06030018 CITY OF CUPERTINO
BUILDING DIVISION PERMIT °�CONTRACTW NFORMATIQ-N
.3,..�,a, c@ex tura.
BUILDING ADDRESS: PERMIT NO.0 6 0 3 0 01 H
10223 S PORTAL AV
7ER'S NAME: PERMIT ISSUE DATE
ROBERT & LEONA PICKLE 03/06/2006
E:
SANITARY NO. CONTROL NO.
ARCHITECTIENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
app LICENSED CONTRACTOR'S DECLARATION
U C I homey-frim Nat I am licensed under pmvisions of Chapter 9(commencing lob Description
in
with
o¢e0nfraDivi on3ofdeBu ncssandProf�unsC de,mdmyliccnub KITCHEN REMODEL-NON STRUCTURAL-CABINETS
p�? LicenseClass /�• / G36 Lic.N�4�
g—a Dals, ?' Canvazwr (Z -' RAY LOGAN CONSTRUCTION PD FOR BL 3/6/06
'�� ARCHmC7SDECLA A 1 f
1 undersand my plans shall he used u public records
Dau
N In Lic nod c
3 WNER-BUILDER DECLARATION
I hemby.11n.Nat I am exempt firm the Conte nwa Licenu Law for the
a O following moon.(Section 703 1.5,Business and Profession Cade:Any city or county
5$ which requires a Permit to construct,alter,improve,demolish,or repair any structure n` -
-ZY Prim will istuarlCe.also Rquires Ncapplieaol for such pannlit to Mo.signed saNment — - -
< Sq.Ft. AreaVaIU Net he is liceasd pursuant m Nc provisions of Ne Conlrmun's Liuemc Uw(Chapter9 �OoS5 ,{{ � ' tbf7000
sc �(cummencing with Section 11100)of Division 3 of the Business and Professions Cale)or U� Vsssr`
$ Net he is esmpt morafrom add she basis far the alleged eaemp ion.Any violation of _
Section 7031.5 by any applicant for a permit subjens the epplicam to a civil Penalty of APN N er Occupancy Type
notmoreNanT,vahundred dollars($S ). 36909 1Q�b
1.a owner.(the ir ��..
❑ property. with madfa their sok7044.Baadese
will dodmwork,
ns end Ne he Conoiamti deratedLivens Lawddfmaahpply 70 a4,Business �r. it,
and ertywhions Cade:The Contemes. ndwho law does tit apply if an owner of I!j\Ift✓1'(''1]f Required Inspections
Own enywyees,pdaored Oilach imprandwha dmneuehendedm rtaredhrough his
wen employees provided pr suchimprovementsarenot intended mortared for sale, r.
however.the building or improvement is sold within one year of completion.purpose
Owner.
builder will have de burden of proving that he did not build or improve fm purpose of
sale t.
❑1,as owner of the prapeny,am exclusively contracting with licensed convectors to
construct she project(Sec.7044,Business and Professions Code:)The Contracures U.
cents Law does trot apply in an ownm of propenywho builds or improv-Nemm,",
who contracts for such Pmkcel with 0 commcwr(s)licensed pursuant o the Contractors
License Law.
❑1 am exempt under See. .B Be P C for this mason
ee Dem
WORKER'S COMPENSATION DECLARATION
1 hereby farm under penally of perjury one of the fallowing deelanlioa:
❑on.as pod wN for by
section
37 a ofCoaemws dlmifore(m Wmkets Co of me
workf r provided for mi Smuan 3100 of the Isbm Code,Ire tits performance of Ne
work for which this permit is issued.
❑1 have and will maintain Workeh Compensation Inwran¢,a required by Section
3700 of the Inbar Code,for the Performance of the work fm which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am: G
Catrier�TnT .�i. ...,.1 Polity No.: a
E CA EMPTION FROM RURf
COMPENSATION INSURANCE .
(ibis sctim necul Out hceo picuid ifthe Permit is froom hundred dollars($1W)
loss.)
1 comfy Nat in Ne performance of the work for which this Permit is issued,I shall not
ernploy any person in any manmr sn as in become aubjm,to the Workeri Cumpeast..
Laws of California.Data
Applicant r
NOTICE TO APPLICANT:If,afar making Out Certificate of Exemption,you should
become subjcn to the Workers Compensation provisions of On,labur Code,you must
.J,Z f n"with comply with each provisions or this Permit shall be deemed mvclud.
Z 0
ECONSTRUCTION LENDING AGENCY
Ihemhy-from Out dere is.conswctinn lcndingagmey for the perfurmanaxof
the work fur which this permit is issued(Sec.3097.Co.C.)
P. Us&,'a Name
.7 z Lender's Address
U0 I certify Nat 1 hoc read Ms apPlieauon and sou that the above information u
U. r comm I agree b comply wit all city and county oce
Ninens and sells laws relating to
0U building construction,and hereby anthoriaa rtpresenutivcs of Nis city w Cour upon the
}a above-mentioned property for impaction pury.ss
(We)agree to ave,indemnify and keep harmmis the City of Cupertino against
liabilities judgments.costs no expcosee which may in any way accone against midCity
t),Z, in of the grousing of this Permit.
'-"
APPLICANT
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
so CE REGULATIONS.
` 2 -- 3��� Re-roofs
Signa canuCo ustor % Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building uccuya LStma or handle haardous material
as defined by Ne Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cone.Section 255320)7
Ayes E]NoAll roofs shall be inspected prior to any roofing material being installed.
Will Or applicant or future building occupant me cquipmem or dcvicen which If a roof is installed without first obtaining an inspection,I agree to remove
emit Wardous air onaminantss a defined by the Bay Arca Air Quality Management all new materials for inspection.
District' P
❑Yos El No
1 have read the hasmh us materials requimmcnu under Chapter 6.95.1'the Califor-
nia Hal"Safety Code.Secumu 25505.25533 amt 25534.1 understand dw if the building
does not currently haw a meant,Out it u my responsibility w notify the occupant of the
to .torments which moll he met pnorw ismanx are Cemnam.rae.panoy, Signature of Applicant Date
S
o nera .' agent D„e All roof coverings to be Class"B”or better
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CITY OF CUPERTINO
I� 1 of 1 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36909003.00
DATE ISSUED. . . . . . . : 03/06/2006
RECEIPT #. . . . . . . . . : 33450
REFERENCE ID # . . . : 06030018
SITE ADDRESS . . . . . : 10223 S PORTAL AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . : '
OWNER . . . . . . . . . . . . : ROBERT & LEONA PICKLE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3349
RECEIVED FROM . . . . : RAY LOGAN CONST
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 47, 000.00 514 .08 0.00 514 .08 0.00
BPFIXTURE UNITS 1.00 9.00 0.00 9.00 0.00
BPLANCHK PERMIT FEE 514.08 686.04 0.00 686.04 0.00
BREMFIXT NO. FIXTURES 4 .00 4 .80 0.00 4 .80 0.00
BENERGY PERMIT FEE 514 . 08 246.76 0.00 246.76 0.00
BREMRECEPT NO. OUTLETS 5.00 6.00 0.00 6.00 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38 .37 0.00
BSEISMICRE VALUATION 47, 000.00 4 .70 0.00 4 .70 0.00
BUSLIC FLAT RATE 1.00 105.00 0.00 105.00 0.00
EPERMITFEE 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
---------- ---- ---- ---------- ----------
TOTAL PERMIT 1691.49 0.00 1691.49 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 1691.49 2590
TOTAL RECEIPT 1691.49
•
• • Community Development
10300 Torre Avenue
/' Cupertino CA 95014
`A . Telephone(408)777-3228
�JCITY I�TINO Fax(408) 777-3333
Building De utment
JOB ADDRESS: /0�Z,� p0 r7WI O p e PERMIT #
6 3� 0 �
O R'S N G e U n PHONE # b&-
GENERAL
GENERAL CONTRACTOR: Ca„ FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
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
6 r1
er Contractor Signature � ate
C CITY OF CUPERTIW
CITY OF AZ14IT APPLICATIONTORM
• CUPEIZTINO
J@VN # 3 (O
Building Address: Mailing Address (if different from building address):
Owner's Name: Ph ne#:
Contractor: License#: _
EC, 4 d ( 6 7
Contact: Phon . yfOdJ)6 Cupertino Business Licenset
G 1,1 Fax: 7
Building Pe 't Info:10
— — /
Bldg [- /Elect 9 Plumb I/ Mech C1�
Job Description/ �,—TC (��v eye o ykG n
Residential (Jd C Q ,b Q-r I uc 01ear Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Proiect: 7 oQQ Occupancy Group?
Type of Construction: Please check this box if the project is a
second-story addition: ❑
oject Size: Standard ❑ Large ❑ Major ❑
Quant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERl Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to IM Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS 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
•
I of 3
v =--. CITY OF CUPFRT�
�F' T APPLICATIONT"ORM
CUPEkTINO
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
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
13PBACKFLOW Atmospheric Vacuum . PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
/ MIXTURE PbIg 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 Lavm S ritMer/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER WaterHeater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
13REINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BRFNLkUdLAN 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 Re]o Furnace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREDMVHOOD Installation of Hood AfECHAIVICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res A liance 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
affisCIW OF CUPERTINO
CITY OF PERMIT APPLICATION FORM '
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMYENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL S mial Inspection BUILDING
BS)VW Swimming Pool BUILDING
BTERZP Temporary Power ELECTRICAL
BTED'IPPERA1 Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
/ BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mecb Permit Issuance MECHANICAL
PPERMITFEE Plambing Permit Issue PLUMBING
PPLBG —Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Commel Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
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