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03120120 (2)7 ZC CITY OF CUI'1 ICHNO � uu1LulNc DrvlsoN PliRM� CONTRAC POR INFORNIA®tN .: BUILDING ADDRESS: PERMITNa03120120 OWNER'S NAME: PERMIT ISSUE DAI'E ROBERT KUN NE: SANITARY N0. CONTROL NO. ARCI IITECf/ENOINEER: BUILDING PERMIT INPO BLDO ELF.CC I'LUMB MECH LICENSED CONTRACTOR'S DECLARATION Ib Description esertP 9 (commencing 1 hereby affirm that I am licensed under povison, of ChapterO with Section 7t1I1(l) of Division 3 of the Bus{ncss and Pmfcssium Code, and my liecnse is in OR mm[ end effect'REPIPE & MS BATHROOM DRY ROT REPAIR Llcanec Class LId.a Do,.— Cumocmr ARCHITECTS DECLARATION 1 understand my plans shall he used as public rccurda Liccr.cJ Prokssinnal OWNER BUILDER DECLARATION 1 hereby affirm dot 1 am csemm From the Cnmmcmf's License Low for the following r.,an. (Section 7031.5, Business and Prorcaions Code: Any oily or county which nequirds a permit lu construct, altar, improve, demolish, or mpelr any structure pilar In i. isst also requires the applicant for such permit to be a signed staoment more Contractor's l:ecnsrlawlehapmry Sq. FL Floor Area Valuation slismacdpursuant tothe prnviaionsofine (commencing with Section?") of Division 3 of the Business and Professions Code) or tial he is ucmpt therefrom and the basis for he alleged eserrulmo. Any viol lion of 3 4�Ls T0i2Ti7Qr0 0 Occupancy Type Pane Y YP Semon 7031.5 by any npfru ant fora permit supjccu the applicant to a civil pcnahy of rmoreman rive humbendonars(S50s. ❑ I, as owner of Om property, or my employees with wages as tbch sole compensation, Required Inspections q p will tlo Incwork, and the is not intenANof Business The Code in Comremon, Licendrendwho Law docs not apply lf an owner of o, Contractor'sLawnot ont pro,rptl onywhions cnywhoh,provi improvcathemogaed won dnwork iia LEE re not craffeed forrdehodut own are venni earof dmplatircd for salts. If. wnemploy¢s,ping uV rt�— or ithataudrotis sold within arta year of complve cntiuderhe huilder foron, peawncrf M1uiltln will have ,hc bnNcn of provin6 Nat he JiJ no, Wild or improve for purpose of i R havl the burden of 4it � q ysOOq JAN b L 3 1, as owner of ,he prnparty, am eaewsively commotio, with licensed aonoanors to st ue, the poet (Sec. 7Ik4, Business and Professions Code:) The Contractor's LF lyman owner of pent'who WilJsu rimprows melena. and cerise&���Tmqe ❑��D�j��/(�_ r(s)Iitto. rmanu. the Contractor[n1S.a&P OrI C for this WORKERS COMPE TION DECLA ATIO 1 hereby aff ter ondcr penalty of perjury one of the the fallowing declarations: I have and will maintain a Certificate of Consent to set Finsum for Work[i s Comic m smion, as provide) for by Section 37W of the Labor Code, for Ne performance of the work for which oris permit is issued. ❑ 1 have and will. maintain Wmkcri Camlverom on Insuonsc, az ¢yvited by Section 3700 of the Labor Cole, for the performance of Ne work for which Nis permit is issued, ' My Workers Compensaion Insurance carrier and Policy number ao: Carrico Policy No.: _ C17RI'WICA1'17 OF E%EMPTION FROM WORKERS' COMPENSATION INSURANCE. (Thissection need not rocompletedBNe permit isforanchundreddnllor (SII%1) of less.) I ccnify that in the parro mane of Ne work for which this Permit is iuocd, I shall not employ any person in any manner, ao as to become subjeal to the Workeri Compensation }awa of California. Date APplumpa NOTICE TO APPLICANT: IL after making this Ccnilic be of Exemption, you shn lid become subject to the Worker a Compensation Provisions of the Labor Code. you must furthwim cam or p ply with such provisions ohis e rm itshall be deemed savored. i CON bTRUCr10NLEN DING AGENCY - 1 hereby agency I'm the performance of ! affirm Nal Nem is aed which Inc work for which this permit Is issued (Sec,1091, Civ. C.) (Seaconstruction0s , Civ. Name Under's Lender's Address 1 aNfy that I have rcnd,his application and sunt that me above information is correct. 1 agree to comply with all city and county ordinances and stmt Daws reaming to building construction, and hereby oothorive repr outativcs of Nis city to enter upon the 1 ahove.manfoncd apartyfarimpectionrorposcs. (We a •eo save, indcmmfy an keep hariNcu Ne Ciry of CupcagCiain,n puZnnio liabilities,ju menu. Cos. and aspens hicF may in any way accrue aloiJy mcanscqu cc of,he granting ufmis r it. APPLIC SUN ERSTANDS AN ILL 1I.Y WITH ALL NON -POINT Issued by: Date SOURC R�GUL IONS. Re -roofs Type Of Roof gnnwrc of I`IIAYARDOUSRIALS DISCLOSURE Wild � Will me split icam of Lome building uaeopaat nova or handle havammm material as defined by the Cupertino Municipal, Code Chapter 9.12, and the Hcalm and Safety Code, Section zssn(a)'r All roofs shall be inspected to any roofing material being installed. 0y. �Nu prior ^ If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant ded equipment or devices which it hazardous air conmminanu as drlued by the Bay Arca Air Quality Management all new ITlatef1a15 for InSpCCL1011. strkt? ❑ Yes g Na l havemadmorm onome rials require mems under Chapter 6.95 of fire Cal for. dc, Sccdons2 5.15533and25534.lunderswdNa,ifNc Mrilding e a rcnan4 a it is my responsibility m no, ft' t nmant arm. A�..hio oa eamtt-rrmiaara c<mr ala ora nay Signature of Applicant llate �',aganl - All roof coverings to be Class 13" or better Data CITY OF CUPEkTINO Mo s-rsrL t;3,lYT 79 kITY OF CUPERTINO® DIV A-0� 1L-Pf2_>1) PERMIT APPLICATION FORM PN # -7 ow y v \-Y Date: 2Z! ZOQ3 Building Address:, Fee Description Mailing Address (if different from building address): '(Dl I I J g Ke"-rwor_�o AuE. CTN Owner's Name: O c v� — Bldg Permits . foot Phone #: Oct �% Z Contractor: )� �����► SoNQ ISS MECHANICAL License #: �' z X66 J c o rnn, ,�� �� Boiler > 500K to 1 M Btu Contact:,-�//1ne: J U7r� BBOILER4 Boiler> 1M to 1.75 M Btu Cupertino Business License#: llC Fax4087 TZas6 MECHANICAL BCONSTAX Building Permit Info: BUILDING BCONSTAX Bld 'Q Elect n BUILDING Plumb'�N Mech ❑ Job Description: Residential V a -r -10`'E 61W-1Q,03-72czn Dr_L %l McStrs% Commercial ❑ Sq.Ft. Floor Area: Hotel and Motel BUILDING $/Sq.Ft.: I BUILDING BELEC1000 Elec 600V <= 1000A Cost of Project: 1 2,S-0 BELEC1001 Elec 600V > 1000A Occupancy Group: Type of Constructin: �� Elec Svcs 600V <= 200A ELECTRICAL Please check this box if the project is a Energy BUILDING BENERGYADD second -story addition: ❑ 42�/��`/J7 `tT � 1 of 3 � 20 y v \-Y Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1 M 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 BMITIGATC Comm. Housine Mit. Fee BUILDING 42�/��`/J7 `tT � 1 of 3 � 20 1CCo CITY or !11 IDCDTIkin OITY OF CUPERTINO 0 PERMIT APPLICATION FORM �l L.` .� ID Fee Descri tion Fee Group e TIGATR uanti!B4 Res. HousingMit Fee BUILDING WMULTI New Multi-Famil Res MECHANICAL WSF&2F New Sf&2F Res Bldgs MECHANICAL WMULTI Multifamily Res ELECTRICAL COMME New Comm Electric ELECTRICAL COMMM New Comm MechanicalMECHANICAL COMMP New Comm Plumb PLUMBING MULTI New Multifami] ResPLUMBING ERTIMEIns ection Overtime BUILDING CKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE BldgPermit Fees BUILDING L BPFIXTURE Pbl Fixture PLUMBING BPGAS Gas Pi in S stem Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeal Fee BUILDING BPREPIPE Re !_ 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 PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAgtIIAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI A liance 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 Mise Apparatus ELECTRICAL BgEMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Devi ce/A aratus ELECTRICAL 'Falla>iI Za F�'ITY OF CUPERTINO* "TM OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREAIRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmd] 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 Ins ection 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 Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 DEC CK�yr.j.2ll � i Setif �l� 7 Cf, ���L°�i�'-1 �E� fl�r''' S•- t 1 CITY OF CUPERTINO r BUILDING DIVISION PERMIT CONTRACT OR INTORMATiON:¢, BUILDING ADDRESS: PERMIT NO. 03120120 3120120 OWNER'S NAME: PERMIT ISSUE DA'Z'E ft ROBERT K SANITARY NO. CONTROL NO. ARCIIITLCT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECII 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby af)rm that 1 am licensed under of hap Proems of Chapter 9 (commencing with Section Division Sof the Business and Pmfessinns Code, and my license is and and in full mmaand arraal. REPIPE & MS BATHROOM DRY ROT REPAIR License Class Conti Dam Contractor DECLARATION ARshall I I understand my plans shall lu used as public mentis use Licensed Professional OWNER-BUILDER DECLARATION I hcrchy offirm 'hal 1 am exempt from the Cenlmemr's License Law for the Following reason. (Section 7031.5, Business and Professions Code: Any city in county which'eyuires a )Broil u, eanslni Nim eer, prove, demolish, or repair any ..sruclure prior ' its issuance, also fcyuircs'he applicant for such permit to file a signed statement a that he is licensed phostrutto the provisions ofnlecnmmnars License Law(Cbapmr9 Sq. Ft. Floor Area Valuation (commencing with Section 7(M) of Division 3 of the Business and Professions Code) exemptor that he is themfrnm antl the basis for the alleged exemption. Any violation or Section 7)71.5 by any applicant for a permit short. the applicant m a civil penalty of m�iaa.�a,r� 3 MU J`Wn el 0 Occupancy Type P Y .of more than five mudmd dollars (150x). YP I, m owner of the properly, or my employees with wnges m lhcir.mle compensation, will dothework, antl We enali offer ed fur sale(Sec. to ad, Business RCgU1rCd IDSPCCtIOns he Core and Professions ldsdc: The Cammcton, License Law docs not apply to an License of rough and who aces such work himsclror through his pruriency who builds or ed that such improvements own provided that such impto own employees, are not intended forme hull mpleemd however, the building or improvement is sold within one year of completion, the thebuilding aid wits owner, err, builder will have the burden of proving that he did not build or improv for purpose or ose of salt.). k1, as owner of the property, am exclusively contracting with licensed contractors to evor centomct the et (Sec. ]1144, Business and Rofeasinns Code) The Cnnvactors Li ply to an owner of perry who huilds of improves themon,and ra r— IUB L` I � shot whocon cle.fo suchpmjectswilbac I ctar(s) licensed pursuant to the Commemrs //a—Or`41, Licen ❑la emit c, See. ,B&,P-C for ,In�i,so/ap.son Owner am l % JAN 2 6 2804 WORKER'S CO PE NELI Tpcbf __�1 �_ I I hereby afrml under penally of perjury one of the fallowing declarations: is p p II 11��D�Gv� V 1 have and will maintain a Ce ti ficate of Consent In at f-imum for Worker's Camper. satima as provided for M1y Section 377 of me Lahr Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 37M of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance tarsier and Policy num her am: Carrier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if the Permit is fnrone hundred dollars ($11X)) Lir less.) I certify that in the performance of the work for which this Permit is issued. 1 shall not employ any Person in any manner sn as In become subject o the Workers Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: IL after making this Cenircatc of Eacmption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith nam Ply with such Provisions muds permi,sholl he deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that Inert is a construction lending agency for the Performance of the work for which this permit is issued (Sec. 3099, Civ. C.) Lender's Name r Lender's Address 1 certify that have readall this application and stem that the shove information is correct. 1 agree comply with all city and county ordinances and start laws relating to huilfing consuuclion, and heathy aathorim'eprcsentatives of Nis city Retort upon the a f ebovetmcnlinned pony for Impcnion purposes (We) a e n save, indemnify an keep harmless the City of Cupcnino against liabilities, ju 991 a, casts antl expense hien may in any way acerae against said City in conical cc 6f the grantin6 of this it. A PPLIC T/fJN FIRSTANOS AN ILL MPLY WITH ALL NON-POINT Issued by: Date SO RC R GUL IONS. Re-roofs Type of Roof gnature of aEIAZA14DOU5 RIALS DISCLOSURE Dam Will Ne applicant or future building occupant store or handle hamodous material as formed by the Cupeninn Municipal Code, Chapter 9.12, and the Health and Safety coca, Section 25532(a)? [ ❑Yea 'RI Na All roofs shall be inspected prior to an roofing material beim P P� Y g g installed. If a roof is installed without first obtaining an inspection, I agree to Will the applicant or future building occupant use equipment or devices which remove hmamous air ctauandee nts as formed by the Bay Arca Air Quality Management all new materials for inspection. Dian"? ❑ Yes �Na I have mad the hit. men in rials reyuircmcnm under Chapter 6.95 of me Cal if., is Healf clyCuJe, Secdam2 85.2551) anJ25574. 1undemossihmif Neluilding does nal ofy a a tenant, I it is my rcsponii M1ilily to nndly t a<upanl nf'hc vatlu to famine t rtapeciofaCemrst,'Ce mar. Signature of Applicant Date 2 All roof coverings to be Class "B" or better 0 aammi..cd agate Data