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04050078Met LO,,F iW 'p66 iqo w U ' we 3u,s- y tO X�OmI+C�y w�v t-Zr QFC a�� u CITY OF CUPERTIN0 4CONTRAGTORIIN'10 TION BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT '904050078 6.4050078 10406 AVENTDA LN M'S NAME: - PIT ISSUE DATE ERM KEN MAPLES PHONE: SANITARY NO. CONTROL NO. ARCHITECTRINGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Descri nQn I hereby affirm Nat 1 am Incensm under provisions of Chapter 9 (commencing P with Section 70W) of Division l of Nc Business and Professions Code, and my license is imm�tome and ermct. BATH REMODEL License Class Lim.F - Dam Contractor ARCHITECTS DECLARATION I undersand an, plans shall W hold as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt form the Connector's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any lily or county which requires a permit in construct, &ter, improve, demolish, or repair any structure prior to in issuance. also sequins Ne applicant (Or such Permit o fie a signed statement Ft. Floor Area Valuation that he is licensed pursuant o the provisions of the Contractor's License Law (Chapter 9 Sq. (commencing with Section 7100) of Division J of the Business and Professions Code) Or Nal he is exempt thcsefmm and the bssis for the alleged exemption. Any violation of Occupancy Type Section 1031.5 by any applicant fon point, subjects the applicant to a civil Penalty of not mom than five hundred dollars (SSW). not O I, as own" of the property. or my employees with wages as their sole compensation, Require will do Ne work and dial, swan¢ is not intended of offered for sale (Sm.7 6.Business and Professions Code: The Conuactor's License Law dors not apply to an owner of nspections eon, and whodeessuch work himulf orNmugM1 his property who Wildsmimproves Nrc own employees. provided Nm sucM1 improvements are not intended or offered for sale, It, however. the building or improvement is sold within one year of completion, Ne owner. builder will have the burden of pmvin6 that he did not Wild or improve for puspax of r of the Property. exclusively coavaning with licensedommenemrs m o rvn Nc . B i jot (Sec. 10d4, Business and (. / ity wh ds or pr vex daemon. red Wilds cense taw docs not apply je ta owner o(pmpcdy who Wilds or ant tovu Centro, and ed Lica contrasts for such projects with o contnnor(s) licensed pursuant to the Contractor's IT law. slam am exempt under See .Bk PCfo Nis azrn 0 nor `Z-('M� r� (moi {� Dale WO.A coop SATION DECIA ON 1 hereby affirm under penalty of perjury one of the following declarmions: El 1 have and will maintain a Ceri fcare rf COment to self -insure for Worker'sCompen- sation, as provided for by Section 3100 of de labor Code, fm Ne performance or the work for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Seedrn 31,X1 of the labor Code. for the pefformanee of Has, work for which Nis permit is issued. ' My Workers Compensation Insurance lander and Policy number art: Canner. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE n-miseetmh nem nO, be eomplemd inW perms isrocid, hhndred dollars (SIM) 1 oneaa.) I codify Nm in the p effomence or the work for which this Permit is issued. I shall not employ any person in my manner Boaz to become subject in the Woricam Compensation ' Laws o(Califomia. Dam Applicant NOTICE TO APPLICANT: IL after making this Certificate of Evcmptkn, you should became $Object to the Worker'x Compensation provisions of dm labor Code, you must forthwith comply with such provisions or this Permit shall 4 deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby thin there is a lending agency for the nerrmmana of which ed (Sec. ' Ne Lurk fur whicM1 Nis permit is issued (See. J091, Civ. C.) Landers Name Lenders Address I codify Nn 1 have mad his application and sate Na the above information is 4 correct. I agree to comply with all city and county ordinances and sum laws «dating to building constmoion, and hereby authorise repro moll of his city to liner upon No above-mentioned property for impecdon porpn •. r (We) agree Or save, indemnify and keep heonleas the City of Cupertino against j liabilities,judgments, costs and expenses which may in any way accrue against said City e in consequence of Ne graining of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON -POINT Issued by: Date SOURC REGULATIONS. Re -roofs / Type of Roof gnature rf Applicam/Conwcror Dam HAZARDOUS MATERIALS DISCLO URE Will the applicant or fumm building occupant store o handle heaardous mamdal ' l/ az defined by the Cupertino Municipal Code, Chapter 9. 12. and the Health and Safety Otic. Sadao 2553$a)7 All roofs shall be inspected prior to any roofing material being installed. p Yea mNO I If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or Rude Wilding Occupant Use, equipment at devkcs which emit haanrdnus it mourminams as Jcfincd by the Bay Area Air Quality Mavgomem all new materials for inspection. District? ❑Yes 1�l Yu I NCedM1. s2 &c6oazm2ate5r1i5al, miffthNc 533wdc S53uan,d1eurnCdhrsaPvmr6 nu kalthha&eSarecatyd Wilding docs not curtently Moe a tenant Nat it is my mspomibility m notify tW ¢eupant of the rewimmen which must he met poor oI.imameOfaCCM fcamo0ccuancy. Signature of Applicant Date All roof coverings to be Class "B" or better Owner or authrri'rcd agcm oat Z CITY OF tCUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM APN# Z /� O3 �fMailing Date: Building Addres Address (' di erent om building address): �. Owner's Name: yin Y i Phoned: ° Contractor: License #: Contact: Phone: Cupertino Business License#: Fax: Boiler <= 100,000 Btu Building Permit Info: ,� Bid Elect/❑\ Plu Mec� Job Description: �/ 1%�.t iT i� Residential Tal ❑ El Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Grou �4 BBOILER5 Type of Construction: Please check this if the project is a BCONSTAX second -story addition: ❑ Project Size: Standard El ElMajor El BCONSTAX Quantity Fee ID Fee Description Fee Group BAPPLOTHER OtherAppliances 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 > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 /�' 7,F CITY of CUPERTINO w CITY OF CUPERTINO PERMIT APPLICATION FORM 'w'Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMNIE 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 Futures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING Ah BPSTORM Stom]/Rain Water PLUMBING wr BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER InstaH/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfrn MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFLYT 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 BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL 2 of 3 sZ--=, CITY OF CUPERJINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, 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 Ternp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERN= 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 1 J • Lp� w %<R nest igOn n t -w ad_J ;au 'a0 9 �OC w—v rz> E'c C F ac3% 4 4 CITY OF CUPERTINO ?r'e s n0^ .zs bM�f ml •'�^r %^ ""� BUILDING DIVISION PERMIT �n .�CONTRACTORIINFORMATION BUILDING ADDRESS: PERMIT '904050078 Q.V4050078 10406 AV W NER'S NAME: PERMIT ISSUE DATE KEN MAPLES 05/13/2004 PHONE: SANITARY NO. CONTROL NO. ARCHITECrIENGINEER: BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description o I hereby affirm Nat I am licensed under previsions of Chapter 9 (commencing with Section 7") of Division 3 of the Business and Professions Code, and my license is - in full force and effttl.BATH REMODEL License Clara Lic. M Date Contractor ARCHI'TECT'S DECLARATION ' I understand my plans shall oc used as public records L cuscd Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason. (Sudan 7031.5, Business and Prefesinns Code: Any city of county which requires a permit to consract. alter, improve. demolish, or must any structure poor wits issuance, idmata tires theap,ham. felines permit m Blcasignedsuamcnt islicensed (Chapter 9 Sq. Ft. Floor Area Valuation thin he pr ant toOcprovisionanrthecontriam'suansavw (commencing with Section 7") of Division 3 of the Business and Professions Code) or that he is exempt thuefrom and On basis for the alleged exnmp ion. Any violation of Section 7031.5 by any applicants for a retain subjects the applicant to a civil penalty of 3 44a4aQufiibcr0 0 Occupancy Type P y yp not mom than raw hundred datim (S50B). L as owner orthe preferly, of my cmployca with wagesas dmir sole mmparatiun. Required Inspections willdo Newark. and the structure is not intended or offered forsase (Sou. 7046, Buum a; and Professions Code: The Contractors License law does not apply in an owner of property who builds or improves thereon, and whodocssuchwod himself or through his - own employees, provided Out such improvements aR nminanded proffered for sale. It, however. the building or improvement or sold within one year of completion. the owner. builder will have the burden of proving that he did not Wild or imprevn for purfuse of sale. . u owner of the property, am exclusively contracting with licensed contractors to n One project (Sec. 7(44, Business and Professions Code:) The Contrxtori V cense law docs not apply to an owner of progeny who builds or improve themon, and who contracts for such projects with a conusctogq licensed pursuant to On Contractor's/ License law. 6 ❑ Iamexemptunder See .B&PCfo Nis an DeaN� jP IPS R��SC NSATION OEC\ . I hereby affirm under penalty of perjury one of On following declamation n I have and will malnmin a Certificate of Consent to self -insure for Werker6 Compen- station. as provided nor by Sccuon 3700 of the labor Code. for the perfnmtance of the walk for which this permit is issued. ❑ 1 have and will maintain Wmau'a Compensation Imi nna, as squined by Section 37W of the labor Codc, for Nc performance of the work for which this permit is issued. My Workers Camre ni ian I... caries and Policy number ate: Caricr. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Door union need not beenmplered if that permit isforone hundred dollars(SIM) car les.) I cartify that in the peif... of the work for which Nis permit or issued, I shall nos employ any person in any manner as as to become subject to On Wular9Compensation Laws of California. Date Applicant NOTICE TO APPLICAM: If, after making this Certificate of Exemption. you should become subject in the Workers Compensation provisions of the labor CMC, you mast ' forthwith comply with Such prstvistnns of Nis permit shall M deemed revoked. i CONSTRUCTION LENDINCAGENCY ' 1 screwy offum that there is lending agency for the pcRarmana of ' On work fur which Nis pefmis is issued (Sec. 3897, Civ, C) s ed (Sec. 30 Lender's Name lander'a Address j I marry that T have mail this application and sum that the above information is ' corcct. I agree to comply with all city and county ordinances and Stam laws relating to building anotannU n, and hereby awhorim representative of Nis city in enter upon the l above-menuoned property for inspection purposes (Wc) agree w save, indemnify and keep harmleu are City of Cupertino against IIab111Ye,jndgmenta, costs and expenses which may In any way accme against said City in consequence of the granting of this permit ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH A NON -POINT �• . Issued by: Dale SOURC REGULATIONS. Re -roofs 1^ Dam rgnawrc of ApphcaHA RDOUS MATERIALS DISCLO URE Type of Roof Will the applicant or future building occupant store D handle incaution, mseahil as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety . 'ode. Odon25533(a)? Yes 9Nu All roofs shall be inspected prior to any roofing material being installed. Will the applicant of home building occupant use a or devices which p If a roof is installed without first obtainingan inspection, I agree to remove p •emit hvardne air contaminants az dc0ncd by Nc Ray Arca Air Quality Management n Ail Qu all new materials for inspection. District? ❑Yes I have sad the hvardous mamrials mquismcros under Charles &95 of the Califor- rd. Health & SafetyCode, Scams; 25505.25333 mil 2553a. 1 undcmand Out if the Wilding' ' docs not currently hose a amount, Nat it or my msponsihility in notify the occupant of the requismen whichmussbcmaprionuissuanccaxCCNBnwo Paley Signature of Applicant Date roof coverings to be Class "B" or better Owner orauthorixdageft CoalAll �\ 11 � k� \ � « 2 Q 9 \