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06020140
z z 0 C2 122 Q � z UO O �z CITY OF CUPERTINO.nAq,gwi amLmNc DlvlsloN PERMIT CONTR'ACTORINFURMAT,ION, a. BUILDING ADDRESS: PERMITNO.Q 6 02 14 0 10401 C OWNER'S NAME: PERMIT ISSUE DATE MARSHALL GOLDMAN 02/23/2006 NE: SANITARY NO. CONTROL NO. ARCH=CrfENGINEER: BUILDING PERMIT INFO 9LDGO PLO MECHI 0 LICENSED CONTRACTOR'S DECLARATION lob Description I hoses affirm Net I mm heaucd under prevision of Chapter 9 (commenting P with Section 70110) efDivWen 3. orthe Businw and Profession Code, and my licence is in Tall Tera able t ¢ d/ ' FIREPLACE REPAIR LI"nee°"' Lie.g De¢ GoetMthr - CARPIO MASONRY PD FOR BUS LIC 2/23/06 CHITECI'S DECLARA I understand my plans Mall W used aspublic reemG Licensed Professional OWNER -BUILDER DECLARATION 1 hereby efrom thus I am exempt from the ComrmCtoes License Law for the following tuann. (Section IID IA, Buaiona and Pmfessiont Cade: Any City or county Q which requires a Parent, an construct. alter. improve, demolish, or mpm my sWqum prior to Its IIIVBIIL'C. also requires ale applleNt for such Permit to rile a signed masom at thatW islicemmed possums a the provisions of the Contractors liana Law (Chapter 9 Sq. Ft. Floor Area Valu 16000 (commencing with Section 7")of Division 3 or the Business and Profusions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of s Number (" �/ Occl Type Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of live hundred dollars not mom than ($50)). 322 641039.00 6 4 Bey !' 01, u owner of the property. or my employees with wages v their ale Compensation, A ,. nom_ s"(7't "'VQ RegUiredInsp6e ions will do the work and theawctuw is notintended oroQeted forsale(Sec. 7011, Bumex, d ProfesUoCode: The Contravenes Uceme Law does oat apply N an owner of anm property who builds or improver Nereon•and who doesmth wmkldmaAfortivoujb his lmpmremanum Intended reoffered foruk. fir, U own employees, provided that such not however, the building or improvement is sold within one year of completion. the owner- �I .1a builder will have the burden of proving that he did not Wild or improve for purpose of talc.). ❑ I, u owner of the property, am exclusively contracting with licensed Conoacmrs to Contract ate pmject (Sec. 7011, Business and Preferment Code:) The Contractor' U. Chose law dents not apply to an owner of property who Wilds or imprevu Nemen. and. , who coocomm for mels prejects with a tonmamet(,) Ileemad pure sm,m use Commerce, Liceed law. ❑Iamuemptundcr a .BAPCfm Nisresaon Owner Dau WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury e e of also following declarations: L hawand will madman a Certificate ocrownt to xelf-Inure for Wohers Compen. sato., u provided for by Section 3700 of the labor Code. for the petformaece of the work for which this permit H issued. ❑ 1 have and will mainmin Worker's Compensation Inwrance, as required by Section 3700 of the labor Code, par the performame of tt work for which this permit is land. My Worker empentation lnmrmtt tamerand Pulicyn Wrve: Camitt: S.PA- Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Ibis mire recd ret t completed Bit permit is from hundred dollen (5100) or less) I certify that In the performance of the work for which this Permit is issued, I Nall not employ any person in my manner an u to become subject In the Workers' Compensation Laws of California. Dm Applicant NOTICE TO APPLICANT. If. after making this Certificate of Exemption. you should become subject to the Worker's Compensation provisions of Nc labor Cade, you most forthwith Comply with such provisions; or this permit Nail W deemed reword. CONSTRUCTION LENDING AGENCY L taby WE. Nu Neter Is • Commct m lending agency fordo perfermame of the work for which this permit Is issued (Sec. 3097. Civ. C.) ' Lender's Name Lender's Address - I «rtify that 1 have read this application and such that the above information Is Comes.1 agree to comply with ail city and county ordinances and mate lawn relating to building eomWction, and hereby m utim, representatives of this city to enter upon uite more-memimled property for IntpeNon purp0al (We)a bpm, indemnify and keep harmless the City of Cupertino against IlabiOdu.ju la,tosm dexpeneswblch may in anywayacnueagamm Wd City In consequc e o the t tin of this permit APPLICA R AN S AND WILL COMPLY WITH ALL NON -POINT Issued by: Date . SOURCE REG L O S. `L3A'G y Re -roofs Type of Roof Signatusee ppliesenUConuactor Dm HAZARDOUS ATERIALS DISCLOSURE Wil applicant or forum (ding occupant mom or handle hnrdous material as deRned by rye Cupertino Municipal Code. Chapter 9.12. and the Health ad Safety eae. Seem.. 255320)7 All roofs shall be inspected prior to any roofing material being installed.❑Ynt ❑Nen If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building CCCUPmt use equipment or dcvims which It hseminus air Conlnminmu as defined by the Bay Area Air Quality Management all new materials for inspection. District? Oyes ON. I have mad the Wardoes materials requirements under Chapter 6.95 of the Califon nice Hcal SafetyCode. Seem. 25505.25533 and 21534.1 understand Nmfruit building does ro c m se a tenant Net it u my responsibility m notify the occupant of the regmrem with nmtmvPm0rWICharCoofaCertirtnteerotm r. Signature of Applicant Date �`L All roof coverings to be Class "B" or better owner raethntirnaa t Da,p 1 V J CITY OF UPERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: © S i PERMIT # OWNER'S NAME: (,o PHONE # - 4F 02-%i GENERAL CONTRACTOR: FAX # o _2 1_ I am not using any subcontractors: 2--Z7-67 6 Si tore Date Please check applicable subcontractors and compl to the following information: Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date CITY OF CUPERTINO CUPEIZTINO PERMIT APPLICATION FORM aDao/�0 orN# 3 ,,2/'(� �"63 % Date: uildin Address: Mailing Address (if different from building address): �P Other Appliances Own's Nam : ` ! Phone #: Yo$ - � S / - 0/ v Boiler <= 100,000 Btu s �;o A-=, BBOILER2 Boiler> I OOK to 500K Btu Con"ctor: .License vlvC #: 12 -2-9(gip Boiler > 500K to 1M Btu l�/C BBOILER4 Boiler> 1M to L75 M Btu Cont: Phone:4o&—y49-OZa/ Cupertino Business License#: BBOILERS Fax: / -9% MECHANICAL Building Permit o: Construction Tax BldgL� I lect ❑ Plumb ❑ Mech ❑ BCONSTAX Job Descripti n: BUILDING Residential aCommercial ❑ Con. Tax for BQ Zone Sq.Ft. Floor Area: q.Ft.: BCONSTAXH Cost of Proi ect: Lr� ISw - Occupancv GrT BCONSTAXR Type of onstruction: Please check this box if the project is a BELEC1000 Elec 600V <=1000A second -story addition: ❑ BELEC1001 ro'ect Size: Standard Laze ❑ Major ❑ ELECTRICAL w 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 BBQILER3. Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to L75 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 BL11LDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <=1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <-- 200A ELECTRICAL 13ENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 11 1 of 3 CUPEIZTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantit3i Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME 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 MIXTURE Pblg Fixture PLU117BING 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 Re eat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING 13PSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap , PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER InstaWAlter Water Pie PLnl[BING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reins cction Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BRENLk IiAN A/C Units <=10,000 cfm MECHANICAL BREMAPPLI Appliance lnstall MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BR.EMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > IOK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREAENHOOD Installation of Hood AIIECHANICAL 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 Heat in MECHANICAL BREMRESAPP Remodel Res Ap liance ELECTRICAL C: 2of3 CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Si , 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 f BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMTTFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMTTFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR PlLnning Long Range Residential PLANNING ZADDCHG Address Chane BUU-DING 3of3 1 t