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05110007 CITYOFCUPERTINOt++�w �• �sar BUILDING DIVISION PERMIT ;CN=TRA•CO,R�I�1E�URMArQ.N BUILDING ADDRESS: PERMrr NO.05110007 0076 PEACHTREE LN NE ERS NAME: PERMIT MUS DATE HERBERT A. NELSEN NE: SANITARY NO. CONTROL NO. ARCHf1ECT/PNGINEER: _ BUILDING PERMIT INFO BLDG ELECT PLUMB MECH At LICENSED CONTRACTOR'S DECLARATION lob Description f I Money afErm WI I am licensed under provision,or Chapter 9(Cammencins P with Soction70(Ilq in fullofOivialon Sof deo Butlmse and Pro(cuium Codosnd mylkonse is +� mreeandeG«t. REPLACE SIDING DammacM° Cee CONTRACTOR: CALIFORNIA WINDOW & SIDING Date conuseCL ARCHITECTS WusS DECIacATION =man I 1 undcrmnJ my plw Nall W used u public recoNs 3yU a G LiaCosed Prorcadonal `m OWNER-BUILDER f DECLARATION 0 1 mat� alarm that 11. eBusin from IM Canumore :A n C LAW o for the 00 which moon.permit t 703 1.3,BIItlan. and w.da nm Calc:Any city st county 3$ which aqulmA a permh re rstconstruct.tlaL narrow.h permit t m mpalr ed avucwm -z� tprior Inhat in,iBWmapumsreto she thWision of far sock umar's RlcaeLAW(ulmnem Valua$&6525 p CthethaWliccmed Scatent wJa provision,3 of the IM Buinessnd ProliAw(Chapter9 Sq.Ft.Floor Area "1' egg (commenting with Smion 7 and the Divisionr of the Rued emora d Pr.My vl Cade)« Julio W exempt lMm(rom and tat hafts rte the alw9ed eumptien.Any violation of Section 7031.5 by airy wplln,m r«a permit atrbjeeu um Applicant to a aaI penalty of APN Number Occupancy Type not roam man RK hundred timed«(ssam. 31633063 . 00 ❑I,mownerof Jmploputy,«myempbyeawim MrAuftuwkcompewdan. will do Newark and meswt«ue6 not NleMed«nRited(music(Sec.7044,Buamsa Required Inspections andP1areeflam Cae:dTM CoContractodeal M (� Contractor,Lleante LAW do I apply 10 an Oman,ar l p property who builds or improves desmon,and who d«ouch work himself or through his own employem,provided that such improvements tie not Intended waffmad forage.If. however.the building orheprovwment is laid within aro wu of compmtion.me owner. Wilder MB love um burden of proving that he did rot Wild or improve for purpose of 4WJ. ❑1,As awn,of she Property,w melumOdy contracving with liamse conuamars in mwrect the project(Sec.7016,Son«u aM Profession Code:)The Coovatars Li- mase Low does WI apply At an owner of property+•M Wilds or improves thereon,ad, who cunmea for such pmjcm with aeommasonr(s)licensed palwnl At dee Conmemrs Lim.Law. ❑loom under sec B&PCfor o Owner Da e WORKER'S RKER'S OM 'IDSA ON DECLA TION I Manby lain,under penally of perjury an,of dee fallowing d0masomana I haw And will maintain a CoNfigte of Consent w self-ism(«WarkeraCompm- mden,u providad f«by Section 3700 of the Labor Cade.far dee performance of me work for which this permit is issued. ❑1 haw and will maintain Warkers Compensation Imurmce,u required by Section 37W oram Labor Code,for the performa�of the wart far which Its permit is Issued My Workers Compen4tion insurance rani«and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (MIS sebum used wthecompka t Ifthe permit W far oochan&eddo0an(5100) or leu) 1 cudry that in the performance of deo wart fm which this permit is Wend,l small not employ any person in soy mmrurso u a beeama mb]lcl to Co�oaaaWan Lowe of California.Das r/ 7� Applicant NOTICE TO APPLICAN7%It.after making this CcniR of Exemption,yen should become sublet m We workers Compcomdon pmvwo M the LAW Code,you mut .,O forthwith comply with such provision, em or this permit shall W deed rewind. zCONSTRUCTION LENDING AGENCY (+ I hareby,aRrm deal mem W a construction Wading agency for the performance of a> the work for which dust permit is issued(Sea.3091,Civ.Q W� Q Lenders Name 7 Z UnMrsAddress U O I Cowry mat I haw mad this application and mm deal the Shaw information IS p••� corms.I agree to comply with all city and county on inamm!AM sum laws rtladng m O SU" building convection,and hereby authadre mpreunuJw of this City w enter upon the W whom-mcationed property for Inspection purposes. (Wm agree to saw,immorally tad keep harmless the City of Cupertino agarol fey rrA liabilillp.)udgments,cam and mpelee+which may In my way seems agaiml said Cby t.)Z in conssqueme of the{matins of this permit ^ APPLICANT UNDERSTANDS AND WILL COMP WITH ALL NON-POINT Issued by: Date SOURCE TIONS. �� Re-roofs Signature or Applicam Canumor �TDa HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Jen applicant or future building occupant gore orhancie husrdom material as de0md by the Capetian Munici 1 Cade.Chapter 9,13•and the Health and Safety ade,Section 35532(a)7 All roofs shall be inspected prior to any roofing material being installed. [I Y. No + will the applicant or future building ocaupant use equipment or dein,which If a roof is installed without first obtaining an inspection,I agree to remove ithvANnmair aenumimntsuby me Bay Arta AirQWltyManagcmcnt all new materials for inspection. Oyu No I haw mad me lonndnm malcdaH requirements undcrChapmr E.95 of dee Califor. nla Health&Safmy Code,Section,25501.35533 wW25534.1 undcomad thYif Jen building dam not currently haw a amount,that It W my respamthilhy In-11, P gaup of require= WhmoatWmupoor win a amaroeea ignature of Applicant Date Owner ar sotharvad agent Da!/ All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue aClOF Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 �UPEkTINO Building Department JOB ADDRESS: PERMIT # o 07 d P26 L-4, ui 0.7i000 -7 OWNER'S NAME: rte, PHONE # GENERAL CONTRACTOR ��\,S'a n kdo FAX # I am not using any subcontractors: Signatur4 Date Please check applicable subcontractors and complete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood y Glass/ Glazing 1 Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock r Tile r Owner/Contractor Signature Date WAT als 4� CUPE(_TINO } Assessor's Parcel Numb//er_�31l0 ' 3 3 —06 3 Name of owner. t kr—A T Al&5—&W Project address.._72yxa& LcT! Contact person. ��lL TGh Phone. a 47 3 /76 Fax. 9 73 Net square footage of lot. Existing Proposed Square footage: First floor: Second floor: Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garraag'e??� Y N Is privacy protection planting required for the project? Y On what floor(s) is work being done? Brief description of work. v Ad v �i7A` eL Code editions:2001 CBC Ci N)2001 CFC (Y-N)2001 CMC (Y-N) 2001 CPC (Y -14)2001 NEC (Y -N) (�,�`,1\ G o.,ti�� .,;�1•� .,�;Y� C V Q c J'd-er+e�or d/, Effective 11/1/02 Plan Review Process Work Book Page-8-Revised 4/28/04 ga CITY OF CUPERTINO CPERMIT APPLICATION FORM CUPERTINO N# Date: �ns-- Building Address:U07(o Mailing Address (if different from building address): Owner's Name: / Ajv,5�w Phone#: yos q73 ��6 /�� Contractor: e q)/dl r- License#: �S2e�Vy G Contact: U/f Phone: Cupertino Business License#: Fax: `W97?- 17 Building Permit Info: .71* sm Bldg 21' Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential fd' Commercial ❑ Sq.Ft. Floor Area: q.Ft.: qjW Cost of Project: �tol zS bD Occupancy; r U5 Type of Construction: Please check this box if the project is a V U second-story addition: ❑ ro'ect Size: Standard Large ❑ 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<= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING Ah BINVESTIGA Investigation fee BUILDING I of X66 . S'�f II I. CITY OF CUPERTINO CUPPERMIT APPLICATION FORM Quantity 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 BOVERM E Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum — . PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE PbIg 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 rinklerBackflo 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 PLUMING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfrn 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 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 2of3 , CITY OF CUPERTINO CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group 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 Insection BUILDING BSWIM Swimming Pool 1UILDING 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 Mechanicalsq. foot MIiCHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3 of 3