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03110023;oo 1d n _ n4� a t' l; .0 Og �p0 3=� z 22 c u�5 's A ./ CITY OF CUPERTINO �r �}rr�+ )A ��yY j� y •'yy�� "d4OyVITRX(-::TCS/� I�F�l4 A j N - BOI;.DING DIVISION PER UrLOINGADDRESs: CAROL & TOM MAKDISSY PERMITNO03110023 OWNER'S NAME: PERMIT ISSUE DATE CAROT. F, TOM MAKT)TRRY 3 PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: - BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION lob Description 1 hereby Off,. the, I am motor or pmvk urx of Chapter 9 (commencing . with Section 70(10) of Division 3 of the Business end Professions Code, mod my license is full Infunmree and effect. in REMODEL KITCHEN & BATHROOM/REMOVE WALLS Clan Lick DdN Contractor .�{{�� ARCHITECTS DECLARATION CIPJAL VV 1 understand my plans shall Ec third as public records s 2004 Licensed Profeaai... I OWNER -BUILDER DECLARATION APRei�'' 1 hereby affirm that 1 ore exempt from the Contractor's License Lew for my ]Ions.; Business and iu Corr: Any city or county following rcasoaPermit rte(Section de or repair any ewcwm improve, demolish. which a a cnnswn, alma improve, O 0 its issuance, Is.m the fors h Perish to signed imminent hapten he its Sq. Ft. Floor Area Valuation ensedprovenI to th,Cxe the nec )ofD�¢mion3oftheBduemraProfhwsCore)ry that ovisio s of Corsi an's (commincinWithSection7the duress and Professions Come) or (commencing it ]Xn r (c 36933024.00 thonion pt on. An Nal he I. exempt therefrom and Ne bum fur the alleged exemption. Any vinlalinn of n. he I. d the basis the alleged APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant m acivil penalty of not more than five hundred dollar, ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Ins eChODS will do the work, and thealructure is not intended or offered for sale (Sec. 7046, Business and Professions Code: The Conuactor's License Law docs nor apply to an owner of q p property who builds or improves thereat, and who does such work himself or through his own employees, provided that such improvemems are not intended or offered for tele. If. however, the building or improvement is sold within one year of completion. the owner builds' will have the burden of proving list he did not build or improve for purpose of sale.). ❑ 1, as owner of the properly, am exclusively contracting with licensed contactors to construct the the project (Sec. 7064, Business and Professions Cade:) The Cmarsctorh Li- cense law docs not apply to an owner of property who builds or improves amount, and ho Commcla for such projects with a contractor(s) licensed pursuanno the Contractor'a cense Lilun Ixe p under S . B & P C for this mason eec. O WORKER'S COMPENSATION D FARATION 1 hereby affirm under Penally of perjury one of the following declarations: ❑ I have and will maintain a Cenifcam of Consent to sel f-insumfor Workereoutput. ation, ar 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 Our labor Code, for the perfrrmance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number art: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSU RANCE (This section Decd not he completed if the Permit is for one hundred dollars (SI W) or lcsx) I cenify that in the performance of the work for which this Permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compens vtion Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Cenifcare of Exemption, you should become subject to the Worker's Compensation provisions of One Lebo Code, you must ' forthwith comply with such provisions or this Permit shall be deemed revoked. i CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is lending agency for the performance of ' s ed (See the work for which this permit is issued (Scc.3(Y37, Civ. C.) Lender's Name Lenders Address I cenify Nal l have mad this application and some that the above infmmatiun is ' contact. l agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above.mentioncd property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against ] liabilities, judgment, costs and expenses which may in any way accme againslsoid City in consequence sequce of the granting of this permit. AP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date U EREGULq]'IONS d� II ��^`s � Re -roofs ignm c of App ammeter e'� m 111CLOSURE HAZARDOUS MATERIALS Type of Roof Will the applicant or future building decupam store or handl. hazardous material defined by the Cupertino Municipal, Code, Chapter 9. 111, and the Health and Safety Cade, Sa0on2.5532(an ❑Ye¢ qN. All roofs shall be inspected prior to any roofing material being installed. 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 call hazardous air commounants u' reform by the Bay Area Air Quality Management all new materials for inspection. District? l u ❑ Ycs I have mad the hanolmomaerials requirements under Chapter 6.95 of the Califon his Health &Sefey Code,Sccrons 25505.35533 and 15534.1 understand thmifdte building does not my hay. a tenant, Nal II is my responsibility te nodiy the occupant of thc mgui Whicb must be met pririorw issuance cis Cenifcae ofaapan.y. Signature Of Applicant Date All roof coverings to be Class "B" or better wrier ter amm rixed agent Date 0 • 0 O*NER-BUILDER VERIFICATSN 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A. All the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked, complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers compensation must be on file at the City of Cupertino Building Department office. Type of work to be I declare under penalty of perjmT*at the above is true and correct. I have read and understand the Owner -Builder Information (r jjer''e side). �J / Property Owner's Signature ) ).ti Aidrtss9, Permit # Any chan -ees to the information Any on this form shall be submitted to the Citv of Cuvertino Build Department. Dear Property Owner: 0 City of Cupertino Building Department 10300 Torre Avenue Phone: (408) 777-3226 An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner -builder you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection' If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding, federal social security taxes, workers compensation insurance, disability insurance costs, and unemployment compensation i contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers compensation insurance. For more specific information about your obligations under federal law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your obligations under state law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner -builder building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N Street, Sacramento, California 95514. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, City of Cupertino Printed on Recycled Paper 4 � ammm")% CITY OF CUPEkTINO WITY OF CUPERTINO* v i i v o2-3 PERMIT APPLICATION FORM APN# 09 33 Oa Date:f/-5- Z�O-� Buildin553 Address: / �. R �© MECHANICAL Owner's Name -dive ol � 7m YYIall�sSj/ Phone # �o,C- �35•� �57� Contractor: 40,0n e , License #: Contact: BBOILER2 Cupertino Business License#: Building Permit Info: Bl Elec P] Mec 7o Description: Residential [-]U'"1 �,,�A ^ " mm i U Sq.Ft. Floor Area: BBOILER5 S/Sq.Ft.: Cost of Project: CAOccupancy up: r ype of Constructi BCONSTAX Ind/Off/Comm/Quasi Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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 > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING ? G� 1 of 3 _ , ama:�,Xla _- CITY OF CU PEkTINO &ITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCONIMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING 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 13PSPRINK 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 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cf n MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l 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 2 of 3 WITY OF CUPERTINO� Cin OF PERMIT APPLICATION FORM CUPER,TINO Ouantitv Fee ID Fee Description Fee Group 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 BREMSIGNAD Rmdl 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 MECHANTCAL AN MPERMTTFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • ki MIN FROIhKM DEPOT +408-000-0000 T-052 0 005/005 F -06T i '— 134 — -- / -- - — 24 —L 12 30 — moi% '—" - 36 30 15e ��1 I In] ff If 1J— 111111' 11 .. IIIA I�� �II• SSS36L WID I I� ; CD; (f0 j_J CIO (hi•0 i -- 36 30 ---/— 9 21 36 #` All drmerMCM d Size designations rre —. This is an original desgn a" mus a Scale :. maximum 0'^'9 no 9MM We su%cm to veri(manon on not be raleasad or copied unbe{ job aike and adjustment to fit jos HOME DEPOT applicable tee has been paid w joD CAROL COLLINS - conditions. ° placed,— CUPERnRO CAR -waive Una# 3 - +d08-000-0000 T-052 P.003/005 F -06T fit t I i — 105`1 -- 1P� 92 y Cj Ir tle&343d? SEBL!S2 FFROB36vo SS533L WO 8 34', d4 -in —.33 - All dimensans 6 size cesipnaoons ...- �w4 This is an alplrml daalpn and mull a-0 a Scale: maxiMum job eredadju toenttoatanon HOME DEPOT not De released or copied unless —Dn,v— job Me and adjustment to fit job aworable fee has been void or job AROL COLLINS C01tl^10n"10553 LA ROOA DR so -S WAAN. •G52 r - — order p�cea. CUPERTI o CA WSIDPLine e 1 OCT -31-2003 13:05 FROM -HOW DEPOT +400+000-0000 T-052 P.004/005 F -OST 128 /'6,-' 36 r'6,' S0 I i W31 .I II1 W3 36' 6LS i W3636. ; 6R S8 BTI llIl k I rl!JL� DISH, 24" 49_ l—i— --47,--- 324 33 _—_ 24 / — - -- 33 3 36 9286 Aa dimensions 4 sore designations me TAIs ,o an onpinv design antl must 1 a2a0dlel Scale ; maximum D" no, pben are outvcct to nniicoban on not be releosed or copied umeo5 pe6T1" HOME DEPOT CAROL COLLIRS job site and etljuftment to tit tOD iffer apPliC&blo fea has been ps,d or joD 10559 LA RODA OR i 08 XA6AigCO cond(dorm. ortler Puced. WaWC Lae x 2 _ -�_ —_._ .-... .... L ICUP@RTtNO CA OCT -31-2003 13:04 FROWNIX DEPOT i 52: I I 37n +408-000-0000. 1-052 P.001/005 F -06T 1 1 NOV jLETfN1 win ■ vst) 8'D _._... _ 72 30 . .. .. 9: 36 --/-.` 22 ....--�5i.: 48 .. ..._ i All a nlenaiana f➢ to tles�gnstiona This is an ongloal design and moat' SC810 : maAinum nw9 ��� fl'=en an subjeCl to veri/Gatltln en I. TnE �� -_ _ jobs tout aajuatment to In job HOME, net be released a Capvd unlasa •..i cOntliNons. aPPkable lee hes been paid orJob�ROL RODA �taB.�epN. order plsbed. t D553 LA ROOA DR. PERTINO LA WamC Line 0 3 TY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFOUMATION o " L. �J E:,"DINGADDRESS: cz,-A CAROL & TOM'- MAKDISSY PERMIT N903110023 E E: PERMIT LSEUE DATE NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDGELECT' PLUMB MECH t_7 EE 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am licensed under proviawas of Chapter 9 (commencing' with section 7011(1) of Billiton 3.f the Business end Pmfeasinns Code, and an, license is in full as a erre"' REMODEL KITCHEN & BATHROOM/REMOVE WALLS Li License Class Lic, x Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used os puhlie rcroNs Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from Ne Contractor's License Law ror the following mason. (Section 703 1.5, Business and Professions Code: Any city er county which requires a Permit to consumer, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit o rile a signed sutentent that be is licensed Pursuant d the provisions of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commm ting with Section 7") of Division 3 of the Business and Professions Cale) or Nm he is exempt therefrom and Ne basis for the alleged exemption. Any violation of 36933024.00 Section 4031.5 by any applicant for a permit subjects the applicant to a civil penally of APN NumberOccu ane T e not more loan force hundred do]$.. ($50W. P Y YP ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do Ne work, and the swclum is Nat intended or offered for sale (See. 7044, Business and Professions Code: The Connow ors License Law does not apply to an owner of Required Inspections property who builtla or improves Hereon, and who doeaauch work himselfor his own employees, provided that Such improvements are net m offered for este. offered �� �� ��® improvement arofintended not owner- however, Be building or den of ildofcomplefiomNrposeobale.). will have Ne burden of proving Nat ha did not build or improve for purpose of he "I" APR 0 6 2004 I, as owner of property, exclusively contracting licensed convectors t. cane ct the project (Sec. 7044, . Business CW and Professions Cade:) noContractor'sthermon. La cense Law docs not apply loan owner of property who builds or improves thereon, and werofnd who contractscontractsfor such projects witha convaeror(s) licensed pursuant to the Contractor'sContractor'sLicense BUILDING L 1 am se t under sec. B & P C for Nis ..on eDale%S^�—J WO KER'S COM ENSATION D ARATION 1 hereby a1Tum under Finally of perjury one of fie following declarations: 1 have and will maintain a Certificate of Consent o self-insum for Worker'sCompen- sation, as provided for by Section 3400 of me Labor Code, for use performance of the work for which this permit is issued. ❑ 1 have and will maintain Worker's Compenemum Insurance, az required by Section 3700 of the Labor Code, for Ne perfmmance of Ne work for which this pencil is issued. My Workers Compensation Insurance carrier and Policy number ate: Cartier. Policy No.: CERTIFICATE OF ID EMPTION FROM WORKERS' ' COMPENSATION INSURANCE (This section need not becompared Bshe permit Is for one hundred dollara ($100) less.) 1 certify Nal in the perrnrmance of the work for which this permit is issued. I shall net employ any person in any manner se, az In become subject to the Workeri Compcmation Laws of California. Dare Applicant ' NOTICE TO APPLICANT: If, after making this Cenifeme of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must - forthwith comply with such provisions or this permit shallIs, deemed revoked. - CONSTRUCTION LENDING AGENCY 1 hemby Mr. that Nere is & Construction lending agency for the performance of one work for which this permit is issued (Sec. 3M. Co. C.) Lender's Name - Under'sAddress I certify that 1 have read this application and state that Ne &bow information is correct. I agree to comply with all city and county ordinances and state laws misting to building construction, and hereby audamim MPresentetiws of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City o(Cupenlne against e costsand expenses which may in any way accrue againuaeid City in consequence n in conuqucnee of the graining of This permit. of the AP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date U EREGUL IONS //^`s Re -roofs Signet sof App an Cmnrazter ate HAZARDOUS MATERIALS ISCLOSURE Type of Roof Well the applicant or future building Occupant stare of handle ha=duras material az defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety de, section 25532(a)9 Yes All roofs shall be inspected prior to any roofing material being installed. future If a roof is installed without first obtaining an inspection, I agree to remove rWill the applicant or building occupant use equipment or devices which Ut ha'sardaus air contaminants as defined by the Bay Ara Air Quality Management all new materials for inspection. istricl? aaaa,s((((g ❑Yes ON. I have read the havaNnu11smatcrials requirements under Chapter 6.95 of Ne Califm- his Hca m & Safmy Code, Seelions 255115,25533 and 25534.1 understand Nmif Ne building docs not arty have a tenant. Na it is my responsibility m notify the a:cupenl of Ne ret which most hcam( pdmtnissuaneeor. cemBcawofaapaney. Signature of Applicant Date .i_s- Q, All roof coverings to be Class "B" or better water Or authorized agent Date