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07020147 CITY FJF CUPERTINO BUILDIN(;DIVISION PERMIT PERMIT NO. BUIL�it�c��l EsFLORA VISTA BAY CON.iTRUCTION 07020147 PERMIT ISSUE DATE OWNER'S NAME: BLESZYNSKI, RICK 852 BETIjIN AVE 02/27/2007 SANITARY NO. CONTROL NO. INE: (408) 87:3-1297 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH p p LICENSED CONTRACTOR'S DECLARATION Job Description U F I hereby affirm that I am licensed under provisions of Chapter 9(commencing :z� with Section 70()U)of Division 3 of Ute Business and Professions Code,and my license is ADD FLOURE S C ENT RECESSED LIGHTS AT EXISTING 2ND <a in full force and effect. j Z License Class Lic.A UNIT w Date Contractor F ARCHITECTS DECLARATION /� � C 'A yQ i w< 1 understand my plans shall be used as public records (;I yy r 'Qt a r t •� )Wd U.t- Licensed Professionary/'owlOWNER-BUILDER DECLARATIONVg ` I hereby affirm that I am exempt from the Contractors License Law for the p O following reason.(Section 7031.5•Business and Professions Code:Any city or county `e$9 which requires a permit to construct,alter,improve,demolish,or repair any structure o Z} prior to its issuance,also requires the applicant for such permit to file a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation ut- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $500 L 5. that he is exempt therefrom and the 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 A� Number Occupancy Type not more than rive hundred dollars(5500). 3260803-7 V[ ❑I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered forsale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does ROL apply to an owner of property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sa .)• 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and. W ho contracts f such projects with a conuactor(s)licensed pursuant to the Contractor's License Law. ; ❑1 am t o r S c. B&P C for this reason Owner C D- WDIMPRIG C PENS D•CLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,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 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Workces Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in dtc fo cc f the work for h this permit is issued.1 shall not employ any son' an i an r so)sl bec subject to the Workers'Compensation Laws of Cal fo Applicant NOTICE TOA LI ANT:If,of r 2a&gWis Certificate o emption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must 0 forthwith comply with such provisions or this permit shall be deemed revoked. z" CONSTRUCTION LENDING AGENCY C/) 1 hereby affirm that there is a construction lending agency for the performance of (Y> the work for which this permit is issued(Sec.3097,Civ.C.) QLender's Name z Lender's Address V C) I certify that I have read this application and state that the above information is LL O� correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building consauction,and hereby authonze representatives of this city to enter upon the above-mentioned property for inspection purposes. W W (We)agree to save,indemnify and keep harmless the City of Cupertino against C liabilities, w'abilities,judg nus,costs and expenses may in any way accrue against said City ,'z U in consequcnc of th nting of this pc 1 APPLI A U E TANDS ND L COMPLY WITH ALL NON-POINT Issued by Date � —Z SOUR NS. C Z' . Re-roofs SignatuR_ofApp1icant/ComiiLctW Data T of Roof HAZARDOUS MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes No Will the applicant future wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new IT aterials for inspection. District? Q Yes No 1 have read the haz us rials iremcnts under Chapter 6.95 of the Califor- nia Health of Sections 25505. 33 and 25534.1 understand"if tftc building t c ly have a tenant.that it my responsibility to notify the occupant of the hich be or issuanceefaCcrtirrcateefoccupancy. Sig nature of ApplicantDate All roof coverings to be Class"B" or better r authorized agent Date vVE.L) p,f r H 'NE CITY 0, NOF11`1 AIN ''ES RD RECEIV.E D of CT� 2 77 10P 7C:)BY I., W 4--j ti ic e&o V1 r',i5 F-2'#- S,,V 7- X'rej, F 7T llj�L 7' S lhfcT 77f4E' /RA,-;v-j 7-C HE* Cf) > CL)7 B&" (ZE) -PACT C/) IL PAO V CE;P 77/ z 0 7-1-41A1 EXIS71-N& MR LL 7 I,v 70 4 L '/�c 7-/N * X T 7 ' 5, 77,",N xv 72� IFI "7 OF Z-lq��Tq FIX 77�,5 , r �j3>, , { --------------- ;M ASTff4e-47-1,91V 7- 7 1/hl- g!, 7-d IL,#TliV ShfI5, z frtil Z>1 7 If -o Z�119wcl�� o ,0--, e-74-/- O/W A,,,=-,C- STh TH -r/T-LE- Re??,7- -3 4,vz) I I 7,-10,4 c-7- INS 7,5 C49AIDaI7­eiv�� LINE j1b4r1fq6 �VIR IWf� T 11 4r � 5CALE N07 TO sX,0* 4 06-104.1 CITY OF -'UPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: amyw COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32608037 .00 DATE ISSUED. . . . . . . : 02/27/2007 RECEIPT #. . . . . . . . . : BS000000558 REFERENCE ID # . . . : 07020147 SITE ADDRESS . . . . . : 10E12 FLORA VISTA SUBDIVISION . . . . . . . CITY CUE ERTINO IMPACT AREA . . . . . . . OWNER BLE;SZYNSKI, RICK ADDRESS CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM RECEIPT INTERFACE CONTRACTOR . . . . . . . : DONG SHENG HAN LIC # 26666 COMPANY . . . . . . . . . BAS' CONSTRUCTION ADDRESS . . . . . . . . . . : 852 BETLIN AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : (408) 873-1297 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL __________ __ ____ --------- ---- BENERGY PERMIT FEE 83 .16 39 .92 0. 00 39 .92 0. 00 BPERMFEE VALUATION 500.00 83 .16 0. 00 83 .16 0. 00 BSEISMICRE VALUATION 500. 00 0 .50 0. 00 0.50 0. 00 ELECTRIC SQUARE FEET 640. 00 51.20 0. 00 51 .20 0. 00 EPERMITFEE FLAT RATE 1. 00 38.37 0. 00 38_ ------ 37 0_00 ---- TOTAL PERMIT 213 .15 0. 00 213 .15 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------ CREDIT CARD 213 .15 MASTERCARD --------------- TOTAL RECEIPT 213 .15 VOICE ID DESCRIPTION VOICE ID DESCRIPTION __ __ -------- - 304 ROUGH ELECTRICAL .501 FINAL ELECTRICAL ENERGY 505 FINAL ELECTRICAL �.. CITY OF CUPERTINO OZ2-o 14:1 CITY OF PERMIT APPLICATION FORM CUPEIZTINO Date: Z_Z7 -0--� CPN# �� Nailing Address (if different from building address): Building Address: ©6! Z G�� 1// s� h��, F" Phone#: Owner's Name: g f eS y�s K�• License#: Contractor: � � (ivy Cupertino Business License#: Phone: �8- Contact: Litt Fax: �'��T'Z S Building Permit Info: Plumb ❑ Mech Bldg ❑ Elect El ,g�Ca( fLc� -'� R�e�5 �9 er . Job Description: Commercial ❑ Residential Sq.Ft.: Sq.Ft.Floor Area: Occupancy Group: Cost of Project: Sia �_ Please check this box if the project is a Type of Construction: second-story addition: El roject Size: Standard ElLarge ❑ Major El - - Fee Description Fee Grou Quanti Fee ID MECHANICAL Other A pliances BAPPLOTHER Boiler<= 100,000 Btu MECHANICAL BBOILER1 MECHANICAL BBOILER2 Boiler> IOOK to 500&Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu BUILDING BCONSTAX Construction Tax BUILDING l nd/Off/Comm/Quasi BCONSTAX ZBUILDING BCONSTAXBQ C'on. Tax for BQ one BUILDING BCONSTAX ,, Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile ELECTRICAL Elec 600V <= 1000A BELEC1000 ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL E lec Svcs 600V <= 200A BELEC200 Energy BUILDING BENERGY Add Multi BUILDING BENERGYADD Energy BUILDING BINVESTIGA Investigation fee 1 of 3 CITY OF C UPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Fee ID I'ee Descri tion Fee Group Quantity BMISCMiscellaneous Fee BUILDING IGATC Comm. Housing Mit. Fee BUILDING BMITNew Comm Electric ELECTRICAL BNU IGATC BNUCOMME New Comm Mechanical MECHANICAL BNUCOMMP N;w Comm Plumb PLUMBING BOVERTIME InMection Overtime BUILDING BPBACKFLOW Atrzospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE P Idg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS GaE Piping System Fee PLUMBING BPINTERCEP Inc.Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plai Check Repeat Fee BUILDING BpREplpE R.-pipe Of Fixtures PLUMBING BPSEWAGE Sewa a Disposal PLUMBING BPSEWER Sewers PLUMBING BpSpgLawn SprinklerBackflo PLUMBING �I{ BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Insta_1UAlter Water Pie PLUMBING BPWHEATER Plater Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/:�Unit> 10,000 cfm MECHANICAL BREMAIlZHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Zemodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN R:location of Furnace MECHANICAL BREMFURNOV Re to Furnace> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREM2%4RApp Re:u 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 Rcmodel Res Appliance ELECTRICAL 2 of 3 .µ� CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quanti 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 Sib Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING / BSEISMICRE c eismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM emporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC 13 usiness License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG PhLmbing Fee sq foot PLUMBING PLLONGRNGC Plannin LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING of 3