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04110136 CITY OF CUPERTINO +'-� '^�' ''^�' "° BUILDING DIVISION PI; T �CONTItAC�'T®RINF�O:R ION `stiEhR� BUILDING ADDRESS: PAUL WALTERS BUILDER, INC PERMITNCb4110136 915 FERNGROVEno nWNER'S NAME: PERMIT ISSUE DATE BOB & MARY KIRBY 100 CRISTICH LAN11 11 /22 /2004 ONE: SANITARY NO. - CONTROL NO. (408) 371-1600 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 .0, LICENSED CONTRACTOR'SDECLARATION Job Description z u C I hereby affan that 1 am licensed under prevision of Chapter 9(commencing sive with Sectio970)11❑)o(Division Sar the Bueiness utd Pr&essimns Cma.and my license is mmnre , ee(A REMODEL BATHRMS (MS/HALL) 5 yh 2 Lice nsyQlasso Li `�+'� 4 e.a, �� .. ... .. gra Dam_j( Cummcrgr ARCHITE=D[CbyRA IT7 c-aand my Pia shall le used as pub iclecnNf D-ddV u.G Licensed Professional -" OWNER-BUILDER DECLARATION S I hemby m,um that 1 am exempt Imre the Ctunuacrofs License Law for the O o following reason.(section 7031.5 Business and Professions Code:Any city or county x$� which requires a permit un consumer.alter,improve,demolish,or repair any structure at—s' prior to its issuance.also mquira the applicant for such permit to lie a signed suiumenr that he is licensed pursuant o the provisions of the Commerce's License Law Chapter Sq.Ft. Floor Area Valuation wFo (commencing with Section 7")of Division 3 of Nc Business and Professions Code)or y this he is exempt thcmfrom and dm basis for Ne alleged exemption.Any violation of Section)031.5 by airy applicant for a permit subjects the applicant to a civil penalty of ct0 0 Occupancy Type not mom than five hundred dollars($500). I,as owner of the property,or my cmployco with wages as their sole compensation, will do the work.and the swnum is not intended or offered far sale(Sec.7044.Business Required etions and Professions Code:The Contractor's Licemas Law dors not apply to an owner of q property who builds or improves thereon,and whodoes such work himself or through his Own employee.provided tat such rat is improvements are am tented mpicti ed the Ow er- howeveroy the bis.pmviilding orimprouch imismldwitdin a=areno yetiddoroffered Ihetuwmr- buildc:will have the burden of proving thin W did not build or Impww for purpose of salol ❑ I.as owner of the pri am exclusively convening with licensed canuaterors to consumer the project(Sec.7094,Business and Professions Cade:)The Contracmr's Li- cmc law does not apply to an owner of propeny who Wilds or improves themon,and who tinwares for such projects with a coefficients)licensed pursuant to this Contncmrs .. List.Law. I am exempt undo Sec. ,B&P C for this reason 'ddnLOwneDam WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury,one of the following declarations: 1 have and will maintain a Cermicam of Consent to self-insure for Worker's Compen- union,as provided for by Section 37M of the labor Code,for the peAormame of the work for which this permit is issued. ❑I have and will maintain Workels Compensation Insurance,as required by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. My WoIllkkkeee///a Compensation lnsmrawe carrier and Policy numbers am: Card ,L.(�P sfs(g ��Pn_'U PoliNo'+'Ge�.#1 CERTIFICATEOFEttEMPr1GN FROM WO KE COMPENSATION( INSURANCE n7museetion reed not he completed Abspcmlit is fortune hundred dollars u1m) err lea.) 1 cmffv Nat in the performance of the work for which this permit is issued,l shall not employ any Peracen in any mannerso as to become subject o the Warfare Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should become subjeet to the Worker's Compensation provisions of the Labor Code,you mug .Jz IC%WRb comply with such provisions or this Permit shall W deemed revoked. z CONSTRUCTION LENDING AGENCY HFes-. I hereby affirm Nat there is a convection lending agency for the performanee of j G' the walk fur which his permit is issued(See.3W7,Civ.C.) Lender's Name / IY 1<nder's Address VQ 1 cenify Nat I have read this application and sum Nat the above information is correct I agree to comply with all city and county ordinances and sum laws miming to O U Wilding convection,and hereby allfofnrepresentatives of Nis city to enter upon the �tt1 above-mentioned property for imPcetlon purposes. (We)agree to saw,indemnify and keep harmless the City of Ca unino against liabilities,judgments,costs and expenses which may in any way aearvc against said City //� U in cmcoqucncc ofthm granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date lf/ S EOTTIONNS. - JyV Re-roofs / S�iyt 'unto A tea VContractm Date J HAZARDOUS MATERIALS DISCLOSUR1__ Type of Roof Will the applicant or fumm building Occupant store or handle havndous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25531(a)? \�,1 All roofs shall be inspected prior to any roofing material being installed. ❑Yes �"o will the applicant or future Willing Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit haa2mnus air contaminants as defined by fie Bay Area Air Quality Management all new materials for inspection. District ❑Yea <No,,��'''' . I have read Ne havamoat materials icyvimm lids under ClmPur 6.95 of the Card., ria Hcalth5 Safety Croda Sections 25505.25533 and 25534.1 undersand Nat if the building docs no i'rely aw a remain,Nat it is my nespOdubdity to curly tine occupant of the rtgmi rh(cntt which st be mel prior to issuance of a Ccrifcam o(Ocvupency. Signature of Applicant Date mer mramhmiwdagemr , Dam All roof coverings to be Class"B" or better CUP�,R`C1�o PED�G1)E c' ��P E PLIJIM a1NC> l Cope tvi . cE� o ®ATV SHO T�„`!54t` NAL ;��' . ra��,�,��yLa11U1rj n90f1ae A-7- l�ow�w, ° 1'p 1stiy B �ahangBs Isgipa tib ndkentten Peifii . Celt, avfOo ��g� �dttor Penmt�' 'Aa �OOZ Z /ION Cr✓�- CITY OF CUPERTIN� CUP TYOF O PERMIT APPLICATION FORM APN # o S�� Date: I I_ 2,2-01 Building Address: Mailing Address (if different from building address): Owner's Name: Phone#: gop R, t 255 O1So Contractor: License #: flUL�f�f 1..1�.5—I�i ULI.D INS 5U34I,'S 13 Contact: UL Wit Phone: '3-7.1-({,m Cupertino Business License#: "ISS Fax: 3 I - 3 2498 Building Permit Info: Bldg ❑ Elect Plumb Mech ❑ Job Description: ( emC-/ REPLF ce FIXr. C 5 IK) Residential X HAI.t BP ft mors wep, Commercial ❑ Sq.Ft. Floor Area S/SqFt Cost of Project: I r� � O/ upancy Group: A S Type of Const ction: Please check t ' box if the p t is �Lcond_slo6 addition: ❑ Project Size: Standar 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 Z 7Y 3� 1 of3 ,(YL ?0_ 17 Village Gla - 4083563007 p. l Dec 17 2D04 .9 18 AM PULP STUG10 INC 310-015-4990 No 0516 P. I • December 17,2004 Village Glass&Mirror r 15687 Los Gatos Blvd. f Los Gatos,CA 95032 —0 Re: Purchase Order#A 180—Job Name; Village Glass Please be advised that the products supplied to the above referenced project, 3089,is a laminated glass product made of two lites of 118 annealed glass and a thermoplastic interlayer,and complies with all ANSI Z97.1-1985 and Cat II safety standards. If you have any further questions regarding this matter,please do not hesitate to call us. S nccrely y 'f9 � ® -0a�fl/613� 3211 S.La Cienega Blvd.,Los Angeles California,90M6 •310.815.4999 T 310.815.4990 F bernard®pulpstudio.com City of Cup ertino � -� Plan Check Transmittal Permit# 04110136 Control# Project BATH UPGRADE Plancheck# 1 Address 915 FERNGROVE DRIVE FileDate 11/22/2004 Owner KIRBY Description BATH UPGRADE(MASTER) Plan Check Status (attach comments and return to Building with pian set) Plan Dept check# Date Due Date Staff Comment Date Approval? Buildin 1 1/22/200 '12/6/2004 POH 11/22/2004 E/I Assessor 1 1 1/22/200 12/6/2004 1 SENT 11/22/2004 RZ Additional Plan Check Fee ❑ Hours Planning Fees Housing Mitigation Fee Amount Heart of the City Specific Plan Fee Amount S CITY OF-CUPERTINOx 'earr*+t ,�:xbrw�a :'-' s # �' ; BUILDING o1vlsloN PERMIT CONTRACTaR INFORMA aION - - �. O ..E__l BUILDING ADDRESS: "' PAUL WALTERS BUILDER, INC PERMIT Ncb 4.1'10136 915 FERNGROVE DR R'S NAME: PERMIT IS'UE DATE BOB & MARY KIRBY 100 CRISTICH LANE 11 /22 /2004 PHONE: SANITARY NO. - CONTROL NO. - (408) 371-1600 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH I� 0 a O o LICENSED CONTRACTOR'S DECLARATION ' Ib Description <�Z C 1 hereby affirm Nat 1 am licensed under proOESCTIp visions of Chapter 9(commencing - n<m with Scetimy701111)of Division 3 of the Buri.and PI�fn.�iiioru Code.and myliccnsc is <�� in fall adc .t 4 Lie. REMODEL BATHRMS (MS/HALL) nFp Da¢ Convactgr -- - --' W / ARCHITECTS DECLIiRAADN7 ?c U rad my on shall W used us public�eeoNs 30G License prufessi...I 3 OWNER-BUILDER DECLARATION 1 Wmhy affirm Nat 1 am exempt from the Convenor's Liccnsc law for the 00 following moon.seedun7031.5.Business and Proreasiuns Code:Any city or county ms m which mquia permit m cnnswcL J her.immw,demolish,of repair any structure '^ prior in its issuance.also tequirrs theapplicant for such permit to Rle a signed statement ._ that he is licensed pursuant to the provisions of the Common's License Law(Chapter 9 Sq. Ft. Floor Area lua[ion ¢gym (commencing with section 7")of Division 3 Of the Business and Proreatmoa Critic)at i $ that he is exempt tberefrom and the basis for the alleged exemption.Any vimlaYon of - - Section 7031.5by any applicant foraPermit subjects the applicant oacivil Penalty ofer00 / OccU C TYP e nor more man five hundred dollars($500). Y ❑1.u owner of the propcny,or my employees with wages u th.ir sale compensation, D _ will do the work.and the structure,is not intended in offered for sale(Sec.7061,Business - and Professions Cade:The Contramars License Law dace not apply m an owner or - Required Inspections propony who Wilda or improves theson,and whodoes such work himreuorthrough his own employees.provided mat such improvements art not mounted mattered forsale.if, however.the Wilding or improvement is sold within ane yeu ofcomplefion,me ownv- builder will have the burden of proving Our he did oat Wild or improve for purpose of sal..). O 1,as owner of tiw propeny,am exclusively contracting with licensed comments to consumer de pmjcm(Sec.706,4.Business and Professions Code:)The Convacmes Li _ terse law does not apply to an mean of propany who Wilds or improves thereon.and who comments;far such pmjem wire a contractors)licensed pursuant to me Convactars License law. O l am exempt under Sec. ,B&P C for this reason , Data WORKER'S COMPENSATION DECLARATION w I hereby affirm under penalty of perjury arc of the fallowing deelarauots: , ❑1 haw and will maintain a Cenifieau of Cmsent to self-insure for Workers Compere Sudan,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 -" 37W of the labor Cade,for the performance of Ota work for which this permit is issued. MyWo I i.Cnmpeuauan Insurance camim and Policy number are: c.they// �/Al[LC��M411 TTT Pdi6N._/A 19 Set 4,9 i X RO CERTIFICATE OF EXEMPTION FM WORKERS' �� COMPENSATIO(N( INSURANCE (Thu section recd not becompleud ilyhep6rmit is formic hundred dollars(SIM) �nr las.) 1 unify ma in the performance of the work for which this permit is issued.l shall not employ any person in any mannerso as 10 become subject to tM Wmrterf Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:IL after making this Ccnificau of Exemption,you should become subject to Oc Worker's Compensation provisions of the Labor CaM,you molt .JO forthwith comply with such provisions mu permit shall he deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm mat mem is a construction lending agency for the performance of Q.' the work fur which this permit is issued(Sec.7097.Civ.C.) G0 Isndch Name =,z Leadels Atltlmss U Q I certify mat I have sad this application and show mat ted show information is ry P corms I agree to comply with all city and county ordinances and sue,laws relating to 0 U building construction,and hereby authorfm rep s.madws Of this city to enter upon one W above-mcmianed progeny for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Capetian against Iiabilitiu,judgmens,costs and expenses which may in any way setae against said City - U Z in corvequence of the granting of this permit. ^ APPLt ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - �.Date /lam S ��TIOINNS. -- Re-roofs 51 A eamACmumethr caw1, HAZARDOUS MATERIALS DISCL Type of Roof Will tis,applicant or future building occupant vert or handle hvsNous material defined by the Cuyenim,Municipal Code.Chapter 9.12.and the,Health and Safety SCNezss3z(a)7 Yes All roofs shall be inspected prior to any roofing material being installed. " Will to applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit havardous air contaminants m defined by the Bay Area Air Quality Management all new materials for inspection. Disuict? ❑Ye Nu 1 have mad the ha allous materials myuimmenis under Chapter 6.95 of me Califon iia Health&Safety Code,Sections 25505.35533=it 35536.1 understand mat if the building dos no m)y caw a tenant,that it m my sax onsibilky w m dly the eupanwf thc mqui which a INmid poor toissuance ofacen;rawo(acupancy. Signature of Applicant Date «�2 �o All roof coverings to be Class"B" or better ncr Lir aumomcd agcm �Daum