03030107 (2) CITY OF CUPERTINOk,($�As >x+.ya""� n ���ttr. + a 'd
BUILDING DIVISION PERMIT �NsTRACT�R Il\FORMATI,
+:nOnt av 3AraiN Ivrn, a 45as. " s, :k3:&
BUILDING ADDRESS: PERMR NO.
OWNER A E: "GEPERMIT D
PHONE: SANITARY NO. CONTROL NO.
ITEC(ENGINEER: BUILDING PERMRINPo
0 ELECT PLUMB MECH
i o o LICENSED CONTRACTOR'S DECLARATION Job Description
O
f� I bmeby.M.Net IAm licensed no&,pmvisiom of Chap,,9 fer mmcncing � p
with Sectio"] of Dleision 3ofthc Beer myyrofcssiom Code,sect myllcen.ch
lo full forte e0. t // :97 -7 O
v P2 2r .J/-1
ones.:ct IJc.IL REPLACE 2 WINDOWS '
fB De` ARCHITECTSC`nIOx CONTRACTOR: ALEXANDER WERT CO�iSRUCT+IONC'
yp(`9 - nJ ,1 {tallMmedn rtsorl /1, c^A
M Licensed Profe �ATae�_ APR 1 1 2003
OWNER-BUILDER DECLARATION
a y I Maseereby.Rlrm on 1 1. exempt face the Cssion o :Any c Lew for the
p o wishfollowing meson.Permit
t 711]13,Business seri vee Profession Code;Any city or roomy ^
$� which rtqulro.permit m mnuruct.aloe hnprow,dcmdixM1,or rtpsir any suucwm
�1^
prior m its luuance.alw¢quires the applicant for such permluo Ole asigned statement _ -
pFG Wman,islicensedpmmmttotheprovWnnaoftoComm�ursL.iceromU.(Chapter9 Sq.Ft.Floor Area aluiition
ASAS rip$ (commencing with Section 70M of Division 3 of the Business and Plnfuslom Coed)at
..
that be Is exempt memtrom mol the bah fm the alleged exemption.Any vlobdm of
Section 7031.5 by any applicant for.permit subjects the applicant ro.civil penalty of APN Number Occupancy not mom than Hw hundred doled(1300). pansy Type
❑I.as owner of the property,or my employs"with wages an their sole comperuation, 35924019 . 00
will do the","ad me.uucture is act Intended oroaered for ale(See.7044,Business
and ProfG.lona Cade:The ComswaaM1 Wmme Law dean all apply to.n owner of Required Inspections
property who builds orimponvG therton,and who doe.suchwmkhlmsefor through his 101 - FOUNDATION
own employees.provided mat each Improvements arc not Intended mortared fondle.If,
how102 - PIERS
however,the ar e building or Improvement B sold within one)eof completion,the awner-
bmldar wW have Eta wrdan of proving that he did not wile m Improve for purpose of 10 3 - UFER
aloe).
1.e.owner of me 104 - REBAR
❑ property. e44, xclusively confessions with licensed Contractors
sonnet mean not pply00nmwenea andProfessionswh Wild.
Co"Incbrs Li• itis - ANCHOR BOLTS.
mhos law aces not apply e a owner of property who sed p or Improves Comm,and
who camncufm such projects with amnv.ctor(a)Iianxapunu.nuo the Conu.dor. 106 - SEWER & WATER
Lka.1eL`n'
0m 202 - UNDERFLOOR PLUMBING
LGempt under See ,Bk PC(or mh reuan
Owner Dam 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION 204 - UNDERFLOOR FRAME
I hereby alRrm under pmaltyaf perjury ane of the following demeretlont 205 - UNDERFLOOR INSULATION
Thaw and will malnulna CtNfinmofconaentroavdnsuro for Worker'.Compco- 301 — ROUGH PLUMBING
aprohthi ranee a Bluer.ao at me Labor coca ren On perrarm.na of On 302 - TUB & OR SHOWER
w which Ino.
I haw and will maintain Workers Compensation Insurance,as required by Section 303 - ROUGH MECHANICAL
)700oflhe laver Cau.(m m,pemmarweaof O.y7rt vOlcn W,permlU.insured. 304 - ROUGH ELECTRICAL
My We, o wUyBJmmen Groa,�mtl Popl ypa pq 305
- FRAME
k C'E PanT�9al1�Q �7'1003
CERnFI_CO Pe EMPnoNPROMwoRKERs 306 - HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
"rlose)CMtssection need not wmmpRwithe Parrott BIna mehunawdollars IS100) 308 - SHEETROCK
I roAfy that In the perlbrmanee of the work for which this permh H Issued,Ishan net 309 - EXTERIOR -LATH
employ any person inmymmnermGmbecame mbj=1to OnWorkmrcampeaxBan ' 310 - INTERIOR LATH
Laws of California.Date
Applica"I - 311 - SCRATCH COAT
NQTICE TO APPLICANT.If,after making this Contritionof Exemption.you should
become subject to the Worker,Compensation provisions of the Labor Code,you mGl 313 - ROOF NAIL
z� mnnwuncomply wimmcnpmaainn.nrmtsprmu.n.nwdGmetlmwka. 501 - FINAL ELECTRICAL ENERGY
CONSTRUc(IONLENDING AGENCY 502 - FINAL PLUMBING ENERGY
Iheroby-Horse that them lu construction lending agency for the performance of 503 - FINAL MECHANICAL ENERGY
x
the
work
for which thin permit Is leered(See 3097,Civ,C.)
34 Q under,"""` 504 - FINAL BUILDING ENERGY
j Z L naer1Aatlma 505 - FINAL ELECTRICAL
JQ 1mN(e WuIply mea W.ty and coon aMsoumm the swwiwsnalatim4
it, correct.coneinlagceetocomplywith yshymamanlynNimncewnd,tsulentrmoretm 506 - GAS TEST
Q buildingconauudiaamdhembyeumoemmprramnivesofWisdtyroenurupnntiu FIN PLUMB G
even-memlaned property for InapecUan purrrasea
H a (We)AS=m ave,indemnify and keep harmless On City of Cupertino against %FI L
InIlebilitle.,judgments,casts mtl expenses which may In any way acmue against Wd Cityis con of me Ir"Ihg of this permit.APP ANT NDERS(ANDS AND ILL COMPLY WI7H ALL NON•POIN( Issued by: ING Date
SO CE LATIONS.
—_y
6 Re-roofs 514 NAL PUBLIC WORKS
t rto ApplinnVConmctor De
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(alum building occurrent mom orhaedlc baudou,murine
an defined by the Cu aenher Municipal Code,Chapter 9.17.and the Health and Safely
Codn.Soden 25532.n All roofs shall be inspected prior to any roofing material being installed.
❑Yes �tMO
t..
he applicant or 1fuutu're building occupant use equipment or devlaa which If a roof is installed without first obtaining an inspection,I agree to remove
us air romeminmu u dofiecd by me Bay Arta Air Quality Management all new materials for Inspection.
, `yp1A�No
mad the MaN1M maudalnequimmenu underChepurl,95 of the Cmifor-
afctyCadc.3cd..25115,25533md25534.1undmwdlhalifthewiloing
ntlyhaw.unset.sen h B myouromihilhybatifywhichm Iwmm 'oruluumce.ractrUBG f currm Signature of Applicant Date
hmired agml ,m All roof coverings to be Class"B"or better
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . : 35924019 . 00
DATE ISSUED. . . . . . . : 03/20/2003
RECEIPT # . . . . . . . . . : 21388
REFERENCE ID # . . . : 03030107
SITE ADDRESS . . . . . : 7503 DE FOE DR
SUBDIVISION . . . . . .
CITYCUPERTINO
. . . . . . . . . . . . . .
IMPACT AREA . . . . . .
OWNER KARLTON PHILIP L AND JANICE M
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4306
RECEIVED FROM . . . . : ALEXANDER WERT CONST
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
�E ID UNIT-- - QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
----- ------- ----- ----- - --------- -------- - - ------- - -- --- - - -
BPERMFEE VALUATION 1, 500 . 00 77 . 00 0 . 00 77 . 00 0 . 00
BENERGY PERMIT FEE 77 . 00 23 . 10 0 . 00 23 . 10 0 . 00
BPLANCHK PERMIT FEE 77 . 00 65 . 45 0 . 00 65 . 45 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
BSEISMICRE VALUATION 1, 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
---------- ---------- ---------- ------- ---
TOTAL PERMIT 266 . 05 0 . 00 266 . 05 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- ----- -- --- ------ ------------ ------------------
CHECK 266 . 05 8777
TOTAL RECEIPT 266 . 05
•
: ATY OF CUPERTINO
CUPTy OF PERMIT APPLICATION FORM
N# Date: O
Building Address:
7503 e, Dh
Owner's Name: Phone#:
Contractor License#:
Contact: Cupertino Business License#:
Building Permit Info:
.Bldg Elect ❑ Plumb ❑ Mech ❑
Job d scup on: �n/_ce��,-W' •//, ��
Resideritial ` �IYU!" ommercial ❑
Sq.Ft. Floor Area: . $/Sq.Ft.:
Cost of Proje Occupancy Grou
Type of Co struction:
Quantity Fee ID ., Fee Description _ Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> l OOK to 500K Btu MECHANICAL
B801LER3` ' "" Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75MBtu 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 Investi ation fee BUILDING
BMITIGATC ' Comm. HousingMit.-Fee BUILDING
1of3 � 6u 0
a" CITY OF CUPERTINO
cuPE o PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMCILTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric. ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME 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
It 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 PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL .
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM 3USWAY 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
2 of 3
gr maCITY OF CUPERTIN�
of - PERMIT APPLICATION FORM
CUPEI�TINO
uanti Fee ID Fee Descri tion Fee Group
BREMPOWER Power Device/Anvaratus ELECTRICAL
BREMRECEPT pp"n Switch& Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Re air/Alter Heatin MECHANICAL
BREMEESArr Remodel Res A liance ELECTRICAL
BREMSIGNAD Rmdl Si Lrns Add Branch ELECTRICAL'
BREMSIGNS Remodel''Si s, Mar uee ELECTRICAL
BREMTHEATR Theatrical Li tin Fix ELECTRICAL
BREMVENFAN Vent Fan Sin le Duct MECHANICAL
BREMVENSYS Ventilation Svstems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inection BUILDING
BSWIM Swimmin Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Tem or' Bld Permit BUILDING
BTEMPSVCS Tem Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC PIPrtrinal qg foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot I MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee so foot PLUMBING
ZADDCHG Address Chane BUILDING
•
3 of 3
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S16fd-bJ : — cificat
This sot of Vi � an sQe
os kept on the jab t all tlmas and it is un
lot°�1u1 to fn51, e-. changes or alterations
Or,
same Withsut Wiltt§n permission from
+, bu bing Dapt:, city of Cupertino.
c y,n np P.�of thls plan and specifications
ermit or to be an
it , fl�l pa ha;d t® pof provisions
vil
o anany
Y
�n1r� Cit amt taf tha .
eXt4^ ��'inxnce or State law
7503 17 Q roe, 1�-
�o�ch
i lack w ino , Ca 9S70I�
l
I
JOB J&r�-�-a,n
• •
SHEET NO.� OF 1
CALCULATED aY '"— DATE 3 I S X03
CHECKED BY c DATE
ATS;
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