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04060066 CITY OF COPERTINOm BUILDING DIVISIR ON PERMI CI,ilY7GRA .T(1 �YN 'URMAT '- INGADDRESS: PERMIT NO0 4 0 6 0 0 6 6 PERMIT ISSUE DATE OWNER'S NAME: GENA BOWEN SANITARYNO. 400AOLNO. PHONE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 0 0 0 u o 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing z with Section]IXIE)of 'vixion3of NC Bu, and Professions Com,and my license is id ren force ad'cffc C' KITCHEN REMOEL 5l2Z License plasf° Lic.M Cpm Da — Commewr CONTRACTOR: PAUL SHEPHERD CONS'. ARCHITECTSS�qqLL¢¢{{../RATION �i 1 understand my plans shall he usctl'd}�btShoucards DEU t w t Licensed Prnfcuinnal �0< OWNER-BUILDER DECLARATION <z I hereby affirm that 1 am exempt Imre the Contractor's License Law for the ymm following moon.(Section 7031.5,Business and Professions Code:Any city or county y S� which requires a permit In construct alcor,Improve,demolish,or repair any suucwm _Za prior to its iumbec.also requires the applicant!orsuch permit to file a signed stnt.mmm Sq.Ft.Floor Area Valu15)p 000 £ that he is licensed pmauant to the provisionsof the CAmorcum's License Dow(Chapter Y y'm (commencing with Secdon 7")of Division 3 of the Business and Professions Code)or i $ Out he is exempt therefrom and the basis far the alleged exemption.Any violation of Section 7031.5 by any applicant for a Permit Subjects de applicant to a civil penalty of APN Number Occupancy Type mow man Bve hundred dollars(5500). 3 6223016 . 00 ❑I,as owner of the property,or my employees with wages az their sole compenmtion, will do the work cad the swctum is not intended or offered for a.].(Sec.7L44.Business Required Inspections and Professions Cade:The Con mom's License Law dam not apply to an owner of q P Rat who builds or improves daemon.and who docs such work himself or through his awn employees,provided Nat such improvements are not intended or offered formic.If. however,the building or improvement is said within one year,of completion,Ne owner. builder will have me burden of proving that he did not build or improve for purpose of *baa_ V L 4 /� soma 1 saw.). W_ C 1,as owner of the property.am exclusively contracting with licensed convectors to centred the project(Sec.7044,Business and Professions Code:)The es Bemor's Li- p p const naw docs not apply man owner of Business who builds Cor ode:) mile t, and me�{YI■ contracts for such projects with a eonuacter(s)licensed pursuant to the Conuacto(s ew L . ex funder Sec. .B&PCfol 0i�s�rclasjyn Owns Da¢�— WOR ER COM ATIO? CLARATION I hereby eRusn u der,penalty of perjury ane of dat following declensions: ❑1 have and will maintain a Certificate of Consent m self-insure for WorkahCamper- sation,u provided for by Section 3700 of Use Labor Code,for the performance of the work for which Nis permit is issued. C I have and will maintain Wurke's Compensation Insurance.as required by Section 3700 of the labor Code,for the Performance of the work for which this Permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Carper - Policy lvh`' CERTIFICATE OF EXEMPTION ORKERS' COMPENSATION INSURANCE (This section need mat be completed if the permit is Forane hundred dollars(SIM) or less.) 1 cenify that in the performance of the work for which this permit is issued,l shall ret employ any persyyn in any manncrsn az w become subject to the Workcri Compensation Laws of CalifomigeOatc Apppp��cam L NQFICE TO APPLICANT.If,after making this Certificate Of Exemption,you should b eame awl in the Worker's Cempenmlimm previsions of dao Labor Code,you mum Z forthwith comply with Such provisions or Unk permit shall be deemed revoked. ZO - CONSTRUCTION LENDING AGENCY H Ihereby affirm that there is a construction lending agency for the performance of M> Ne work fur which this permit is issued(Sec.3097,Civ.C.) 6Wi Q Lender's Name / z Lender's Address �I V 0 1 mortify that I have read this application and sure that the above information is IL P correct 1 agree to comply with all city and county Ordinances and sate laws relating to O L) building convection,and hereby outhorim representatives or Nis city to color upon the W shove-mcmiuned property for inspection proposes. 0. (We)agree Ire save,indemnify and keep harmless Ne City of Cupertino against fA liebilitiea,judgmenu,costs and expenses which may in any way ecdem against said City (,)Z in consequence or the granting of this permit. 6GAk��TT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT Issued by: Da OURC1F�EG - `�'�� Re-roofs igna arc oFApplHAZARDOUS MATERIALS DISCLOSURE Dau Type of Roof Will the applicant or future building Occupant store or handle humorous mawrial - as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cale,Section 25532(.)? Alva All roofs shall be inspected prior to any roofing material being installed. Claus Will the applicant or fewrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit haaamous air contaminants as dcdned by the Bay Arca Air Quality Management all new materials for inspection. Disuid? ❑Yes �Nu I have mad the motabu materials requirements under Chapter6.95 ofthe Califon .is l&SafetyCod.,becomes 25505,25533 and 23534.1 und.rsund due done building drl have a Rnant mal it is my responsibility m notify dw mcupwi of Ne u1mmen wh� mum be met prime,issuance ofa Cenidcam of Oc`eypency., / Signature of Applicant Date oadag.nt ��� All roof coverings to be Class"B" or better 7 ? Z t= YEO 9 0_%, .__ CEG/!✓� ' , - tVoT49�-._ . +!IAP ��` p4 'dpS 'a alit - — - any e+ .SSW dung to emUen (MI -- pn m d CuPetflttD, the ibis P an OT Nvidd ¢-L S z he At �IN1,4O0 ARIM T I , Li - -- _ -. _.-- --_ -----CIvioF - - - - --- p�lg OF I � 17 ..... ... -7- .......... i A XTVV'"Aa V b3 4c* ot4ij dO Ao r I 77' LL WTY OF CUPERTINO aCITY0 CUPE TINO PERMIT APPLICATION FORM `f APN# /Z Z o / Date: (� 6 Building Address: Mailing Address (if d' fele from building address): 7 7 'ra l G ' Gvud l Owner's Name: Phone#: C) G �.. v-o -7 Se ql�lntractor- - License#: Contact: Phone: Cupertino Business License#: Fax: © 0 Building Permit Info: / Bld Elect Plumb 2' Mech ❑ Jo D criptio��n: Residential 11 5A )I q apt Piloo mercial Sq.Ft. Floor Area: $ q, , Cost of Project: cupanc ype of Construction: Please check th ox if roject is a second-storyaddition: Project Size: Standard ElLarge ElMajorEl Quantity Fee 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 IM 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 13INVESTIGA Investigation fee BUILDING 7 1 of 03 41ITY OF CUPERTINO 0 ` of PERMIT APPLICATION FORM CUPERTINO 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 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Buswa s ELECTRICAL BREMEIXT 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 BRENU RAPP 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 CITY OF CUPERTINO CUPEfZTINO PERMIT APPLICATION FORM ®' Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips 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 BSEISNHCRE 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 s. 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 i 3 of 3 CITY OF CUPERTINO � v¢%-v : BUILDING DIVISION PERMIT C'cAfiu"Iftb T>�1 11tMATTQN� BUILDING ADDRESS: PERMIT N0O 4 0 6 0 0 6 6 2'A q0TTTRR1-1TT.T, CT OWNER'S NAME: PERMITIRSUEDATE GENA B WE 6: SANITARY N0. CONTROL NO. ARCHITEC IENGiNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Z9, LICENSED CONTRACTOR'S DECLARATION- I hereby of on Net 1 am li onud$oder provision of Chapter 9(commencing Job Description wish section 70y0f iaicO Sof Ne Base and Professlnn Code,and myli=enec is id fat in nnqpd�err �/' C7 KITCHEN REMOEL 'bZ Lkenu clam— V LI0.d Qp9�o Da — coSSnlQQnFFc�mr.. r- CONTRACTOR: PAUL Sy At ON I undersand my Tig pI a,mI be uudY3}ibbit.cords G Licensed Professional L�+3 OWNER-BUILDER DECLARATION DECfes 2 I hnmhy alErm that 1 am exempt form the Contractor's License Lew far the ' C 1004 Ca following mason.(Section 7W 1.5,Business and Proassion Code:Any city or county which requires a Permit to co.atrust.Slur.Improve.demolish.or repair my Structure Mprior to its issuance,aim mqutre the applicant for such permit to file a signed smwment that he is licensed personal 0 the provision of theCammcwrs Lieonm law(Chapter 9 Sq.Ft.Floor Ar Valuo� )o p 0 0 tt� (commencing with Section 7000)of Division 3 of the Business and Promasion Code)or 3.- that he is exempt therefrom and the hssk for Ne alleged exemption.Any vlolatfan of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type net ream Nan five hundred dollars($500). 36223016 . 00 ❑I,uowmrofthepropcny,armyemploycawiNwagmuftiraokcompenution, will do Newark,and Nesmrmure is not intended oraffened forsale(Sec.7064,Business Required Inspections and Profession Code:The Connector's License Law door ree nst apply to an owner of q P property who builds or improves there n,and wha docs such work himself or through his ownemployee,provided Natench improvements me not intended or offered formic.if. however,Ne building or improvement is mid within one year of completion.the owner. builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed conua=wrs m contract the pmjem(Sec.7066,Business and Professions Code:)The Conaacwre U. cerate law door not apply to an owner of property who builds or improve thereon.and who contracts for such projects with a commelor(s)licensed pursuant an the Cannacme, L'mole ave. 1 ..c under Sec. B&�PCCRSNis�gn Owns Data _=r—t/ WOR E COM ATIO LARATION I hereby a irm a der penalty of perjury ane of Ne following Maturations: have and will meinam aCeNficate of Consent to self-insure for Workcr'sCompen- utlan,u provided for by Section 3700 of Ne labor Code,for the performance of Ne work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Ne Labor Code.for the performance crime work for which this permit is issued. My Worker's Compensation Insurance canner and Policy number art: Ca er. Policy CERTIFICATE OF EXEMPTION ORKERS' COMPENSATION INSURANCE (fhisucuon need notea completed if the Permit is forone hundreddollms(SI W) or less.) 1 certify that in me Performance of The work for which this permit is issued.l shell not employanype nfin any manerso as of become Subject to the Worker'Compensation - Laws of Califomr . c Arg ICE Zone subject ct to Me Work r' atom making this Certificate of M Exemption,you should Zone subject y it Worker's Coon or this provisions of Ne one!! Code,you must .J,Z forthwith comply with such provision or Nis permit shell x deemed mvoketl. rO CONSTRUCTION LENDING AGENCY [tip I hereby affirm NU there is a convection lending agency for the performance of a> me work for which this permit is issued(Sec.3097.Civ.C.) Igl Q Undoe's Name z Lendee's Add. U 0 1 certify Net 1 have read mix mplicatien and mute that the above information is comet.I agree to comply with all City and county Ordinances and state lam mining to V building construction,and hereby.mor Oce representatives of this city m anter upon me Ii7 abovcmentioned property for inspection purposes. (We)agree to Save,indemnify and keep harmless the City of Cupertino against t�y liabilities,judgments,cam and expenses which may in any way see=agtinuaid City U Z in consequence of me grad all of this permit. UNDERSTANDS AVD WILL COMPLY WITH ALL NON-POINT Issued by: 620 IJV Da RC G ~ OUA `l`O T Re-roofs Igna urea(Me pl AZARDcOUS MATERIALS DISCLOSURE Date Type of Roof WIII Ne tur applicant or future Wilding Occupant sore or handle hvaAous mauriad as defined by me Cupertino Municipal Code.chapter 9.13.and the Health and Safety Cade,Section 25532(.) All roofs shall be inspected prior to any roofing material being installed. ❑Yes oi4- Will the applicant or future building Occupant use equipment or devices which C If a roof is installed without first obtaining an inspection,I agree to remove hazamous air comaminats as defined by the Bay Area Air Quality Management all new materials for Inspection. trrsuicl? 13Yce P�Nu 1 have road Nc haranlous materials requirements under Chapter 6.95 of Ne Califon ria Halm&SafcryCede,SextonMM,25533 and 25534.1undersand)het if that Wilding J n 1,havea tenant,that it is my maponsibilily w nodl'y Ix occupmt or me uimmen whmaetxmetpdort essmancc ofa cemrceto ora pre=y, Signature of Applicant Date O All roof coverin dagem g s to be Class"B"or better rauthad'r �