04070119 (2) CITY OF CUPERTiNO
BUILDINGDIvlslory PER CONTRACTnRINkORM?
�-
BUILDING ADDRESS: PERMIT NO,
AMERICAN BRANDS CONSTRUCTI N 04070119
NER'S NAME: ORT DR PERMIT ISSUE DATE
PHONE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo0 LICENSED CONTRACTOR'S DECLARATION
u p I Ac�my rijmt th I I.m Iicenucd ander Provi on of Chapmr 9(commencing Job Description
4zw with scrtnn1]�°'q Division3 of NC Dusinmzandl r suras coat.and my lmcnsc is
jaiIvcf`nuamea «em �� .-� PATIO ENCLOSURE (217 SQ. FT. )
Li is Lic.p
iFo Dam —2 y Co rmcmr �'
',' ARC ITE-CTS DECLARATION
�i e e 1 undersand my plans shall he used as,public records C�V�
yU C
Licensed Professional
S OWNER-BUILDER DECLARATION �V
<P I hereby
maso affirm that 1 1. exempt s an the Centimeter's r•a :Any c Law for the
p O whichm q moon.Permit
t ]BT Sit Business improve,
ve,demolish.
Cndr:Any my or manly
Km which its isssa Permit ncnnsarucl,alter.Improve,demolish,orerepairsig any structure
ar-'^
priortoitsissuance.oao mquime tWvisionam for such Contractor's
BlcaeLaw(ned ahaptert
le that mencingwitpursuant 70th)of visions ofofthe he 9 usi em nd Proclaw(Chapler9 Sq. Ft. Floor Area Valu tion
FIs-$ tommcne
(commencing anion t(and the
basis
r du NC Businexe and on.Any
vi Code)of
y�_ Nat he u exempt tMrtfrom and the boa for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pooh subjects the applicant o a civil penalty of 3 M1C111�IIlr)�er0 0 Occupancy Type
not more than five hundred dollars(SSW).
❑I.as owtterofthe property,army employees wit wages as theirmlecompemation,
will do the work,end Ne muaute is not intended mofrred hostile(Sec.]0a4,Business Required Inspections
end Profusions Code:The Conbacnri License Law does not apply to an owneer of q P
pmpeny who builds mimproves thereon,and who oarsmen work himself Or through his
own employers,provided Nat such improvements are not intended or offered for sale.If. -
however,Nebuildingorimprovement is sold within one year of completion.Ne owner- t
builder will have tot burden of proving that he did not build or improve for purpose of
.1e.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7044.Business and Professions Code:)The Contractor's Li
came Law docs not apply to an owner of pro,amy who Wilds or improve Nemon,and
who contracts for such projects with a eontractoos)licensed pursuant to to Commerce's
Liccnew Law.
C] I am exempt under See .B&P a for Nu noon
rear Dere `/
WORKERS COMPENSATION DECLARATION
1 handy aRrm under penalty of perjury ane of the fallowing declarations:
❑1 has and will maintain Serum.
37Mficam of Convent nCade,far for Worker ose of n- �)
anion,o provided for a Section 3]00 of to labor Cade,for one performanu Of Uw
work for which this permit is issued.
I have and will maintain Worker's Compensation Imuran,o required by Section
3700 of the labor Cade.fm she performance of the work far which this Permit is issued.
My/W it i, Coymp._ensation InsuraniMe carrier and Patey number am
Cure:l�A xCcA Pali<Y Na.: 3
✓
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not he completed if tW Permit is Roane hundred dollars(SIIX)
or Ito.)
1 certify that in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner or as to become subject o the Workers'Compensation
Laws of California.Date
Applicant J
NOTICE TO APPLICANT:If,arm,making this CemEcan of Exemption,you should — -
became subject in the Worker's Compensation provisions of the Ichor Code,you must
.J Q forthwith comply with such provisions or this Permit shall W deemed revoked.
Z CONSTRUCTION LENDING AGENCY
P.0 I hereby affirm that there is a eonsuuetion lending agency for the performance of
a the.,it fur which Nis permit is issued(Sec.3097,Civ.C.)
W ALender's Name
P, Under's Address /
az
V O 1 ramify that 1 haw mad Nis application and state that the above information is
W E' comraL I agree to comply with all city and county ordinances and some laws relating to
O V building construction.and hemby authorin mpremourtives of this city to enter upon the
Y' W above-mentioned property for imPcetion puMoma
r� gL (We).,me to save,indemnify and kip harmless the City of Cupenioo against
liabilities,judgments.costs and expanses which may in any way starve against mid City
V Z in Mmoruenee f,he granting of this permit,
.. APPLICANT,UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: to
SOU Rc,E EGULATIONS.
( , L_,� 7 ZO ( Re roofs
Signature of ApplicanJComishoor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appiicam ser[marc building uccupam store.,handle havarduus mm mul
o"i by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
da,Seeuan 25532(a)? All roofs shall be inspected nor to an roofing material dein
❑Yes akNa P P Y g being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit W armus air comnminams as defined by the Bay Area Air Quality Management all new materials for Inspection. B
DisoicR
❑Yes )fou
1 have mad Ne hazardous materials requirements under Chapter 6.95 o1 the Culder-
nia Health&Safcty Cada,Sceuoo 25515.n333 ud2553a I understand Nuif tbe Wilding
docs not currently have a want Nat it is MY responsibility to nobly the occurrent of the
mquimmc rots ,h uslbem tpdortn'ssu:ncc of a CcniOcam of Occupancy.
�l F Signature of Applicant Date
ow ormilm,rdimenl / Sia w Date 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: Elk: Lot :
APN . . . . . . . . : 35611016 . 00
DATE ISSUED. . . . . . . : 07/20/2004
RECEIPT # . . . . . . . . . 26375
REFERENCE ID # . . . : 04070119
SITE ADDRESS . . . . . : 8121 HYANNISPORT DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : DAVID & CINDY TAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4063
RECEIVED FROM . . . . : AMERICAN BRANDS CORP
CONTRACTOR . . . . . . . : HORST VON BLOES LIC # 22737
COMPANY . . . . . . . . . . : AMERICAN BRANDS CONSTRUCTION
ADDRESS . . . . . . . . . . : 1145 HAWKS HILL ROAD
CITY/STATE/ZIP . . . : SCOTTS VALLEY, CA 95066
• TELEPHONE . . . . . . . . : (408) 210-4945
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-- -- ------ ---- - - ------- ---- - --- ---- - --- - - ------ ----
BPERMFEE VALUATION 12 , 500 . 00 201 . 96 0 . 00 201 . 96 0 . 00
BPLANCHK PERMIT FEE 201 . 96 269 . 52 0 . 00 269 . 52 0 . 00
BREMPOWER POWER UNITS 1 . 00 47 . 96 0 . 00 47 . 96 0 . 00
BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00
BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
BENERGY PERMIT FEE 201 . 96 96 . 94 0 . 00 96 . 94 0 . 00
BSEISMICRE VALUATION 12 , 500 . 00 1 . 30 0 . 00 1 . 30 0 . 00
PPLBG SQUARE FEET 217 . 00 17 . 36 0 . 00 17 . 36 0 . 00
ELECTRIC SQUARE FEET 217 . 00 17 . 36 0 . 00 17 . 36 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMFEE SQUARE FEET 217 . 00 17 . 36 0 . 00 17 . 36 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---- ----- - - - - ---- - ---
TOTAL PERMIT 840 . 52 0 . 00 840 . 52 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
---- - - - - --- - - ---- - - -------- - - - ------- ------- - --
CHECK 840 . 52 5197
TOTAL RECEIPT 840 . 52
•
TREAT UNION HIGH SCHOOL AFRICT
589 WEST FREMONT AVENUE
SUNNYVALE, CALIFORNIA 94087
• 408-522-2200
Developer Impact Fee Compliang tiii ED
Building permits will not be issued with t rm etedly
Certificate of Compliance ' AM11
IUt 2 J cw4
Building Permit Application,m OF(;UPERTINO
C,��,�,� 6 r IPPARTMENT
The City of has received a request for IRWA i K'rm1 described as follows:
___ New Residential Development ___ Residential Addition (501 sq. f t. or more) ___Commercial Development
Name of Owner/Developer: �'w C`'8� T AK
Project Address: y� ^ "S Pb�( Lot/Parcel # 3 S 5 l l-C'16
Square Footage: lJ Description: S��c`" `-�✓" '
Permit /P / # I
t e: By:
jty Building Inspector
Square footage verified by the city prior t -issuance of a building permit; fees may be adjusted accordingly.
Feeder Elementary District: _ L,( —YY�
SCHOOL DISTRICT DEVELOPER IMPACT FEE
CERTIFICATE OF COMPLIANCE
The amhorirrd repreeeruative of it Fr mons Union High School District has reviewed the
City of �
Building Permit Request described above and hereby certifies that the developer or authorized representative has
met7th requirements oflhe District's eveloper Impact Fee equirement.s.
Dated: � By: �r /)
is
Fremont nion High School District
` td•�; Authorized Representative
':.�t IJi s••
t
Certificate notLJalid without
Distric
t Seal,initial„anilbate., Fee$ e�
Rev. 11/02 Facilities Planning--,-White City-- Yellow Requestor--Pink Accounting --Gold 111/02- 1,0001
Cupertino Union Schooltistrict N° 7975
10301 Vista Drive, Cupertino, CA95014 -
Tel (408)252-3000 • Fax(408)865-0326 Check Number:
Developer Impact Fee Compliance
The Cupertino Union School District has adopted Resolution Nos. 1403 and 1404, imposing
developer impact fee pursuant to Government Code 53080.
Building Permit Request
r�
The City of C � � v N O has received a r�n�Ne9 Inter 't db as follows:
Residential Development Project Co me riaTDeve p Yct
v..,�,✓JAL �� 2B!I
Name of Developer: 17A v�� -k-- "
Project Address: t t dr^^`S Oo,r
Description: U
1
Square Footage: Lot/Parcel#: X60_ «-0�6 Permit#:
r _
• Date: By:
/CityAuthorized Represertltative
Square footage will be verified by the city prior to is/ante of a building permit;fees maybe adjusted accordingly.
SCHOOL DISTRICT DEVELOPER IMPACT FEE
CERTIFICATE.OF COMPLIANCE
r
The authorized representative of the Cupertino Union School District has reviewed the
City of T7 NJ
Building Permit Request described above and hereby certifies that the developer or authorized representative has
met the requirements of the District's Developer Impact Fee requirement
Dated: / By:
Authorized Representative
Cupertino Union School District
r� �. EXEMPTED
0 " by
• C nis ac to not valid with ASB 1929
March 14, 1988
District Seal, Initial,and Date Fee$
Facilities Planning-White City-Yellow Requestor-Pink Accounting-Gold
( - •CITY OF CUPERTINO*
• CUPERF PERMIT APPLICATION FORM v /
APN# Date:
Building Address,, Mailing Address (if different from building address):
g
Owner's Name t Phone #:
Contractor: License #:
Contact: Phone: - Cupertino Business License#:
lkav�v Vow V?(oe Fax:
Building Permit Info:
Bldg ® Elect ® Plumb ❑ Mech ❑
Job Description: n
Residential F�] gv,Ctviu(Z42— Commercial ❑
Sq.Ft. Flookyea: $/Sq.Ft.:
Cost of Project:" Occupancy Group:
LY' 1.�� SU U
Type of Constru tion: Please check this box if the project is a
t5tto 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELE 200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
z637s�
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OCITY OF CUPERTINOO
CUP TYOF O PERMIT APPLICATION FORM
uanti 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
BNUCOMMP 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 Ston]/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
BREN AIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> 1 OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMNHSC Misc Apparatus ELECTRICAL
BRENfNRAPP 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
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WITY OF CUPERTINO*
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMYENFAN 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 Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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