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03120031
CITY OF CUPERTINO � BUILDING DIVISION PERMIT A CONTRA.CmOR,TNF, Ulh'I,ATrON 'r; BUILDING ADDRESS: PERMrr N0. 03120031 R'S NAME: PERMIT L%UB DATE PHONE: SANITARY OL NO. ARCHIl13LT/Et1GINEER: BUILDING PERMIT INFO BLDG ELECT B MECH t� �a0 Zp LICENSED CONTRACTOR'S DECLARATION Job Description l 1 Wmby affirm that 1 am licensed under provisions of Cbepmr 9(mmmcmin{ - with Section 7M)oMiviahm Sof W Bush.and ProfmrinnsCode,and my license is p p gg �k�AM Y`d`` 6 Lk.1 �D� CJS 0 GAS LINE FOR FIREPLACE FINALE® Oen$ Convector .' ARCHITECTS DECLARATION (1 �isss... I understand my plans'hall he used as public rccnrds v E C 9 2003 3 5"d Licensed Professional OWNER-BUILDER DECLARATION BUILDING I barely'(Rise that 11. exempt from the Convns Co License Law for the L a0 (allowing mann.Permit i 7031.5.Busmen and Professions Cade:My Ny or County $ which its Isla a permit ran enn$mtl,elm.Wprow,demolish,m mpsin signed stru mn, ter priAn Wisl iauuepatsont M erre aisios of foram such Weatti Liecon flic Law(Chapter thuW is licensed punuunmthe pnrvialon$of the COnuaclor's Lkerrse law(Chepmr9 Sq.Ft.Floor Area Valuatio 3a (commencing with Section TODD)of Division 3 of the limmma and Profesdons Cnde)m Net he 8 exempt t escfrom and the be4 for Me alleged exemption.My violNon of Section 7031.5 by any applicant far a pemdt.objects the applicant m a civil penalty of 3 IVYtb19t�er O 0 Occupancy Type nor mom than Ave hundred Mullan(5500} ❑1,As Owner of the property,m my employes with wage As their Aute compensellon. will do the work and the structure is not intended ca offend for sale(Sao.7044,Business Required Inspections and Profession,Code:The Conusems''Licata'law des not apply m an owmr or q P propeny who bel Ids m improves thereon,and who doe.uch wart himsel f m Muough his ownemployeca.provided thusuch Improvements art trot invaded oroResW formic.If, however.the Wilding m 4npmsanent Is AuM wiNinose You of mmpktine,the Owner- bulkier wner- WIRkr MA haw the Wmden of proving that he did not Wild m Improve fes purpsm of sale,). 1,As owner Of the prop,",un asclu.ively comeaming with licensed mnuamn W construct the project(Sec.7044,Business and Profusion$Cade:)The Conuacter'.W- ecue Law does not apply to an owner of pmpeny who Wilde or impmws themon,and, who contracts for such projects with AconmamKO licensed pursuant An the Caalraerora Lice.law. - ❑T Am exempt under Sec .B Ar P C for this reason Dam WORKERS COMPENSATION DECLARATION 1 hereby&M m Coder penalty of per)ary arc Africa following dalarldD= ❑1 haw and will maintain a Con fiesm of Cmuent a self-iuum fm WakeY.Compen- arion,As provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. ❑1 haw and will maintain Workers Compensation Immo nce.As required by Section 3700 of Ne Labor Code,for the performance of Ne work for which this permit is Went, My Worker,Compensation Insurance canis and Polity number me: Carrier•. Policy No.: CERTIFICATE OF EKEMPrION FROM WORKERS' COMPENSATION INSURANCE (f h 4 eeNm read ser be canphmd LIMA permit Is fm ons hundred dollars(SIM) or Ica) 1 unify that in Ne performance Of to work for which this permit is laced.I shall nm employany peranin sj�ym rAu yam hncsub*LIG tie WOrken'Compen$atim laws OfCWfomia.gYlgJ — - APPllnnt /.iHZ29 I/f NOTICE TO APP ANP,IL Cmr ,king this ,unix or of Eamplmod you should become m..p m tic Worker's brm s W thin provision$of Ne a LOA,Cnde,. mal ,J z forthwith comply with such pmvidon$or this permit ahN h dcemctl vatted. Z O CONSTRUCTION LENDING AGENCY [-r IherebyAbse Ow Neto 4 a cmauixdnn lending agerey for the perfurmarmof a NC wash for which 344 permit 4 issued(Sou 3W7,Civ.C.) Q Lenders Nsme Z)z Landers Adders U(D 1"rely that 1 haw reed this appllmdon and sum that Ne AM"infamudm 4 LT.^. Correct I agme It,comply with all city and County Ordinances and Sone laws totaling to OtSJ' building construction,and hereby jushorin representatives Of this City 10 CAW Upon Me W ahow-mandoneti property for inspection purposes (We)agree to an,indemnify and keep harmless the City of Cupertino against r„r In liabilities,judgments,Com and expense which may In my way scene against said City V 7 in consequence Of the Stating of this PCrmiL. Fl APPLIC&NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR GuunD 7�= , SZauureof Applian onuanor l �p n�— Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the epplianr m to.Wilding occupmtatem mhem is baallous numcnal 1 decd by Ne CupeAl Moni11 I Code.Chapmr 9.13,and tW H.10 and Safety Section 15532K)'? All roofs shall be inspected prior to any roofing material being installed. ❑Yea O Will the applicant or fumrc bulldin amaPart use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit haeardnes air commit. a dc0 by Ne Bay Ama Air Quality ManaScmcnt all new materials for inspection. District? ❑Yee I have told the haardms neurula netmoneems under hmmr6.95oftheCslifm- n4HealthA,SefctyCOde.Sable 25505.25533 aced 25534.1 undnsund that 11 de Wilding does not currently haw a rent,that It 4 my namemetelily An notify the oecupal of M mquimmc rah must be met Alarmivuamc ofaccrificamof Occupary. Signature of Applicant Date sQgd a �?��04 All roof coverings to be Class"B"or better Owner or authorised gent Dom • CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: suem COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31633092.00 DATE ISSUED. . . . . . . : 12/05/2003 RECEIPT #. . . . . . . . . : 23978 REFERENCE ID # . . . : 03120031 SITE ADDRESS . . . . . : 20127 APPLE TREE LA SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : VAN OVEREN ARTHUR E AND ELEANO ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2001 RECEIVED FROM . . . . : STEVEN PARKER CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . . _ • TELEPHONE FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL __________ _____________ __________ __________ __________ __________ __________ BPGAS OULETS 1.00 5.00 0.00 5.00 0.00 BUSLIC FLAT RATE 1.00 100.00 0.00 100.00 0.00 PPERMITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00 __________ __________ __________ ---------- TOTAL PERMIT 140.52 0.00 140.52 0.00 METHOD OF PAYMENT AMOUNT NUMBER _________________ ------------ _______-_________- CHECK 140.52 1313 TOTAL RECEIPT 140.52 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING • -%, CITY OF CUPERTINO •CUP TYOF O PERMIT APPLICATION FORM APN# 33 09 o7 Date:1 Building Address: ©12'Z Owner's Name: Phone#: i '1 �1 - 1�3 Contractor: License#: IcQ.rL Gv To q S'o 0 Contact: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Job Description: Residential jifl Commercial ❑ Sq.Ft. Floor Area. $/Sq.Ft.: Cost of Project Occupancy Group: 400 Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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 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 Elec 600V> IOOOA 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 1 of 3 CITY OF CUPERTINO CITYOF PERMIT APPLICATION FORM CUPER,TINO Quantitv 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 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 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 HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREM:ACOVER 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 > l 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 2of3 ' CITY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, 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 BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection 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 MPERNUTFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chan e BUILDING 3 of 3