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6040100BUILDING DIVISION BUILDING ADDRESS: ARCHITEC IENGINEER: Z LICENSED CONTRACTOR'S DECLARATION u 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is = o in full force and effecL ' zLicense Lit, p " p Date Contractor ARCHITECT'S DECLARATION I understand my plans shall be used as public records .0 H Licensed Pwressional a ; OWNER -BUILDER DECLARATION _ X I hereby affirm that 1 am exempt from the Contractor's License Law for the O following reason. (Section 7031.5, Business and Professions Code: Any city or county 'o 9 which requires a permit to construct, alter, improve, demolish, or repair any structure [ y prior to its issuance, also requires the applicant for such permit to fide a signed statement C < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 " $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or r .. that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code. The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold 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 contractors to construct the project (Sec. 7044. Business and Professions Code:) The Contractees U. ccnse Law does not apply to an owner of property who builds or improves themon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations ❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen- sation, as provided 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 Worker'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 _ Cartier. a Cr / )=Policy No, 1 00 1 dr' — A • 1 CERTIFICATE OF EXEMP17ON FROM WO RS' COMPENSATION INSURANCE ( (his section need not he completed if the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must O forthwith comply with such provisions or this permit shall be deemed revoked. " 2 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued (Sec. 3097, Civ. C.) A Lendces Name 2 Lenders Address Q I certify that I have read this application and sate that the above information is " ^ correct. I agree to comply with all city and county ordinances and sate laws relating to Vbuilding construction, and hereby authorize representatives of this city to toter upon the W shove -mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against f,n liabilities,judgmcnts, costs and expenses which may in any way accrue against said City Z in consequence of the granting o this permit. "^ APPLIC NT UNDERSTAN AND WILL COMPLY WITH ALL NON -POINT SOUR REGUL ONS. Qi Signator ofApplicanVC ntractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building oct:upant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑Yes *0 Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes $,No I have read the hazardous materials requirements underChapier 6.95 of the Califor- nia Health& Safety Code, Sections 21505.25533 and 25534.1 undersand that if the building docs not currently have a tenan, U#t it is my responsibility to notify the occupant of the requiremenwWhich mist be met itior to issuance of a Certificate of Occaoarim Owner or PERMIT NO. CONTROL NO. BUILDING PERMIT INFO ELECT PLUMB MECH Job Description SFD REMODEL, NON-STRUCTURAL. KITCHEN, BATH, LAUNDRY, OFFICE, FAMILY ROOM, DINING AREA, MASTER BATH Sq. APN Number Required Inspections Issued by: Re -roofs Type of Roof on Type Date 3_-m All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better QTY OF CUPERTINO a00F PERMIT APPLICATION FORM 0-"00-75 CUPEkTINO APN # 3UU _ QO _ 0� O Fee Description Fee Group Date: IY $_a -,-? Building Address: L23 YYf (Z... Mailing Address (if different from building address): Owner's Name:�. a-m �A� Boiler <= 100,000 Btu MECHANICAL Phone #: e�6 Contractor.- MECHANICAL BBOILER3 License #: Contact: � 1_?4>L a.,l Pho S f? -3 p / ? Fax: 97 -0 - V7 --C-76-0 Cupertino Business License#: Building Permit Info: STD BldgMr,Elect I WV N UG r& - kt,14'lGl�1 baa' i�ww j 1 alp ovca�, n�sEr p,� Plumb Mech C `K Job Description - Residential Boiler > 1.75M Btu Commercial ❑ Sq.Ft. Floor Area: Construction Tax BUILDING Sq.Ft.: Cost of Project: Z66, cc BCONSTAXBQ Occupancy,oupj Type of Construction: BCONSTAXH Hotel and Motel Please check this box if the project is a second-sto addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ BUILDING BELEC1000 Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Apphances 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 > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 ✓©DwL 11 ITEMS OF 11 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36640010.00 DATE ISSUED.......: 04/13/2007 RECEIPT #.........: BS000000971 REFERENCE ID # ...: 07040075 SITE ADDRESS .....: 22336 REGNART RD SUBDIVISION ......: CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: GERALD MCINTYRE ADDRESS .......... CITY/STATE/ZIP ...: CUPERTINO CA, OPERATOR: kiersaw COPY # : 1 95014-4825 RECEIVED FROM ....: RECEIPT INTERFACE CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096 COMPANY ..........: TBD - TO BE DETERMINED ADDRESS .......... CITY/STATE/ZIP ...: , TELEPHONE ........ FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- BENERGY ------------- PERMIT FEE ---------- 1,499.04 -------------------- 719.54 0.00 ---------- 719.54 ---------- 0.00 BPERMFEE VALUATION 250,000.00 1499.04 0.00 1499.04 0.00 BPFIXTURE UNITS 7.00 63.00 0.00 63.00 0.00 BPLANCHK PERMIT FEE 1,499.04 2000.47 0.00 2000.47 0.00 BREMFIXT NO. FIXTURES 39.00 36.07 0.00 36:07 0.00 BREMRECEPT NO. OUTLETS 36.00 35.68 0.00 35.68 0.00 BREMVENFAN NO UNITS 2.00 52.41 0.00 52.41 0.00 BSEISMICRE VALUATION 250,000.00 25.00 0.00 25.00 0.00 EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 MPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 TOTAL PERMIT ---------- ---------- 4546.32 0.00 ---------- 4546.32 ---------- 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- CREDIT CARD 4,546.32 -------------------- M/C, EDWARD STEMPLE TOTAL RECEIPT --------------- 4,546.32 lofts Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 CITY OF Fax (408) 777-3333 CUPEkTINO Building Department --i I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date JOB ADDRESS:PERMIT 3,% 2 0-3,% # 7a -7s' BUSINESS NAME OWNER'S NAME: PHONE # Wt5 3 - 3 Cabinets & Millwork GENERAL CONTRACTO(;vj FAX # ( - --i I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date 7 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 7 Owner/Contractor Signature Date a-4spav n aulu�r. kaewoa T i aaviegol q apz :Ileus -a { uol�eweo}ut bZ eIl!1 I3elep a,+UuraW 1t71ae pua h- : jp d.o 0919-296 (0981 xvd £L£E'696 (099) : a 4dalal 9ueld -040-1;Sano ( uo ow 44048 V❑ ` -w ge n❑ _s _ 6E046 V❑'�+a!A alquswsy 44206£z09'O`d ! 4!1 J.P.ea0akl 9EEZZ a� 4 F s:apoo allIM11MV owaa aopa#ul �OuBisOa 1epueplsab 041 a $ a Ab d out j=k { 'G # L/ s � Z-1 NyAllNS b h ❑ ❑ In b ❑ ❑ E5 a- is ❑Ill❑ b 1 o 161- $s° I $&p RR � 3 l ig18s$gp � 8 aa �. a 51 9 g jg g#SgsY s%� Ages 9$§j gg 3 -fill S' � #3g $$ g X3`8 i�ri, i E44 M $� $ 1 �' Min :m§ 7 8 aiqk a �9�yg a ��g �k � S3T�I�i 5 §ag�$� $ �" SSPS$ 9#I� k k � $�ie"$��� �{�R l ° �dd� d�p�$ 2 I 3i?°=$ a'�'x � a ". g _ s � Iit $ i s ga $ � -3i g' +aWlaNawtl eulueep : toaguo❑ , ;au �egog o4 apza+: Pew•e a++UupW fipag Pue A++a❑ :. 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