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05100225
CITYOFCUPERTINO �r"r * t6wm».�a�reY,FL.e �"' ar �CuO ` BUILDING DIVISION PERMIT '�"WWR�4,G�TUR IrTFURM TI ear�,✓s'x .,<_.., .�, a�>�, BUIL DING ADDRESS: SUSAN DONALDSON P"ND 05100225 21940 OWNER'S NAME: PERMIT SUE DATE SUSAN DONALDSON 1 0/ NE: SANITARY NO. CONTROL NO. ARCHIIECTIENGINEER: BUILDING PERMIT INFO BLDGis t MECH O loo LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby afDrm that 1 sm IkvN aunder Provtsiau of Chapter 9(commencing P with Section 70f10)ofDiv1,1an S of Ne Businessand Pmfesslam Code.atb my licemc is in fall tow-and affect DECOR. FIREPLACE License Class Lim.N S t- Da¢ Cantrsolar ARCHRECI'S DECLARATION f I undentsnd my plans anal(be used as public means, J s c Licensed Professional OWNER-BUILDER DECLARATION ContsON Coe; i hemhy.(Bern that 11. exempt fon the Canous Co :My taw for do p o fallowing won.(Section 7031.5.Budnes+and Pofetsmm Cade:My city or county 5 which equina a permit re cores the,aiicr.improve,licant pars, demolish.m repair it to rile a siany ed southerndeem $600 printa mheislkeasedpumunits issuance.alto ntbiNcpmvGanaoftheComch uteslsenseLAW(C"Pmt9 Sq.Ft. Floor Area Valuation 5�$ (comment.SMWScNm7000)mDivWan3Oflhe Business and Profrshons Cade)ur - that M is exempt therefrom and use basis for des alleged,-^^pian MY violation of Semis 70513 by my applicant for a permit subjects the applicant In a civil penalty of r Occupancy Type not mom dun Bw hundred dollars 15M 1,as oxmr of um yoperty.m mY wPlayen Wth oyes u theksolecampewtian, will do thework.and the structure is Out attended or offered farsaie(Sm.7061,Business Required Inspections and Pmfesdlrac mu Cade:The CoLicense, roner a LiceLaw does t apply W an owof q P property who builds or i mprow,thereon,and who does such work himself or Nmugh his own employees,provided that inch improvements ase mtinnteed osoRered fatWe.IL however.the buildins w Improvement ts sold within ane your of comPletim,the owmr- builder will have den burden of proving that he did net Wild or improve for purpose of Like). ❑1,an aw s r N use property,am exclusively contracting with licensed contraarom W construct de Pmket(Sec.70th,Dean.and Putraslam Code)Toe Contractor's L5• came law noun,not apply he an owner of propenywho Wilds or improves chances.and, who contracts for seen projects with a cornmem(s)Ikestmd penwnt m the Contractors ldcenas Law. p� J ❑Iurnas In older Sec. .BdPCfar dna Beason Data 10-47- /h 1377CWORKERS COMPENSATION DECLARATION S 1 hereby a01res under penalty of perjury arc of the following declarations: I have and wilt sealants a Ceolfiosn of Cansemut self-home for WarkeelCmnpcn- M m,u pmvided far by Sndm 5700 of the labor Cade,fm the pmfarmuuce of ase k for which this permit u issued. I haw and will maintain Workers Carepemuion Imavuta,as required by Scadm of ase labor Code,for IW perfarmutcoa(the work farwhkh thin permit is issued Worker,Compewdan nusoruwa miff and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Tdsucti n need mthecompiced ifule Permit U farm hundred dollars(SIM) ar fns.) 1 certify that In the performance of the wart for which this Farrah is Issued I shall rot employ anyR ninanymanmrsoasnbecamc rvbjeetmddee Warton'Compens lawso(C IIf l& rD- AP-� AFPlleant NOTICE TO APPLICANT:If,afar making this Coolness:of Exemption,you should become subject le The Workers Compemsdon provisions of de Labor Code,you muss .,O forthwith comply with such Prevision W this permit shall W domed rooked. Z t;! CONSfRUCnON LENDING AGENCY (•" I hereby arum thio Nem is a comnatma,lending agency for the pMomana of a �. the wads for which this permit is issued issued(S 5097.Civ.C.) 0aQ Lenders Name z Leaders Addw U O 1 certify that I Mw mad this application and sue chis the aWw Infamatim is U. correct 1 agree m comply with all city and county onsieate c,and state is.missing m Q building construction.and hereby aothoda eprosonWives of this city to enter upno ase 6W. aheve-mmdomd pmpenY for inspemlon purposes. (We)&Sam be on.indemnify sed keep homeless the CRY of Cupenim against rrA liabilide,judgmcnn.emu and aspen.•es which may in my way some against mid City U Z in cOmequeMe of the Standing of this Permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date () - SO CE REGULATIO (/ "9 _ el4J' /D-48-DS Re-roofs i nuum o(AppIi HAZARDOUS MATERIALS DISCLOSURE or Dan Type of Roof Will de spplkant or future building Occup atuom orhendle haendo s material as de0md by the Cupertino Municipal Cade.Chapmr 9.13.and ase Health and Safety Mo.Section 25553(.)7 /// All roofs shall be inspected prior to any roofing material being installed. Cl You pDNa Will the applicant or future Wilding Occupant one equipment or devices which if a roof is installed without first obtaining an inspection,I agree to remove mit hammom air contamimnu as denaad by the Bay Area Air Quality Mutual;emeat all new materials for inspection. District? �/ ❑Yue ION. w m 1 have the loseaNu/u�mau Isis mcf immcros order Chapter 6.95 aflhe Ctlifor. nts Hcud"Safety Cone,Smdw 35303.35375 and 75531.1 undemxM that lfue building dem rot cummlyhaw a wool that I,u my sop bility a ratify tie a pmt of the req menu whichmme munpru tonsuaneaefacetifwnaroccepamy Signature of Applicant Date /o- -D DAll roof coverings to be Class"B"or better Owner er rvtharimd a en1 am Community Development ` J 10300 Tare Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEI�TINO Building De artment JOB ADDRESS: PERMIT # 0?l9*0 lfoCAEe oR , 7aS /oat-2.4 OWNER'S NAME: 6U519AI DoNAb. 5o N PHONE # 4 o g-9 9 - 3 93 GENERAL CONTRACTOR: p W E FAX # I am not using any subcontractors: /D -a S'-0,5- . Signature Date Please check applicable subcontractors and complete the following 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 r Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date WeYROU M-P 411,'MMI arTY0 CUPER_TINO IN E IN Assessor's Parcel Number: Name of owner. 5 0519,41 Q/t/A L Z) X0/1/ Project address., 9 J-F C> Dd, (2, U /1 , Contact person. 0 w/V E RPhone.-1-bo K — 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 garage? Y N Is privacy protection planting required for the project? Y N On what floor(s) is work being done? J W r B z7a&� %A:de Brie of work 0 Code editions: 2001 CBC (Y -N)2001 CFC (Y - N)2001 CMC (Y- N) 2001 CPC N)2001 NEC (Y- N) Effective II/1/02 Plan Review Process Work Book Page-8-Revised 4/28/04 art % CITY OF CUPERTINO CITY PERMIT APPLICATION FORM ' CUPERTINO IrN # / / o Z--I, Date: /0 O ,.� Building Address: Mailing Address (if different from building address): / 9 0 1fUC, kE Q Owner's Name: Phone#: Sus A, 0 s og - 296 - 3 93 Contractor: License#: O W C/ iio. Contact: Phone: Cupertino Business License#: 0 WAW E Fax: Building Permit Info: I NSTi4J- I Ng bEColQfj T/(/E F%REf��fid CE Bldg ❑ Elect ❑ Plumb [P— Mech ❑ Job Description: Residential ❑ Commercial ❑ Sq.Ft. Floor Area: q.Ft.: Cost of Project: �O© Occupancy Group _S Type of Construction: Please check this box if the project is a second-Story addition: ❑ ro'ect Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 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 BB0ILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUEDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTA)MQ 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 3 � � bz . CITY OF CUPERTINO , cuPE�i►vo PERMIT APPLICATION FORM Quantity Fee ED Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BN JCOMME 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 lnterce for 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 InstalVAlter 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 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY .. Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BRErg'URN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> 10K 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 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 CITY OF CUPERTINO ' CUP PERMIT APPLICATION FORM ERTINO Quantity ee 1D Fee Description Fee Grou SIGNAD Rmdl Si Add Branch ELECTRICAL MSIGNS Remodel Si Maz uee ELECTRICAL THEATR Theatrical Lighting Fix ELECTRICAL Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUfLDING BSEISMICOM Seismic Commercial BUILDING j1PLL0NGkRNGCP1ann1ng HCRE Seismic Fee Res BUILDING CLAL Special Inspection BUMDING IM SwimmingPool BUILDING MP Temporary Power ELECTRICAL PPERM Tempora BldgPermit BUILDING PSVCS Tem Dist Svcs ELECTRICAL LIC Business License . BUILDING TRIC Electricals foot ELECTRICAL ITFEE Elec Permit Issuance ELECTRICAL MFEE Mechanical s . foot MECHANICAL MITFEE AZech Permit Issuance MECHANICAL ITFEE PlumbingFermi- lssne PLUMBING LBG PlumbingFees foot PLUMBING GRNGC Plann1n LR Commel Multi-Fam PLANNING GRNGR Plannin Lon Ran a ResidentialPLANNING DCHG Address Chane BUILDING 3 of 3