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07060083
CITY OF CUPERTINO BUILDING bIVISION- PERMIT Ctl�eF�'R � T+QR I� }RMATIE�N PERMIT NO. BUILD+NG�An'kI LLER AVE #1 TBD - T D BE DETERMINED 07060083 OWNER'S N.SAME; PERMIT ISSUE DATE CORY FUGEMAN 06/12/2007 )NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O p LICENSED CONTRACTOR'S DECLARATION u I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description z with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE KITCHEN SINK t a a in full force and effect. ; z License Class Lie.# NEED CONTRACTOR INFO F Date Contractor ARCHITECTS DECLARATION m U ,a I understand my plans shall be used as public records G y Licensed Professional y OWNER-BUILDER DECLARATION j<M I hereby affirm that 1 am exempt from the Contractors License Law for the .00 following reason.(Section 7031.5,Business and Professions Code:Any city or county <m rZ which requires a permit to construct,alter,improve,demolish,or repair any structure 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 ;>q.Ft.Floor Area $10 0 Valuation H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 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 3 691403 i . Number Occupancy Type not more than five hundred dollars(5500) "y ' ❑1,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 for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of q p 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 sale.). as owner of the property,am exclusively contracting with licensed contractors to nstruct the project(Sec.7044,Business and Professions Code:)The Contractors li- cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts ucbq 'ects with a contractor(s)licensed pursuant to the Contractors Lice ❑I m exempt under Sec .B BcyC or this Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I 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 Workers 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 ono hundred dollars($100) or less.) I ce ',that in the rmanc of thc w9d f which th permit. issued,[shall not C. ploy any persa 'n ann so�s cc c o rs Compensation ws of Califon Da All NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. z O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of (x.� the work for which this permit is issued(Sec.3097,Civ,C.) aQ Lendces Name a z Lender's Address U C) I certify that 1 have read this application and state that the above information is ' correct.I agree to comply with all city and county ordinances and state laws rclating to Ubuilding construction,and hereby authorbe representatives of this city to enter upon the a above-mcntioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against Htz liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of thi r '^ ►-� APPLICANT UNDERST AND WILL L W H`ALL t{ 1 Issued by: Date 'V SOURCE REGULATI Re-roofs Signature of Applicant/ Dale HAZARDOUS MATERIALS DISCLOSURE Type of Rc of 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 s'iail be inspected prior to any roofing material being installed. ❑Ycso Will the applicant future building occupant rise 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 Ute Bay Area Air Quality Management all new materials for inspection. District? Cl Yes IMNc I have read the hazardous materials requ' nts under Chapter 6.95 of the Califor- nia Health&Safct Sections 25505,255 25534.1 understand that if building docs not c y have a ten ha ' is my nsihility to notify up t require nts which must be et r issu c ofitCertificate o cu� Signature c f Applicant Date n All roof coverings to be Class"B"or better Owner cnl Dale CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bl-,c: Lot: APN . . . . . . . . . 36914035 . 01 DATE ISSUED. . . . . . . : 06,'12/2007 RECEIPT #. . . . . . . . . : BS000001618 REFERENCE ID # . . . : 07060083 SITE ADDRESS 10;53 MILLER AVE #1 SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER COLY FUGEMAN ADDRESS 10-` 53 MILLER AVE #1 CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . COF.EY FUGEMAN CONTRACTOR . . . . . . . : TBI - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBI - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY PMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPFIXTURE UNITS 1. 00 9 . 00 0. 00 9 . 00 0. 00 BSEISMICRE VALUATION 100. 00 0.50 0. 00 0.50 0. 00 PPERMITFEE FLAT RATE 1. 00 38 .37 0. 00 38.37 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 47 .87 0. 00 47 .87 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 47 , 87 --------------- TOTAL RECEIPT 47 . 87 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 512 FINAL HANDI-CAP OWNER-BUILDER VERIFICATION 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 hirec to do: A. All of the work B. A portion of the we rk (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. I will utilize unlicensed person(s) ether 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. Person/Firm Address/City Phone Number Type of work to be performed ...............................................................................,..................................................................................................... I declare under penalty of perjury that he abid correct. I have read and understand the Owner-Builder Information (ttt%�Zz Property Owner's Signature: Date: Job Address: 0 "?j 1�3 M I w�- 2 '6%.4 C_VA�11,qo Permit# Any changes to the information provided on chis form shall be submitted to the Ci of Cupertino Build Department. CITY OF C+UPERTINO cuP��tNo PERMIT APPL=ICATION FORM D7U�0063 APN# 035 Date: Building Address: Mailing Address (if different from building address): Owner's Name: ,L` AM G A,4__rj Phone #: 40S,— l' n Z` Contractor: License#: 00 ontact: p Phone:�-j Cupertino Business License#: #TL 1,r42��/1 1 Fax: d5 y?L6 Building Permit Info: Bldg ❑ Elect ❑ F lumb L Mech ❑ Job Description: (' Residential 0�— f � N l� �t-�� K Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: ( 0 4 Occupancy Group: r Type of Construction: Please check this box if the project is a second-story addition: ❑ ?roject Size: Standard'L✓J Large ❑ Maj)r ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boi er<= 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 Bc iler> 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 Con>tax –Resi/Mobile BUILDING BELEC1000 Ele, 600V <= lOOOA ELECTRICAL BELEC1001 Elrc 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 cf3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM 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 1Vlechamcal— -- --- MECHANICAL BNUCOMMP l',few Comm Plumb PLUMBING BOVERTIME Ir spection 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 Incl Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plai Check Repeat Fee BUILDING BPREPIPE R,� i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lavin S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT A:t of Drain &Vent PLUMBING BPWATER Inst<<ll/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT I:einspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cftn MECHANICAL BREMAIRHAN A/C Jnits<= 10,000 cfm MECHANICAL BREMAPPLI appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT bighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relc Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC :gisc 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 RE location of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Rem Ddel Res Appliance ELECTRICAL 2 of 3 CITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Th,-atrical Lighting Fix ELECTRICAL RE VRNFAN— - ent Fan-Sin--le Duct MECHANICAL BREMVENSYS V zntilation Systems MECHANICAL BSCBLVD 3cb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING _ BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Tem orary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC :73lectrical sq foot ELECTRICAL EPERMITFEE Eke Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mevh Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Plannin LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING 3o`3 Community Development r. 10300 Torre Avenue r - Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 '7.UPERTIN0 Building Department JOB ADDRESS: PERMIT # a3 �3 M `ul C'vo�C't�,�� a ©off OWNER'S NAME:ATIJ t-L.#r ;P—Lc�Y Cr M PHONE # ° GENERAL CONTRACTOR: 4::57) FAX # I am not using any subcontractors: Z °117 Si;nature Date Please check applicable subcontractors and complete the following information: 21 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 Til Owner/Contractor Signature Date