08120076 CTTY OF CUP
ERTINO
BUILDING DIVISION PERNIIT SCO1YTRACTORINFORMATION'- .
BUILDING ADDRESS: PERMIT NO.
22284 PA64 AVETBD — TO BE DE
OWNER'S NAME: PER`RWr ISSUE DATE
N6:
A 9 8 CONTROL NO,
ARCHITECT[ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 bertby affirm Wt 1 arhn Iicena0 under provisions oI CMptor 9(eommmaing
cervi Section 700)of Division 3 often Business and Pro(wium Code,and my licence is
noH in full force andeffc RMDL 1 MSTRBTHRM(42 . 7SQ) , 1 GUST BTHRM(41 . 6SQ) {NO
j'/a License Class cony
Da¢ TSDECL RE—RF & NO STRUCTURE
ARCHITECTSQQ7W ARCHELTS DECLARATION
2< 1 undenund my Phos Hill h usere
d u pnbfit eoNs
ac.
S c.�n Licensed Professional
3 'OWNER-BUILDER DECLARATION
s� f 1 hereby anban Net 1 am exempt from the Convenors Licence Law for to
p O following manBodeen and(Section,703I.S,Bodeeand Prefesdom Code:Any city or county
m which tequuca•permit to...L alar.improve.dcmol4h.an repair any sounure
prior be its imuame.too require the applicant for catch permit to file a signod smemont
< that he islicented paramour to ft provisions of the Contractors Ucenm Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y�g (commencing with Section 7000)of Division 3 of the Rostrum and Prefessioru Code)or 20000
.-
than he u exempt therefrom and flan buts for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
.1 maro than five hundred dollar:(Scot). 35704032 . 00
❑I.asowm of the the
annum mmyemploym with mgt nNe'v oto7W.Redrew
.at m the work.tad ton he Cont ac urr intended ora w do for sale(Sec.7OLI,Redrew
of
aM Praretiam code The cmmetor,I.iQu:<Law mea ad'apply to an owner sur Required Inspections
property who bulks or ,i teprovsa theronn,and who does such it himself sur through his
own employers,provided thalaueh improvements are not intended Gamicared!male.If.
however,the building or improvement Is mid within one yeti of completion,Ne ow ar-
builder will have the burden of proving that he did net build or Improve for puryou of
talc.). / .
SQ.I/as atom of the property,a n exdusivdy contracting with Iiceaed ronvaaon to
cmuwct the pm)m(See 70ss,Boorman and Professions Cade:)Th Convxtora U.
dense Law does not apply to an owner of property who Wilda;or improv the em.and,
who contracts for such pmjecm with a eanvactor(s)Bcrroad pmuam in the Commerce,
License Law.
01 am exempt under see. .B &P C fn,Ni,moon
Owns / • Date Z /ZDO
1 O ATION DECLARATION
1 hereby.farm under pmad y of perJmy arc of the following dmlasations:
I hewandwillmaieuin aCer Ommof Comen(sarelf-insumfmWorker'sCompen-
tion,n provided for mby Section 3700 of the Labor Code.for the performance of to
work for which Nis permit is iuued.
0 I have and will maintain Warmer Compensation Iwuun¢,n regdred by Section
3M of the labor Code,for the performance of the work for which our permit is issued.
My Workers Compennma Wurmae carrier and Policy number im:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thts=am and hwtbecompmcd ifthe permit Isforaro hundred collars(SIM)
or leve)
I certify Net in the pe ormamr or the work for which Nu permit u immod.l shall rot
cmplry any pemoni ymarsu bbeeomc subject tothe warkm'Compewtion
Laws of Cilifo at
Applicant
NOTICE TO APPLICANT:If, making this Certificate of Eaemptiou,you should
become Subjectto the Workcra .Formation provisiots of the Labor Code,you masa
.,Q forthwith compsuch ly with ch pmvitW oms ce this permit shall domed ro
oked.
z CONSTRUCTION LENDING AGENCY
(-� Ihereby affirm lice Vert u a construction lending agency for to performance of
aNe work fm which this permit ts 097
issued(Sec.3 .Civ.C.)
ZLanders Name ,
z Lenders Add.
U Q 1 terrify that l have and this application and stem that the above information u
ty F corrom l agree to comply with all city and county anticancer and sum laws relating to
D U building commuct10n.and hermy'whorlSrepresentatives of this city in enter upon to
r f]] ahm-mentioned property for inspection purposes
f~ G (We)agree m save,indemnify and loop turnabout the City of Cupertino agilnst
h.v Vy liabilities.judgments,cow and expense,which may In any way accrue against mid City
(�z incotesacciame of the Starting of this permit.
^ APPLICA UNDPASfANDSµD 11'ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR G ONS.
2/ Gain Re-roofs
Signatureo vplicantCo m Dam
H or.bMATERIALStam.orhaRE Type of Roof /
Will the applicant mfuture Wildingeceupsutsmrcor and the
Health and Safety n deftoW by to Cupertino Municipal Code.Chapter 9.13,end to Halth and Safety
Code.Section 25533(.)7 All roofs shall be inspected prior to any roofing material being installed.
EYca Na
Will do.pplicantar tiro Wildin pantuceyuipmun(ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
I hvadam air conumiwhu o mT by the Bay Ama Al,Quality Management all new materials for inspection.
inert?
0Yo u yy
I have mal the hacadom mu d.11requiremewtimer Chaplerti.95cfNcCalifer-
nisHocaW&S9myCade,Sce 25505,25533u MN.Imtlrraa irthe bilking
dm not cumnt iu,e nen.nl it u my responsibility in rorty the osupant of lir
requirements hon Wmal r to issuance of a Cmulleme ofOccu' Signature of Applicant Date
L
ownercera ,rd agent Dam' All roof coverings to be Class'A."or better
CITY OF CUPERTINO
• 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35704032 . 00
DATE ISSUED. . . . . . . : 12/08/2008
RECEIPT # . . . . . . . . . : BS000006779
REFERENCE ID # . . . : 08120076
SITE ADDRESS . . . . . : 22284 PALM AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RYOJI WATANABE
ADDRESS . . . . . . . . . . : 22284 PALM AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2709
RECEIVED FROM . . . . : LILY C LI
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
---------- ------------- ---------- ------- ------- ----------
1BSEISMICR VALUATION 20, 000 . 00 2 . 00 0 . 00 2 . 00 0 . 00
IREMRESBAT SQ FEET 83 . 50 429 . 00 0 . 00 429 . 00 0 . 00
1STPLNCK HOURS 1 . 00 122 . 00 0 . 00 122 . 00 0 . 00
---------- ----- ----------
TOTAL PERMIT 553 . 00 0 . 00 553 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- ---- ------------
CHECK 553 . 00 #125
---------------
TOTAL RECEIPT 553 . 00
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CITY OF CUPERTINO
". t�r� ADDITION/REMODEL
. CUPEkTiNO PERMIT APPLICATION FORM
APN # 35-70 yo 3 a, U J Date: JIL—
Building Address:
�2—'-3i> Pcs,twi rive o GA. '. SP14-
Mailing Address (if different from building address):
Owner's Name: Phone#
c��e- ( y���) 2SzE37S
Contractor: Phone#:
.Jntl CDoIg64i Fax #:
Contractor License #: �f 5 U33
Cupertino Business License#:
Contact: Phone#:
Fax #:
Building Permit Info:
Bldg. Elect. Plumb. Q--� Mech. ❑ Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including addition)?
Remodel Includes Re-Roof: Yes ❑ No [4 .If yes list number of squares
Remodel Includes Structural: Yes ❑ No [V�
Do you have the pre-application planning approval? Yes ❑ No
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
b
Remodel: Kitchen Bath off Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Valuation: 2 C, dna Please check this box if the project is a
second-story addition ❑
Pro'ect Size: Express 9 Standard ❑ Large ❑ Major❑
Please complete relevant portion of the Green Building
hecklist & attach it to the application or if applicable, Green Building Points Achieved:
�eved:
Pic,, in plan set & the sheet index.
***For Office Use Only***
Over-the-Counter 0 Revised 10/01/08
.r
CITY OF CUPERTINO
`�=��'�
a ADDITION/REMODEL
CITY OF
CUPEkTINO FEE SCHEDULE .
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
ADDITIONS 1R3SFDADD
PLLONGRNGR Long Range PL
Planning/Residential
1R31NSP Dwellings Inspections B
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1R3REPPLNC Dwellings Repeat Plan B
Check
1R3HINSP Dwellings Hillside B
inspection
IR3HPLNCK Dwellings Hillside plan B
check
1R3HREINSP Dwellings Hillside B
Repeat Inspection •
1R3HREPLNC Dwellings Hillside B
R eat Plan Check
1R3ALTINSP Dwellings Alternate 8
Materials Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check
1PCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
Disposal System
1PRSEWER Sewers P
1BPSPRINK Lawn Sprinkler/Backflow P
1BPWSVCS Main Water Service P
1BSEISMICRE SeismicResidential B
1REROOFRES Residential Re-roof Each B
100 SF
DECKS 1R3SFDADD OR
1R3SFDREM • .
1DECKWOOD Deck (Wood)-Each B
(Each)
1 DECKRAIL Deck Railing-Each B
(Each)