06060252 CITY OFCUPERTINOM7i'r< e � F
a� Bks
BUILDING DIVISION PERMITaCq,NT12AC,T(1R TiV 'l'1IM� T0131
BUILDING ADDRESS: D & D CONSTRUCTION PE'tMIT NO 06060252
21075 FREEDOM DR
OWNER'S NAME: PERMIT ISSUE DATE
Ak GERALD PAN 1447 HAMPTON DR. 2006
14 ZONE: SANITARY NO. CONTROL NO.
(408) 666-5298
ARCHIIECTIENGINEER: BUILDING PERMITINFO
'BLDG ELECT PLUMB MECH
i00 LICENSED CON'TRACTOR'S DECLARATION Job Description
I harcbW
y AlErm t 1 am Iiemd under provisions of Chapter 9(commencing
with Section 70fk0 of Division 3 afihc Business and Professions Cade.and my license is
± „ infallfamcandefrea REMODELING BATHROOMS - MASTER, HALLWAY, DOWNSTA
a n o$ LicenseClass Lk.P
s h Dau Contractor
ARCHITECTS DECLARATION
1 undersand my plans shall W used as public records
5yU
e G(•a Licensed Pmfessionai
`a OWNER-BUILDER DECLARATION
I I hereby a1Rrm that I am cumpt from me Com ones License Law for tM
COO following moon.(SeNom 703 t.5,Business and Prnfesaioa Code:Any city or county
$ which requires a permit to construct,alar.improve,demolish,m repair any suuetum $10000
prior to ire Issuance,she requims the applicant forsuch Permit to file a signed statement
£' that he is licensed pursuant to the pm.isions nano canumemra ueeaml,w(Cam pmr9 Sq.Ft.Floor Area Valuation
e (commencing with Section 7000)of Division 3 of she Business and Propellant Code)or
5
that M is eumpt 0v+efrom and de basis for the alleged esunpdon.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of U U. Occupancy Type
sat more than Rw hundred dollars(5500).
0 I,an oweaf of W property.or my employees with xges u ten mte compemdon,
MR M the work and the Mom is out amended m altered par raic(Sec.7434,4.Bummss Required Inspections
and professions Codeore, ns ns
:The Contractor's Lorne law alaant apply le an awor 9 P
property who Wilda or'unprmeamercan,andwho damsuchwort himselfor Wauth his
own employee.provided measures ierprowmenu are not intended araRerd forma U.
however,the Wilding of improvement is sold within arc year of comptetian,the awaer.
builder will haw the Wrden of proving that K did net Wild or improve for purpose of
role.).
Q L as owner of me property am eulueiwly contracting onth licensed contracars to
construm me project(Sec.7044,Businm and Profcations Cade:)The Co traemr's U.
tens taw dors act apply to an owner of Property who Wilds or improves mmus n,and,
who comma for such pmjecu with a conmector(s)Ikemd purwnt a the Canoicar9
Liters Law.
❑lamesemptundersec. .B&PCTctmiareamn
owner Dau
WORKER'S 001 :NSATION DECLARATION
41 1 hereby allhm under P<^aity of perjury one of the following declua0mte
❑1 hew and will maintain aCenifcau ofComnt to self-ioum far WarkcYs Compcn.
aetun,a provided for by Section 3700 of the IsbOr Cade,for the performance of me
work for which this permit is Issued.
❑1 have and will maintain WorkcA Compensation Insuram,a acquired by Section .
37110 of the JAW COM,far me peformance of me arctic for which mu permit Is Issued.
MY Worker's Compensation carries and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Ihisseedan need not W completed RIM Permit 4 foam:hundreddaOm(5100)
or lett)
1 unify that in me p almorenee of mO work fes which this permit is issued.l shall net
employ any person in my m snaerm an m became subject m t e Warkerf Campemtron
Laws of California.Dam '7 O
Applicant
NOTICE TO APPLICAND If,after makingCNCleae,of Exemption,you should
become subject a the Worker's CamPemtia proviaiora of me labor Code,you must
Q O formwim comply with such provisions or this permit be dnemcd rewked.
.Zi CONSTRUCTION LENDING AGENCY
4 I hereby affirm met mem is a construction lending agency for me Performance of
ai
to work fur which sols permit In Wood(Sec.3097,Of.C.)
W Q Lowest's Name
Lenders Add.
U Q I unify that 1 haw mad this application and sum Wt the show,inrctmatiun is
W correct.1%&Me to comply with all city and county Ordinances and sum laws totaling to
0 building convection,and hereby authodae reymmnuaiws or thiscity a cart,upon the
W show-mcntluncd property far inspccdon pugwms.
P. (We)agree to un.indemnify and keep hermless de City of Cupertino.'TZ"
rF"y h Wbilitie4judgments.cam and espouses which may in anyway acme against trialCity
U Z in comqueace of the sandal of this Permit.
^r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULATIONS. / 2�i�1✓C
�1 Re-roofs
Signature of Appl inUCamracm Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII Ra:applicant or ftuvo Wilding azupmt care or handle hazardous material
as MOnad by the Cupertino Municipal Cade.Chapter 9.12 and the Health and Safety
Cole.section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yns ONO
Y411 the applicant or future building occupant m equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air communana a Maned by the Bay Area Air Quality Management all.new materials for inspection.
District?
❑Yes ONO
I hm mad the Weardno materials mqulmmcnu underChapter 6.95 ofthe Califor.
.is Huai"SafelyCode,Sense.25505.25533 and 25534.1 undeamead that if the Wilding
dna not currently haw a mount.that It 4 my responsibility in notify de occupant of the
requirements which most k met prior to I$uance of a 011111catc of OSWp�y, Signature of Applicant Date
Owner or authorbmd a cot I Dam All roof coverings to be Class TIB" or better
CITY OF
BUILDING DIVISION PERMIT ^
s�n .rr ry. rs4^ '
BUILDING ADDRESS: D & CONSTRUCTION __..rNo06060252
21075 FREEDOM DR
NER'S NAME: PERMIT ISSUE DATE
GERALD PAN 1447 HAMPTON DR. 2006
ONE SANITARY NO. CONTROL NO.
(408) 666-5298
ARCHITECT/ENGINEER: BUILDING PER INFO
PL
BLDO ELECT PLUMBMECH
0 0 0 0
loo LICENSED CONTRACTOR'S DECLARATION IOb DCSCrIpIIOn
l I hemby affirm Nn
al I am limed under proen
visions of Chapter 9(commcing
with Section 7000)of Division 3af the Business ad Prokesiou Code.and my lkence is
+�a in fall fame aadef(.L REMODELING BATHROOMS - MASTER, HALLWAY, DOWNSTA
j =cc33 License Class Lie.g
�Contractor
it$ Dam ARCHITECTS DECLARATION
1m 77WA I..demand my plana Mall he used u en
public rtrN
6
s G Licensed Professional
3 OWNER-BUILDER DECLARATION
1 lerehy aRrm that I ae ucmpt from the Contractors License law far the
p O following recon.(Section 71131.5,Bushes ad Profd...li Calc:Any city or county $10000
$ which its ires a ketneeralso re construct.shut.improve,deermitt ore A sig anystrumum
_ZLa prior in its innaedpaluant10 the thovisios of launcthe Cahpennitwnkss signedstatement
ardor heuliansaJpurauua Nc provisions of the Consramr's License Law(Chapter9 Sq.Ft.Floor Area Valuation
E�S (commencing with Section 7000)of Division 3 of Ne Business and Pmfessiou code)or
that he is basis for the
lation of
_ Secti x703.5 Useeby cry applicantout therefrom wad r.permit=bit-alleged exemption.
ee.pplkm a CMI Penalty Occupancy Type
Penalty of
nut mom than ova hundred dollars(M).
D l,uawmrof NepmputywmyemploycuwMN muthelrmicrompemdon,
will do the work and Neswctum B notlnundW or offered Waste(Sec.7044,Business " Required Inspections
and Profeadu oCade:The Contractors License law doe,not apply m an.arcs of q P
.opany who bullda or improms thereon,end who dues such work himself ar through his
n
owamployeu,pm+dded Nm such imprmemenu am trot intended aroQrsW for Wes H.
however,the building or impmnar nt is aid within one year ofcompletion,the owner.
builder will have the burden of proving that he did out build or imptowe far purp cam of
sale.).
co 1,is aarcr of ct(Sec.
,Business sielusively canuacUng wW:)Theti mmecess m
conn La d project(See.nano .fi and Profudoui Cade:)71re Contractors LI-
who law doe out apply ja an owner of pmpeny who builds ra improwe thereon,and. ,...
who contracts faraueh projects with a mnmetoKU Iimrtmd pumum to the Conuactoh
Taw.
0License
am
D lam exempt..tire See .B&PCfar Nu moon
weer DateJO/
OR ER'S CO ENSATION DECLARATION /
1 hereby alnno under penalty of perjury ane of the following declantiwu: O/
D 1 ham and will maintain aeuti0owortomcat m self-insom forwoukers Campco- t0
scion,u provided for by Section 3700 of the Labor Cade.for the pedorreance of Ne
work for which this permit is issued
D 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700.(the Labor Code.for the performance of the work for which this permit is issued '
My Worker's Compensation Inrumme camicr and Policy number tie:
Carder. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(ihh seed.reed natbecampieted If the Permit Is forane hundred dollars($100)
m kat)
1 mrdfy that In the performance of No work for which this permit is Wood.1 shall at
employ any person in any mucor,an as to became abject to the Workcu'Compematlon
Law.of C.Iif..I.Data
Applicant
NOTICE TO APPLICANT.If,after making p1Y N!¢am of Facmptirn.you should
become Subject m the Worker.Compeoudo provisions of the labor Code.you muss
Q O forthwith comply with inch provisions or this permit shall x deemed revoked.
'Z'y CONSTRUCTION LENDING AGENCY
(r / Ibereby aM.Nm Nert 1..mnsuncdnn leading agency Can Ne pctfurmanm of
ai 7 the work for,which this permit I.issued(Sec.3097,Civ.C.)
W_0 Lender.Name
z Landers Add.
V QI Unify that 1 ham mad Nis application"sum Nu the above inkerstim u
Il.f~' co rtct.I agree to comply with all city and county ordinances and sum laws relating to
0U
building construction,and hereby authorim represcrutivca of this city to enter upon dim
W ahme-mentioned property for inspection purposes.
P. (We,)agree to um,indemnify and kcep hermlcas dm City o(Capertina against
r-r cn Iiabilitietjudgmenu.costs and aagahma which may in any way accrue,againstuid City
V z in consequence of the gmnting of this permLL
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date
SOURCEREGULATIONS,
"-2-y:rJi Re-roofs
Signatum of Applicur/Conuacm Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or factum building acmpanumm or handle havardous material
as dcflwd by dm Cupertino Municipal Code.Chapter 9.11,and Ne Health and Safety
• Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Dy. []NO
Will the applicant or future building occupam ban equipment or devlaa which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardnua air contaminants as dcrined by the Bay Area Air Quality Management all.new materials for inspection.
DivrkO
Dy. DNo
I have rand the huand.materials requimmeau under Chapter 6.95 of the Califor-
nia Health&SafctyCoEe,Smdons 15505,15533 cad]5534.1 understand that ifthe building
doe+at currently ban a tenor that It u my retpansibility m nmify the occupant of the
requimmcnu which must be met prior Or issumce of a Ccaificam of�a upancy.- of Signature of Applicant Date
G . Z4,
Owmr or...hmi'V.gout Data All roof coverings to be Class "B" or better
Ory OF CUPERTINO
J CUPEI�F PERMIT APPLICATION FORM
APN# �21 ^ M q. Date:
Building Address: lL `J f 1 Mailing Address (ifdifferentfrom building address):
Owner's Name: � f Phone#: �u 7 7
� 7 Gtr '7 —o(a
Contractor: License#:
Contact: 6(Ati Phone: 7 77 — pertino Business License#:
Fax: Z7
Building Permit Info: p Acp 6LX fo � ►c�1wc Q�w� rtc�J c
Bldg ❑ ( Elect Er Plumb (3-� Mech L9`o
lob Description:
Residential ❑ Commercial ❑
.Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: ( Occupancy Group:
W p nou —
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Laze ❑ 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
•
1 of
Is CITY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Grou •
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 Cess ool 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 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 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Mise Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
2 BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2of3
SIDE -COVER-SHEE .'
, RESIDENTIAL -,T .T
it
,
0-TTY OF
CUEQTlNO
Assessor's Parcel Number:
Name of owner.
Project address. � ir ck Y
Contact person. C Phone. —7 77 --6 61�
Fax.
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
• Are there at least two 10 foot by 20 foot clear spaces inside the gar N
Is privacy protection planting required for the project?
On what floor(s) is work being done?
Brief description of work. C4 '>7;41e f7 C
Code editions:2001 CBC (9 -N)2001 CFC �- N)2001CMC <V- N)
2001 CPC &7 -N)2001 NEC N)
ICED" PY
IN ACCOfDVC714%y u,
CQPERTINO CODES AND ORDINAKES
®FPIC
DATE E,
SIGN� THIS PLA bri7LOCop. A ON
set
of
I plans
An
ns
This and Vsppecific�aficns MUST
ne kept on the job at all times and it is un THE JOB AT ALL TIMES DURING
lawful to Make any changes or alteration's
on same without written permission from CONSTRUCTION.
,gigne building Dept., City of Cupertino.
Whe stamping of this plan and specificationS
3HALL NOT be held to permit or to be ar,
ipproval of the violation of any wonaW
,1 gnv rmv n,ri-nworp. or 1,7*to 1,%t
Plan Review Process Work Book Page-8-Revised 4/28/04
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