05040059CITY OF CUPERTINO
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BUILDING DIVISION PERMI
BUI DING ADDRESS:
)444 q RTANTT7.V AW
CALIFORNIA BATHROOM R DE
PMYDO5040059
OWNER'S NAME:
PERMIT MET DATE
NE::
SANITARY NO. CONTROL NO.
4083609706
ARC HI'IECTrENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED COWMACTOR'S DECLARATION
- Job Description
1 hereby affirm that I am licensed unndder provision of Chaplcr 9 (commencing
ith section 7=) of Division 3 of the Business and Profcmion Code, and my license u
in full force and effect
ti "Pi( '11
BATHRM REMODEL/WINDOW (1)
Licca 1 a Lic.I
Dam'' I �T� conuaeror A _fy
REPLACE PLUMBING, FIXTURES SAME LOCATION
ARCHITECTS DECLARATION
I understood my plana aha) w used as Public mend:
WINDOW GFI OUTLET
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Convenors Licente Law for the
following anon. (Section ]0315, Basins and Profession Code: Any city or county
which requires a Permit to mows am, improve, demolish, or repair any suuelme
! prior m its issuance, also mquims the applicant for such Permit m ole a signed sucommI
Leto. Law(Cheptv9
Sq. Ft. Floor Area
Valuation
that heolicemcd lorauant 1. dw provisions of the Conmcmr''s
(commencing with Section ]()W) of Division 3 of the Busincer and Pmfesaion Cede) or
812000
: Nu at be eumpl therefrom and Ne basis for the alleged eremption. Any violation of
APN Number
Occupancy Type
Section 7131.5 by any applicant for a permit subjects the applicant an a civil penalty of
am more than five hundred dollars (6511).
❑ I, as owner of Ne propany, m my employees with wages a, their sole compenmtion,
Required Inspections
q p
will do the work and theswnure is not intended or offered fmsae(Sec.]041, Business
and Profession Code: The Co tuacmr, Liceam Law does not apply m an owner of
prepenywho buildsorimproves themon, and whoddessuch work himselfor through his
born such ements intended tarsals, e,
ate. �t
aftoroRemd
vemempro
however, thers,pmv, or i pr
bowever.oybuildingdeimprovementissoldwithin an yearofcompletion, the owmr-
old whin ame
��
builder will have the burden of proving that he did not build w improve for purpose of
frttiJ'—^'
� �
N.I.
((�� a!/r//}�sA61
❑ 1. as owner of de, property, am emlosively contracting with licensed eradication, to
Li -
construct the project (Sec. 7064, Business and Profusion Code:) The Contractors Li-
came w does not apply an owner of property who wilds or improves thereon. and
aLam
. I 1 J Las005
�i
MAY
who contracts for such projects with a eonmcmr(s) licensed pursuant to the Can=tors
License Law.
❑ l ace emano under See . B A, P C far this moon
I1fp1', )}1] /y�a��1/a+ya
W LU
Owner Dau
rw�' 1t�\�IfI�I'
�{ `moi
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
-
�,] 1 how and will maintain a Cervfinm ofConmm to aelf-intim for WorkersComp ct-
urian, as provided for by Section 3100 of the labor Code, for the peRommn¢ of the
work for which this permit is issued.
ktyC have and will maintain Workers Compensation Inuvna, u required by Section
-
J701 of the labor Code, for the performance of Ne wort for which this permit is issued.
My Workers Compenatif. Insurance carrier and Policy number am:
Carrier. S14 -_(-c rv1d Policy No.: 17-119
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
- COMPENSATION INSURANCE
(This section need not w complemd if the permit is form= hundred dollars (SIM)
Or less)
1 certify, that in the performance of the work for which this permit is issued, I shall not
-
employ any person in any manner art as N wcrme subject m the Workers Comp.nation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: IL aper making this Certificate of Exemption, you should
become subject in Ne Workers ComPeoction provisions of the tabor Code, you mum
: forthwith comply with such prmisinn or Nis perm it halt be deemed revoked
ON LENDING AGENCY
CONSTRUCTION
nn Wadding agenry for the performance of
is. construction
I herby alrmm that Nem is m
edfSca
' the work for which this permit u issued (Set 3097, Civ. CJ
ndrs Pierce
U aaera Aadrem
r
1 eanify that I have nese this application and sum that the above information is
' correct. I shred to comply with all city and .runty ordinances and sum laws ml.d.9 to
building construction, and hereby authorise rep esenuuws of thh city to enter upon dm
a ahov.•men0oned Property for inspection Purposes
(We) ague to save, indemnify and keep humorless the City of Cupertino against
9 liabilities, judgments, trim and expenses which may in any way aceroc against mid City
r in consequence of she granting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC Ric TIONS.
Re-roofs
Type of Roof _
Signature fflApplimmuccourachor .lDa> a
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant some or handle hmallous materia
as defined by the Cupertino Municipal Coda. Chapter 9. 12. and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yta ❑Nr
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it ha'aTdums air contaminants as dcfned by Iw Bay Arta Art Quality Management
all new materials for inspection.
District,
Q Ycs 0 N
I have read the lu aNrwsmamnals requirements under Chmmr 6.95 attire Califor-
outHealm k SafayCoda Sections 255U5,25533 and 25534.1 undcraund Nat flux, wilding
data not currently have a tenant that it IS my resprnihility to notify the ecamem of the
requi toto
Signature of Applicant Date
0"�� '�' ` 3�
All roof coverings to be Class "B" or better
0wner or Ahomed agent Dae
1 �a. •
CITY OF
CUPERTINO
"ITY OF CUPERTINO" o S, -o o�s,�
PERMIT APPLICATION FORM
APN #
361-
Fee Description
Fee Group
Date:
Building Address:
MECHANICAL
Mailing Adi&om building address):
l0 q 4 qS. BL trAleYA
1/P.
BBOILER2
Owner's Name:
L ej 6 3 0o./f-t
&Al
BBOILER3
Phone #
Contractor:
BBOILER4
Boiler> 1M to 1.75 M Btu
License #: Q '
C,4L/Folt,✓11r A-TN6.aO
trTQYA1
P s e1efJ
6q
Contact:
Phone:
uo8- k q 4.27-ij
Cupertino Business License#:
Af.Ly,✓
Fax:y
_ o-8797
BUILDING
Building Permit Info:
Hotel and Motel
BUILDING
BCONSTAXR
Bldg Elect
❑
Plumb
Mech ❑
Job Description:QFP6Qc'e p4,✓M6iA/e-
k/xr-wel JA^c
Elec 600V > 1000A
Residential A G F?
D ✓'r le+ T
Elec Svcs 600V <= 200A
Commercial ❑
Sq.Ft. Floor Area:
Energy
BUILDING
$/Sq.Ft.:
y S
BUILDING
BINVESTIGA
Investigation fee
Cost of Project: S
Occupancy Group:
Type of Construction:
Please check this box if the project is a
second -story addition: ❑
Project Size: Standard ❑
Large ❑
Major ❑
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 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 > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
1 of 3
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IN OF )h9
CUPEkTINO .I�r�. .5
Assessor's Parcel Number: 3 6� 0 4 C4
Name of owner. U NO G !i t-1,( Al61 �,A./
Project address. % 0 V V 14 5 OLA WP Y A+
Contact person.Phone. 4( `'L 3 b —`t700
Fax. `(ag 344�' 47 47
Net square footage of lot.
Existing
Square footage: First floor:
Second floor:
Garage:
TOTAL:
Proposed
Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y 0
On what floor(s) is work being done? J
Brief description of work. P,IZ UL flk4 a Ko f Q ti` V A ,x1 / T Y ,L 1.✓ i A.10 -D %A/
Code editions: 2001 CBC (Y - N)2001 CFC (Y - N)2001 CMC (Y- N)
2001 CPC (Y - N)2001 NEC (Y - N)
Effective 11/1/02
Plan Review Process Work Book Page -B-Revised 4/28/04
•Ii„ j � � i P,
V .✓L
APR 12 2005
S• From Planning &", Detailed & Quality CraRmanship
BA RM WMZ License No. 698718 HIC
MO, CHEN 1261 Lincoln Ave., #204 • San Jose, CA 95125
REMODELERS ®tq (408) 360-9700 • Fax: (408) 360-9797
r N
CITY OF
a[UPERTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
jottqq S. 6 L a (n r Avg .
PERMIT # . O '- 60
Z N z 83
OWNER'S NAME: b S a,✓ a i ,a rss
PHONE # � o $ - Zi z -3 y g
GENERAL CONTRACTOR C f3 X eZ
FAX #
I am not using any subcontractors: 4 AML ✓`— �^ CJI
Signafure Date
Please check applicable subcontractors and complete the following information:
60
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
CX
Owner/ Contractor Signature
4// L o r
Date