provided for by S.edon 37011 of the labor Code,for the perfofinenme of due
work for which this permit is issued.
❑1 have and will maintain Workefa Compensation In mance,as required by Seeded
37W of the labor Code,far de,perlianum e,of the ware forwhich this permit is issued.
My Workers Compensation Insurance cardia and Policy number art:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(That.,,.nod nm W completed ifthe permitI,forms.hundred dollars(SIM)
cit less.)
I c.nify Net in Ne serramosom of the work for which Nis permit is iuucd,I shall not
employ any Panama in any mannerso is,an become subject o the Workers'Compewmlon
Laws of California.Date
Applicant
NOTICE To APPLICANT:If,after reeking Of.CmIricam of Eaemptian,you should
become subject m the Worams Commnsasion provisions of dm labor Code,you muse
O forthwith comply With such provisiaas or this permit shall W deemed mwked.
CONSTRUCTION LENDING AGENCY
[—t I hereby affirm that then is a construction lending agency rot the performance of
C(i> the work for which this permit Is issued(Sec.3097,Ci,C.)
WM Q Lenders Name
o-7 z Lenders Address
V 0 1 canify that I have read this appllcmion and sum them the show Information is
cancel.1 agree to comply with all city and county ordinances and sou laws missing m v
OU building contraction,and hereby anthemm representatives or this city to color upon the
4T1 alovamentioned property rte Inspecdon Purpaua
0. (We)as=m save,indemnify and keep harmless dm City of Cupertino against
N Ilabilitles,judgmenss,coals and expenses which may In my way acme againstuid City
[�7 1 quenca of diagraming aI W rmlt.
r7 LICANT UNO RSTAN ILL COMPLY WITH ALL N N- OI Issued by: Date
E GyL D 5. ,eew f; o
a Re-roofs r
Cp Winume ofApplicWt/Contractor Deta
HAZARDOUSRDOU
HAZARDOUS MATERIALSDISCLOSURE
or URE Type of Roof
Willy dueCps"imsfulorc Wiltlin6occupam score ar handlepev and
Sari,u de0ned by dm Cupertino Munieiryl Code.Chapter 9.12,and Ne nea1N and Safely
odc,Section 25532(')? All roofs shall be inspected prior to any roofing material being installed.
1 C3 Yu
Will the applicant orluwm building Occupant usecyuipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
coal haydrdnus air contaminants as defned by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
I have mad led humdnu alsmquircmcnu under .Ch'pmr6.'35ofdmc Califon
ni aW&Softy Codas 25 5.35533 and 25539..Imdanmadthalifthe Wilding
t currently haw a tees the rya my responsibility m notify the Occupant of the
t.m e w ah et met it Carafe Signature of Applicant Date
OwmV oratolux eds an, Da All roof coverings to be Class"B" or better
• CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32618041 . 00
DATE ISSUED. . . . . . . : 09/01/2004
RECEIPT # . . . . . . . . . : 26902
REFERENCE ID # . . . : 04090004
SITE ADDRESS . . . . . : 10100 PHAR LAP DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER CAROLYN MILLER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1112
RECEIVED FROM . . . . : CAROLYN MILLER
CONTRACTOR . . . . . . . : JEFF MILLER LIC # 25439
COMPANY . . . . . . . . . . : JEFF REY MILLER, GENERAL CONTR
ADDRESS . . . . . . . . . . : 1550 DRLL AVE SUITE I
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 866-1345
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 3 , 500 . 00 104 . 76 0 . 00 104 . 76 0 . 00
BPLANCHK PERMIT FEE 104 . 76 139 . 80 0 . 00 139 . 80 0 . 00
BREMFIXT NO. FIXTURES 30 . 00 29 . 50 0 . 00 29 . 50 0 . 00
BREMPOLE NO. FIXTURES 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00
BENERGY PERMIT FEE 104 . 76 50 . 28 0 . 00 50 . 28 0 . 00
BREMPOWER POWER UNITS 1 . 00 47 . 96 0 . 00 47 . 96 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BREMRECEPT NO. OUTLETS 2 . 00 2 . 40 0 . 00 2 .40 0 . 00
BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00
BSEISMICRE VALUATION 3 , 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPE€2MITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ---------
TOTAL PERMIT 536 . 90 0 . 00 536 . 90 0 . 00
• L
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 536 . 90 1010
TOTAL RECEIPT 536 . 90
•
*CITY OF CUPERTINO*
CUPERTINO PERMIT APPLICATION FORM `f
APN�rl ( _ / �// Date:
Building Add-res :0 o T� � Mq>,lipg Add ,qs jif(f diffy v� bu}l�Wing address):
Owner's Name: �PJhone(��(��(j`�G�/7/.(// Q
Contractor: ,�F.-p Licenses: �7 / v
Conta�L� ,{ /` Ph Cupertino(—C Cupecrttiino Business License#:
Building Peennit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: ��j�
Residential ❑ � ` commmq l 'T r �
Sq.Ft. Floor Are . $/Sq.Ft.:
Cost of Project: i Occupancy Group:
Type of Construction:k Please check this Ooxif the r " ct is a
second-sto addition:
Project Size: Standard ❑ Laze ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
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
BBOILERS 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<= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
4- z6 7
1 of ���� / ��
WITY OF CUPERTINO'
CUPEI�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOM M 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 hiterceptor 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 rinkler/Backflo 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
BRENCkMIAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM3USWAY Remodel Busways ELECTRICAL
tj BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BRENMAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
-` BREMPOWER Power Device/Apparatus ELECTRICAL
REMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2of3
t WITY OF CUPERTINA
CUPEII`TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sigris, 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 Chane BUILDING
3 of 3
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REMO D PATIO COVER
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DRIVEWAY
CITY OFCUPERTINO `^i >�l4iA -
BUILDING DIVISION PERMIT €CONTR'Alb- OR'T1Vjy,ORMATR x'BUILDING ADDRESS: JEFF REY MILLER, GENERAL C " 4090004
10100 PTJAR TAP nP
OWNER'S NAME: PERMITISSURDATS
CAROLYN MI
Eo SANITARY NO. CONTROL NO.
(408) 866-134S
ARCHITECT/ENGINEER: BUILDING PERMMINFO
BLDG ELECT PLUMB MECH
a o 0 0
am z' LICENSED CONTRACrOR'S DECLARATION Job Description
!l d 1 hereby Mnrm that l am licensed under provision of Chapter 9(commencing
with Sendon 70111)of Division Sof the Business and Profession,Code,and my license is
a, LienmeesMertea 3 SKYLITS/30 CANLITS/4 CEILING FANS
j n z Dam Clue Lk.g
J ppp
Dam TS DEtar
oilAs shall use DECLARATION
Y II-- 1 understand my plena shell le used u public mmrtls
OWU
aO J fiomsed Professional
.7] OWNER-BUILDER DECLARATION
I hereby olEren that 1 am exempt from the Contractor's License Lew for the
n o following mum.(Section IW 1.3,Business and Profusions Code:Any city or county
$ which meolru•permit to c muuct,alar.improve,doure ith.or minim Any arucime
t prior he in issue=.Alan mquima the applicant fortuch permit in rile a signal statemant
a< Ihat heis licensed punuanitnthe provisions ofWeCamracmitLicense Law(Chaptor9 Sq.Ft. Floor Area Valuation
(commencing with Section 7")of Division 3 of Ne Business and Professions Cade)or
5J Met he it exempt therefrom and do basis for the alleged exemption.My violation of
Section 7031.3 by any Applicant for a permit subjects me applicant e a civil penalty of 324aT99uk1er0 0 Occupancy Type
not seam Ihan Ove hummed dollars($SW).
❑I,samemarof Nepropeny,army employees with wagaudmeirsoleeompensation,
will dodm work And the strumae is mainu deed aroffred forsake(See.7044.Business
And Proreasions Calc:The Contractor's Lice=law mat not Apply as an awns of Required Inspections
property who builds or improves memon,end who dens such work himself car through hit
own employes.provided flnsuch Improvements Am sot Intended or oBeed for sale.If,
however, the Me building okprowmmtitmid wain oneyeaof ce
r mpletion,Ne owner-
beildo will haw the LaWm of proving Nn k did nm tsdld or Improv for purpose of
ale.).
net property,amudusively. contracting Cod licensed ntrumces . �r
.Laft (Sec.7014,Business r p Professions Cade:)The Ca duccoms And.
cense laappy u m owner of property who builds or impmvea themon,mal, gAyA
who canch projects with a eomneem anted pursuant se me Conuxtors //��/�License❑1r B PCforr'ORKER' OMPENSATIONDEC R gI ��Im111 Yntlef pClnlly 0f peljNy GlnofInfallaWln{dClaa110N: ` �hewainWn a CalOeateof Comuant to ulf-iuum farWork sCompen- Sdon,ufor by Section 3700 of the Inbar Cade.for the performance of the
work for which this permit is issued.
❑1 ban and will maintain W~s Compensation Insurance,As required by Section
3700 of the Lobar Cade.for the perfroans of the work for which this permit u issued.
My Worker's Compensation Inanram a carrier and Polity number am:
Cartier, Policy No.:
CERTIFICATE OF EXEMPT ON FROM WORKERS
COMPENSATION INSURANCE
(Thts secdon reed not kcampleted ifthe Permit Itherme hundred dollen($100)
nr lees)
I certify Net in me performance of tic work for which this permit is issued,I shall not
employ any person In any manners as to become subject in me Warkers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPUCAND If.After making this Con ficau of Exemption.you Would
become subject in me Worcm's Compensation provitiom of me take CMB,you must
.JO formwim comply with such provisions or this Permit Mall be deemed rowked.
'Z yCONSTRUCTION LENDING AGENCY
[-+ Ihemby Off.met mea is construction lending agency for tic Performance of
lYi me work for which this permit is issued(Sec.3097,Civ.C.)
WMQ Lender's Name
z
U 1 LcndeYAddress V
U p I certify that I haw mad this application And Aisle Wt Ne show information is
U. F correct.I alme to comply with all city and county eminences and sue saws relating to
Or, building construction,and hereby Aobodn repmsemadves of this city m enter upon me
W
ban-menduned property for iuN
pean Purport{
LL (We)agree a aw.Indemnify and keep bamleu site City of Cupertino against
rr y Iiabill a,Judgments.com andexpenses which may in anyway acemeagalnst said City
V'z i names of the granlug o! emit.
LICANT UND RSTAN ILL COMPLY WITH AI,L N N- 1 Issued by: Date
G 0 S. 9� D
Re-roofs
Gj aoeaf Appli ,macer Dee
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tite applicant or future building oompmamm or he Anum.] ,
u dented by the Cupenino Municipal Cade,Chapter 9.13,and the calm and Safety
ala, C3 et zss3z(An All roofs shall be inspected prior to any roofing material being installed.
Yet u
Will the Applimm or ,tam Wilding=open,use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I hasommus air contaminants u dented by me Bay Area Air Quality Management all new materials for inspection.
QYcf lion
I have and thehuardmm 'siereyulmmcnts under Chapter 6.95M the Califar.
nl Alm&Salaycodc,5 8 3.35533 m12553A.1'monstandmaLiftimo Wilding
of currently haw a nAn4 me 1 my respouihility u nMl'y the accup t o!the
I c w h met r Cortirteateor Cqcup Signature of Applicant Date
0 caretha vea a em Da 0 All roof coverings to be Class"B" or better
0