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04070140 CITY OF CUPERTINO 14'4 `>a ri_ Vii' err BUILDING DIVISION PERM CONTRACTOR INFORMrN .,, BUILDING ADDRESS: SAMUEL CONSTRUCTION ...".04070140 rTTP7T?TTN0 RD OWNER'S NAME: PERMIT ISSUE DATE NE: SANITARY NO. CONTROL NO. 4 ARCHITEC(ENGINEER: BUILDING PERMIT INFO �4�wa�L C�J7)S�Ti..�C i BLDG ELECT PLUMB MECH Z38 LICENSED CONRACTOWS DECLARATION 6 1 beaky affirm that I am licensed under provisions of Chapter 9(commencing Job Description with Sc UIIU)of Division Sof Jm Husirmssm��prDfcssiom CoJc.and myliccnx is -'i Ltf�nm%deer / -J TSG 77� INSTALL BATHR TUB (HARBOR BLDG) NA I e, ✓�� LK.N �1 Z;: DOW Co.'., E9 �!'5 ARCHITECTS DECI:91ATION gym, land my plans shall be used as public records SEP 2004 A. ; SEP L a Licensed Prufcssioml 5 OWNER-BUILDER DECLARATION �p a qqq) 1 hereby.sec that I em exempt from the Colic.Coca: License Law for the ILA ft p p -s' tf o o following trema section th 7(131.A Business and PmCssiuns COJe:Any city or county fL(�4"�3f' elL��' TNI m which mquires a permit to eomtruct.alter.improve,demolish,m repair any structure prior or its issuance,also requires the applicant for such permit to file a signed summer. that he u licensed pursuant 10 the pmvisiom of the COnlractm's Liave Law(ChaPmr 9 Sq.Ft.Floor Area Valuation ,,FG hearmcncing with section 7")of Division 3 of NC Business and Profcuiam Coda)or i Utes he is exempt darefman and dm 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 3WNS9tfaber00 Occupancy Type not mom Nan five hundred dollars(5500). ❑I.ssawoerof Ne propmy,wmy cmployeu with wages as dteir sole compcnsstion, will do the work end the swcwa is not intended or Offered forsale(Sec.7014.Business and Pmfesaions Code:The Conuacmr's Liccrve Law does not apply in an owner of Required Inspections prapcny,who builds or improve Ihemon,and who does such wmkhimaclf orBirough his own employes,provided that such improvemenss art nor intended oroRered forsala If, however,Ne building or improvement is sold with.one year of romped...the owner- builder will have Ne burden of proving that he did not Amid or improve for purpose of .in J. ❑1,as Owner Of the property,am=elusively contracting with licensed Convectors to consumer the project(See.7014,Business and Professions Cale:)The Contractor's Li- me Law dans not apply As an owner of Progeny who bilds Or improves thcmon,and who comncts for such projects with a cmat uo,(q licensed punot an,m the COnvacmea License Law. ❑1 am exempt under Sec. .B&PC for this mason Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby M.under penalty of perjury arc of the following declaration: I have and will maintain aCambium of Comem to self-insure for Worker'sCompcn- sation.u provided for by Section 37W of the Labor Code.for Ne performance of the work rot which this permit is issued. ❑1 have and will maintain Warker's Compensation Ince ,as rrryryvimd by Section 3700 of Nc labor Codc,for Nc perfarmancc or Ne work for ich An Affront is issued. My Workers Compensation lnsumna camS1r and Policy number am:p ('J Policy No.: � '`D` 1 3 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSUkscv (Thissection nead..t becomplemd if the permit is fortune hundred dollars($100) or re aJ 1 anify Nat in the performance of the work for which this permit is issued,l shall nut employ any person in any manner so az to berome subject to the Workers'Compensation Laws of California.Dar Applicant NOTICE TO APPLICANT:If,arm,making this Can runic of Exemption,you should become subject As Ne worker's Compemmion provisions Of Ne Labmr Code.you must .�Z foMwith comply with such previsions or this Permit shall be deemed invoked. Z O a CONSTRUCTION LENDING AGENCY ,e. .4. I hereby affirm that than,its convection lending agency for the performance of C 7 the work for which Nu Permit u issued(Sec.3097.ON,C.) UJ In Londcis Name = z 'lender's Address U Q 1 cenify that 1 have mad Nis application and sum that she above information is !i P correct.1 agree m comply with all city and county ordinances and sum laws relating 10 O U building cortswction,and hereby autharim mpmsenutixrs or this city to Omer upon the fbl alown-menumncd progeny for impaction purposes. LL (WO)agree to save,indemnify and keep harmless Ne City of Cupenina against H fq liabilities,judgments,costs and expenses which may in any way accrue against said City U in consequence of the granting of this permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOU RQyEGU�LATIGNS. l 5---_ r/�2 Re-roofs ware Of ApPli1 clot m / pp(A' S MATERIALS DISCLOSURE Type of Roof Will the ap,llcgaa r to building Occupant atom or luada haOuslou material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Hnalth and Safety Code.S�cO;oC525532(aY' , I All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove mit hayardous air contsminum as thermal by the Bay Area Air Quality Management all new materials for inspection. Disvict7 ❑Yes NN. 1 have aml Ne bmamous no renals reqummorms under Chapter 6.95 of the C difm nia Health&Safety Cole.Scom.25545,25533 and 2553x.1 unlcommad Last ifft h,ilding docs not currently hoc a rend.Nat itis my responsibility An notify An,ocempant33tf the mquimments which must M met prior m issuance ora Cera a(O .Pancy.. SlgnalUie Of Applicant Date 7�2y ° All roof coverings to be Class"B"or better ncr tar aDsa uthpnrcJ age W ch �Lbj L • cat a ;PPRovi�® .,DANCE WI i THE CITY C E N Ore r 4A CES DATE • S�:N set of plans and sp 'rfiand is MUST be is unlawful keot on the job at all times and i to make any changes or alterations on same LW without written permission from the Building Department,City of Cupertino. specifications Tl.c stamping of this plan and spec c TALL NOT be held to permit or to be an a»roval of the violation of any provisions of • Luq Cay Crdinance or State Law. Jul 22 2804 Yu u �'Y diV1'Y bY`L gyp} i�UMOpG DEPARTMENT Lov!� TD f)-r`'4 C/,e- maP score f W012K re o �- h2c.joGo� e �rct� -• a - c oc-c4 c F IC_4 'c 3 - �,e�laCe hem � �,b ut 4h ' C {tars ©L� -TUB EMO Gook �?yacti,d o❑ BLbL.11ln Le jPk I WS o S W" L ddo wed AAEod � will ii a � Pm,�� g ❑ a' ❑� ❑❑ m �❑ O m y u ❑❑ J G MAR-15-2004 MON 10: 19 AM AUTOMATED FAX SERVER FAX NO. 1 P. 03 eanx¢o nu(al[CLINC ................ �'tQ.v�1�"�1 ' i raKowLL i rxt�a v�l i i r[r[ICCTR"AWFUN IOC -� `. I 1 Ile+' vlrx av[a at raa rur cpmla I i Ir nuw 4voiI v Fir r Uvwx van•r[ y4al RRx Fig 3 Rough-in with water supply from the wall and floor drain. • OFFEM 1W=VMIL Nr OJIL, �l• r I� lal W 1fA A/�1 I I raaLf4 vYt :[ LLicliRld,Jena Wi Ir { I Im a FLEX �{ rrM mKa Ia[rcaw ° i u,� r a1MxK1 wsl[vVC Rr Iu ¢�n•ow r °•MY a xu Fig 4 Rough-in with water supply coming from the floor and wall drain. ® Note: A floor drain can be used with the water supply coming from the floor and a wall drain can be used with the water supply coming from the wall. 4 MAR-15-2004 MON 10: 19 AM AUTOMATED FAX SERVER FAX NO. 1 F. 02 ® Space See Fig. 1 for"minimum space"required and Fig. 2 for"preferred space" requirements. Requirements: I 21 21 I I _ ..t_--- Figure I Figure 2`� I Minimum Space Required Preferred Space U J� Rough-in Drain requirements: 2" drain—See Fig 3 or 4 for location. Requirements Hrequirements.Hot and cold water supply 3/4" m supply lines with on/off valves with 3/4"NPT female threads. We recommend 3/4" ball valve with 3/4"NPT female ports. Valves supplied by others. See figure 3 or 4 for recommended locations. For optimtun performance, dynamic pressures should be nominally equal. Maximum static supply pressure: 145 PSI. Maximum dynamic/maintained supply pressure: 81 PSI, Maximum supply Hot water temperature: Consult local requirements for maximum allowed supply temperatures. (Not recommended over 120'F) Electrical requirements: 120 Volts AC 60 Hz 25 amp (minimum) circuit. Codes in most locations require that circuits in"Wet" locations be provided with ground fault protection. (Tub is rated at 20 amps at 120 Volts) See Fig 9 for location of field wiring connection point. 3 - *CITY OF CUPERTINOW , 7o a CUP TYOF O PERMIT APPLICATION FORM Ahk APN # 3 / /s / I Date: Building Address: J Mailing Addre s (if hifferent fro building ddress): -- Owner's Name: S tir\ny�� }`off Phone #: (,40!') 2 s3- 4-3 ob Contractor: 50..vv�e L License #: g6'y_-7-12- Contact: 1ZContact: SaPhone: Cupertino Business License#: e- Fax: 2 z Building Permit Info: Bldg ❑ Elect ® Plumb RI Mech ❑ Job Description: iZE „ash-m LL �Q{ 1t 11-1. Residential ❑ Commercial Sq.Ft. Floor Area: S/Sq.Ft.: Cost of Project: Occupancy Gro p: Type of Constructio : Plen Ia project is a second-sto 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 IM 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 BELE 200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING B19VESTIGA Investigation fee / BUILDING 1 of 3 sly z . 3 7 WITY OF CUPERTINCS CITY OF ATION FORM .. CUPEkTINO PERMIT APPLICATION Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMIv1P New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING 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 Heater/Vent 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 BREMBUSWAY Remodel Busways ELECTRICAL . BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace > I 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 BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT . Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 Q- WITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmd] Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, 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 Inspection 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 Issue PLUMBING PPLBG Plumbing Fees foot PLUMBING ZADDCHG Address Chane BUILDING • I 3 of 3 CITY OF CUPERTINO �em 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp : Rng : Sub: Blk: Lot : APN . . . . . . . . : 32615130 . 00 DATE ISSUED. . . . . . . : 07/22/2004 RECEIPT 4 . . . . . . . . . : 26410 REFERENCE ID # . . . : 04070140 SITE ADDRESS . . . . . : 22445 CUPERTINO RD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER SUNNYVIEW LUTHAREN HOME ADDRESS . . . . . . . . . . : 22445 CUPERTINO RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SAMUEL CONSTRUCTION CONTRACTOR . . . . . . . : BEN SAMUEL LIC # 24634 COMPANY . . . . . . . . . . : SAMUEL CONSTRUCTION ADDRESS . 3427 FLORAVISTA AVE. CITY/STATE/ZIP . . . : SANTA CLARA, CA 95051 TELEPHONE . . . . . . . . : (408) 249-2828 GFEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL ----- - - - - - -- -- - - - -- - - - - - - - - - ----- -- - ------- -- - - - ----- -------- - - - - - BPERMFEE VALUATION 2 , 600 . 00 83 . 16 0 . 00 83 . 16 0 . 00 BPLANCHK PERMIT FEE 83 . 16 110 . 98 0 . 00 110 . 98 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00 BPTRAP NO OF TRAPS 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BENERGY PERMIT FEE 83 . 16 39 . 92 0 . 00 39 . 92 0 . 00 BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00 BSEISMICOM VALUATION 2 , 600 . 00 0 . 63 0 . 00 0 . 63 0 . 00 BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00 EPF.RMITFEE 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 --------- - ---------- ----- - ---- --- - - ----- TO'T'AL PERMIT 492 . 37 0 . 00 492 . 37 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- - - - -- ------- --- - ------------ -- CHECK 492 . 37 4012 TOTAL RECEIPT 492 . 37