04070152 CITY OF CUPERTINO ''"^'' ' ''
BUILDING DIVISION PERAD "YtA-CT812'INCf
BUILDING ADDRESS: CRW INDUSTRIES P�"MRN004070152
O R'S NAME: PERMITMUEDATE
SHARON SAFADIG
PHONE: SANITARY NO. CONTROL NO.
(408) 378-2477
ARCHITEC(ENGINEER: BLDG BUILDING PERMIT INFO
ELECT PLUMB MECH
30o LICENSED CONTRACTOR'S DECLARATION Ib Description
1 hereby affirm that l em IicauOeSCTIP
cd under provisions of Chapter 9(commencing
with Section] f of Divbian7sef the BuslnusandpmFAW...C.ck,endmylimaxaia
mmnmreeAn r r y REPLACE 9 WINDOWS/1 .PA((t {{{���] (��7 ��ttr��� a s
LicensA Clws L.A.. 1 RNA
'f (f,�®
.3 �CuntARCHITECTS preed�+azr:R ' B lglt—fIJ NNLI'O[t-,�{\IL�'-ajLl�-'r'
i
1 un�l'It!unJ my plea Chat hew J u puhlie(eenOrtla
LicensedPrai.a.Aal JAN 2 C 2005
OWNER-BUILDER DECLARATION
H2 S 1 hereby shat that 11. exempt from the CanuestCo License law for the
ioO followingmuoa Pieria 7(131.5,Businessend ver,demolish,
Code:Any City or coonly
�$E which rtqulma a permit re cowwct,alar.Improv,demolish,car repair ed smetum Ran
F ir^ pdarmiu iensedprm,anqulree lhovisios nt ofoxeachmmeal RleaeLawJmmmem n
�< thathe is(mmum.,AS wit punuanuothe.f D1vlom of the Corm tad Liccnmlaw(ChaprerY Sq.Ft. Floor Area %%
won
he is xempt tseclbn 70n d the basis f r th the alleged
u pt on.Anynvi Ction of
��.. that he b exempt therefrom end 0te bub for the alleged cumpllan.Any violation of
Section 7031.5 by any applicant for a permit rubjocrs the Applicant o a civil penally of 3 404MIAe10 0 Occupancy Type
not more than five hundred dollars(35°0).
❑I,uowncrofthe property.mmyempluycca with wagmuthe'd sole wmpensadon,
win da thcAmma Codd:he Con isrot Licamse Law
does not Apply W In Own Of Required Inspections
proand erafessl ban Coda:The Condense..Liecwe Law don not apply lf an awns is q P
Own enywha employees,fumorimprove th hurpr and who mesamhwmk himself ed for ughWe his
owner.thprovidedthat appaochimprovematsare.year f or offered for We.If,
builder.Ne building arimprovementi.soldwidtinone year ofimprovforNeowner-
bullder will have Ne burden of proving the he did not build or improve for purpose of
1,as owner of the property.em exclusively contracting with licensed a.ar.ewn IA
cowwct Ne project(Sec.70W.Business aAd Profnaians Code:)The Cnnusctor's Li.
Game Taw dam not apply An an owner of properly who builds of Impmvm d:man,and
who contracts for such projects with a cantramr(s)licensed pursuant An the Condacte.s
License Law.
❑l Are exempt under Sec ,B k PC for this rexan
Par De:
WORKER'S COMPENSATION DECLARATION
j 1 hereby affi m under penally of perjury one of the fallowing declara0am:
❑I haw and will maintain aCeaincan of Cement to self-Imum for Worke.aCompere-
.atlon,At,provlded for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insunna,u required by Section
3700 of the labor Code,far Ne performance of the wank for which this permit is issued.
My Worker..Compensadon Insunn6
a carrier and Policy number art:
card . SPATE ";; Policy No.: / AH&
CERTIFICATE OF EXEMPTION PIOM WORKERS
. COMPENSATION INSNIANCE
Obbscedao and not beamplat d Jim pall is faro.hundmd doll»(5100)
m luta)
T certify that In the pmionnum o of Ne work for which this Permit Is issued,I shell not
employ any person in any manes As At become subject o the Warkcss'Compensation
Law,of Califomis.Dam
Applicant
NOTICE TO APPLICANT:If,after making this ceniRcaw of Exemption.you should
become subject An the Worker's Compensation provisions of the labor Cede,you most
.,0 forthwith comply with such provision or this Permit mail he deemed revoked.
z0. CONSTRUCTION LENDING AGENCY
,4 1 hereby affirm that them Its consductlnn lending agency fur the perfmamnm of
ani dte work for which this permit is issued(S..3097.Civ.C.)
W Q Lender's Name
z Lender's Address
V Q I certify that I have read this application and slow NCI the above Information is
ly!" Correa.I agree to amply with all city ad county ordinances and sue laws relating to
OSV" buildingconswction,atdherebyeuthmbampm+autiwvofthiscitytoenteruponthe
[T) .thaw-mcntiomd property fm impaction purposes
gy (We)agree An save,indemnify And keep herml.the City of Cupertino against
y Iiablliliesjudgmenu,ewts And espemw which may in my way same against said City
U in consequence of the grating of this pcoaiL.
APPLICANT UNDER S D WILL COMPLY WITH ALL NON-POINT Issued by:9 :,ate
SOU CER ULA71
7'fGfi" q Re-roofs
sem fApPIimHAZARDOUS MATERIALS DISCLOSURE ora Type of Roof
Will the applicamor futum building occupantatare or handle huardous materiel
s deMAd by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
a.Section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ym AT.
Will the applicant or furore building occupant sax equipment ar&A.which If a roof is installed without first obtaining an inspection,I agree to remove
Amit henrdaus air canlomimmus as dcOncd by Jte Bay Area Air Quality Management all new materials for inspection.
DistrictT
oYas Nu
1 haw read the hamNnusmawrlels rcquirconcnu underCNpwr 6.95 of the Califor-
niAHcxWAsafclyCmI S.d.ns25505,25533.d25534.1undersandthslr cbuilding
J�aLp Aaw a sen thol t a my nee responsibility m nodl'y Ne�c p f the
req ems ch mux m rmissuaccofaCcrJOnuofOceapa Signature of Applicant Date
tier or adlharirA asanr Data All roof coverings to be Class"B" or better
i
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•
DATE—. __
SIGNED
The Se' of pl s E d sp ' ations MUST be
k:dt
nth ob at nme and it is unlawful
A: rnaka an Ian is alterations on same
n^it written per fission from the Building
L :u,invent, City of :upertino.
Stamping of thIan and
&TALL NOT be he p ���
"mul or W Do aft
eaproval of the viol ' n of L
« State
w.
(� IJ�NDou�
YED
JUL 2 6
CITb aF cU ERTINo
a Ott�in�r- ARTMENT
ROM �2
5'xq°
• SHAR,0N S.4FDIE
10108 R1D6tr1J42)21
Gd e4r(�No GA• 4501y
CITY OF CUPERTINO*
•CUPEI�TINO PERMIT APPLICATION FORM `'
APN# Date:
/ 7-zG-oy
Building Address: Mailing Address (if different from building address):
/0108
R�vbec>A D2.
Owner's Name: Phone#:
S11A4a4 .SAAAD;s 378 i'v77
Contractor: License #:
6,R,4). 204ays;Ayes '{oz y8y
Contact: Phone:q06 q2G-081,5 Cupertino Business License#:
PSAN }Pdrm aso,v Fax: qoe 379 •2goq
Building Permit Info:
Bldg 0 Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Er ftPw,s q cJwaows 4 1 4Avto pao& Commercial ❑
Sq.Ft. Floor Ar $/Sq.Ft.:
Cost of P ject: Occupancy Group:
66,OVr
ype o ons jon: Please check this boky the pro' is a
OWP r44M446, second-story addition:
Project Size: Standazd Laze ElMajorEl
QuantityFee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
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
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1 of
7. 73
? WITY OF CUPERTINC*
UPEkTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMNM New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTRAE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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 Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER 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
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
2 of 3
*ITY OF CUPERTINO*
CUPEI�TINO PERMIT APPLICATION FORM
QuantityFee 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 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
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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