04040102 CITY OF CUPERTINO °
BUILDING DIVISION PERM* 4CONTRAC�T. ORINk'0ORMA.7N
BU]MING ADDRESS: 11111N'04
ERMITNOO4 04 0102
OWNER'S NAME: PERMITISSUEDATE
MELV
ONE:
SANITARY NO. CONIAOL NO.
ARCHITECUENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
L_00 LICENSED CONTRACTOR'S DECLARATION
n❑ 1 herby affirm Nal 1 Am licensed under provisions of Chapter 9(commencing Job Description
'IW with llform IXp)of Division 3of NC BusirraaeM Professivat Cade.and mylicerve is ��'��'■ ss ®
n-Cin Tense Clcendcffat. REPL/ADD LIGHTING ■`bi■■A 1
Dannm Clus Contractor
X—C Dale ARCHITECT'S DECLARATION
.v I understand my plans shall hu
e used public meet& 1,��u4 IMTTAI
seater" Licensed Professoatl
3 OWNER-BUILDER DECLARATION
. C I hereby.(Sero on I em tempt from the Contractor's :My c taw for the
p O following ration.(Sinton 703 1.5,Business and m.de ons Cod,:My city s moony el
m� which its ram a o,also re cnno,the allay,impmw.h Perot t ri repair any moment
prim to les issuance,also nL to the the applicant for such pmmit to nlc a signed sutem,m
es 1- thalt hs,(commeliansithSection70the 0)ofDivis.ofNeCononessalJcenselaonsCodmr9 Sq. FL Floor Area Valuation
y ti-$ (ed Ins is camp, omfon7000)th Division BusA,cdreaand Pm Any Amino
or
�.. Net he V exempt Ibuefr.m and the btu for tite alleged exemptim.Any violation of r-A,rswrn,,T.�ar�
Session 7031.5 by any applicant for a petrol,subject the applicant to a civil penalty of 3 Jin W 40ja*et0 0
..tm.m Nan Bw hundred dollars fi WL C y ,ype
01.uownsofdmp.pty,mmyemplo5 withwarnuIhedsole MMN=don,
will an rise we&and do,swetumisact intended oroffend for sale(Sec.]t3W,Business Required Inspections
and Professions Code:The Contractor's Liceme,Law dans
not Apply to An owner of qU�4
property who builds or improves thereon.and who does such work himmlfor through his MAY L 2
own employes,provided Nat such impmwmenu art not imeMd molferW farsale If,
however.the building or improvement is sold within one year of completes.the owner-
b It.). will have the burden of proving Net he did not build or improve for purpose ofU I Ira'
t� Q
It.). tQlA�ry�l
1,a owner of the property.am exclusively contracting with licensed contractors m
co on dte pmjem(see.7W,B.i"...and Propos..Cade:)The Comm mmri U. _
came law does not apply m an owner of property who builds or improv daemon.and
who contracts for such projects with a conga ctor(s)located pursuant o Ne Conuactor'a
Liccrvc law.
❑luno pt under Sec. B&PCfqdAisoi&&om
WORK CO PENSATION DEC N
I hereby afn=under penalty of perjury one of tk following daclantio.:
1 haw And will maintain aCerdOate.f Consent to self-insure far Workers Compen.
sties,
As provided for by Section 3700 of the labor Code,fm Ne perfomrsnm of the
wart for which this permit is issued.
them end will maintain Workers Compensation I.unnce,as required by Section
3700 of the Labor Code.for the pm rormuee of the work for which this emot is issued.
My Wofkals Compensation hermana carrier And Policy number Am:
Carrier. Policy No.: _
CERTIFICATE OF EKEMPOON FROM WORKERS'
COMPENSATION INSURANCE
(This acclion need not he completed if the Permit is foram,hundred dollars($IN)
.r Ran.)
1 Unify that in Ne Performance of the work for which this Permit is issued.l shall not
employ any pctern in any mannerao As to hecomc subject o the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject 0 thc Worker's Compensation provisions of tM labor Code,you muss
.J O forthwith,comply with each proviso.or this Permit shall ba deemed revoked.
z2 CONSTRUCTION LENDING AGENCY
I hembynrm Net them iaamatSlending agcuy,for the p,rfmm manof
W V
7.> site work for whiccNis is permit is issued(See.3M.Ci,C.)
LO 0..Q Lindero Name
Z z Lcndcr's Address
U Q 1 maify Net T ham read this application and stale that the above information is
4s.F comm.l agree b comply with all city and county ominao es and sure laws relating to
0 U building consomion.and hereby authority mpmsenutiws of this city to enter upon on,
>v UJ above-menduned property for impaction purposes.
(We)agree he save.indemnify and Imp hamIkAs the City of Cupertino against
F'h liabilities,judgments.costs and expensts which may in any way sector,against said City //
U Z in consequence of Ne Starting.(this permit. f-. -
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by:1) (:�-,7 (� Date V
SOU E EGULATIO / �
/ �
nazum of Applican onm"nor 0 Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will Ne appli.nt or future building ocrupamtsmm or handle hoo moo material
As&food by time Cupertino Municipal,Code,Chapter 9.12,and the Health And Safety
cov<.Section 2ss32(a)]
p r. <No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
trait ha ardo.air comaminacOncd by the Bay Arta Air Quality Mutagcmcnt all new materials for inspection.
DistrictT
❑Yu u
1 haw mal the Icewsmaterials rtquiromcnts under Chapter A.95 ofdte Giifor-
niaHcdth&5'afclYCmde.Smm.25505.25533 and 25534.1 undrotand thalifthe Wilding
docs not cumady have a ran .Nat it is my responsibility m notify the men AM thc
requirtmeats which M be par or res; u ce la C,rdricalc of�/9y. �y Signature of Applicant Date
�l}y "/^-'s'a'� / All roof coverings to be Class"B"or better
Osumi ser am onxd age calm
CITY OF CUPERTINO
!em 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN 35606033 . 00
DATE ISSUED. . . . . . . : 04/16/2004
RECEIPT # . . . . . . . . . 25209
REFERENCE ID # . . . : 04040102
SITE ADDRESS . . . . . : 22014 BAXLEY CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER MELVIN KUSCHILL
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4744
RECEIVED FROM . . . . : MELVIN KUSCHILL
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - - - - - - - -- - - - --- ------- -------- - - ---------- ------ - - -- - -- - - - ---- ------ ----
BPERMFEE VALUATION 5, 000 . 00 107 . 00 0 . 00 107 . 00 0 . 00
BPFIXTURE UNITS 1 . 00 8 . 33 0 . 00 8 . 33 0 . 00
BPLANCHK PERMIT FEE 107 . 00 90 . 95 0 . 00 90 . 95 0 . 00
BENERGY PERMIT FEE 107 . 00 32 . 10 0 . 00 32 . 10 0 . 00
BREMFIXT NO. FIXTURES 15 . 00 16 . 65 0 . 00 16 . 65 0 . 00
EPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
BREMPOWER POWER UNITS 3 . 00 77 . 70 0 . 00 77 . 70 0 . 00
BREMRECEPT NO. OUTLETS 3 . 00 3 . 33 0 . 00 3 . 33 0 . 00
BSEISMICRE VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
---------- ---------- ----- - - --- ------ ----
TOTAL PERMIT 372 . 08 0 . 00 372 . 08 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - - -- ----------- --------- - -- ----- - ------------
CHECK 372 . 08 4599
TOTAL RECEIPT 372 . 08
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
•
Sol 40ITY OF CUPERTINO * U
CITY OF PERMIT APPLICATION FORM
CUPERTINO
N #-3S O � a 7,� 1
Date: y /G
/o y
Building Address: Mailing Address (if different from building address):
>1O/ L :), G %
Owner's Name: Phone #:
Contractor: License#:
L J F/ F
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bl ❑ Elect Plumb ❑ Mech ❑
Job Description:
'Residential L A+v 9 L i Commercial ❑
Sq.Ft. Floo Area: $/Sq.Ft.:
Cost of Project: Occupancy G uL�b'ox
Type of Construction: Please ch ck thithe ' ct is a
second-stor
Quantity
Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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/ uasi BUILDING
BCONSTAXB 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
->6l
1of3 7 � Z v�
C1 PITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEI,TINO
Quantq Fee ID Fee Description Fee Group
BNUCOMME 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 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 rinkler/Backflo 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
BREMAIItHAN A/C Units<= 10,000 cfm. MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
r BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Fumace> l OK 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
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Maz uee ELECTRICAL
2 of 3
P�
tTY OF CUPERTINO
OTY OF PERMIT APPLICATION FORM
CUPEP%TINO
Quanti Fee ID Fee Description Fee Grou •
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swirruning Pool BUILDING
BTEMP -Temporary Power ELECTRICAL
WBERM Temporary BldgPermit BUILDING
VCS Tem Dist Svcs ELECTRICAL
IC Business License BUILDING
RIC Electricals foot ELECTRICAL
TFEE Elec Permit Issuance ELECTRICAL
FEE Mechanicals . foot MECHANITFEE Mech Permit Issuance MECHANICAL
TFEE Plumbin Permit PLUMBING
G Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
•
3 of 3
o ~
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►op , 6 IM4
C11y C)� CUPERAM®
BULD0NG ®EPAPThRENT
CE COPY
b
rhPPROVEIV, 4 '�t
IN ACCORDANCE ITNfa:CIPY
UP_ERTINO A 0
~ � e
ATE t.
SIGNED
\ This s t of lens and specific 'ens MUSTt� be kept he job at all times and itt:un
T<,
lawful to make any changes, or. a<
• n same without- Mrit4n parmissic n:
t..° bui',3ing DUPt:r EitiJ of Cupertino.
i'**i of ibis ow A specifica5ons � ry
S{IO� +�1 Y@ pi;l� t9 P3rmh or to Be Z
3 4f ami prowsrons
. ni gr�yi�lty Wr�l(>A,AGB or �--''iS 12+1.
f f Q4
6-,
APR Z�+► `�
BUILE)BNC,
a.
PD �.
T 4
This set1t a
be kept on the
la to R•, ,.a fay+t rt;
+rful
aRY Cl; .._
OR seR}e WIt;70Ct 71lIt:,,RL5S or
the 6�jnfurC Q"At., cl of CuP10��or R a.am.
• The
SHALL ;tQ Ea f this AG:R arty s ,
hE,d f� Qy.,,* ALC,,�tcass 3
Of@ ;� r,c
R . ,. ,,70R
CITY OF CUPERTINO �,F > °tea '`�
411
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION.-
BVILDING ADDRESS: PERMIT NOO 4 0 4 0 1 0 2
OWNER'S NAME: PERMIT ISSUE DATE
MELV
I. in
E: SANITARY NO. CONTROL NO.
HITECfIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSEDCONTRACTOR'SDECLARATIONIobDescri [ionP forte and effect' REPL/ADD LIGHTING
S`=0,= Licenm Class Lk.B
,,gigs Dale Contractor MAY P1,6 2004
Qq ARCHITECTS DECLARATION
�i 8 I understand my plans shall bo used as public records
7 WyU
its Licensed Pmfusional BUIL DING
^ OWNER-BUILDER DECLARATION BUIL
3 S I hereby mfRrm that 1 em exempt form the Cuntemo's License Law for the
20 following mason.(Section 7031.5,Business and Profession Code:Any city of county
x m which requires a Permit to constrict,alter,impmvc.dcmolim.or mpair any structure
in prior to its issreme.alsu minims the applicant for such Permute Me augind stalemem
�r< that he is licensed pursuant to the provisions of the Connector's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
�$ (commencing with Scctiun 7W)of Division J of Me Business and indications Cudc)or
_ that he u exempt dicmfmm and the basis for Ne alleged eamnption.Any violation of �A.ifs.�rrmau4,
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of 3.i'si tine)W4 W et0 O Occupancy Type
ant mom ten me hundred donate(sW0). P Y YP
❑I.asowner of Ne propeny,mmy cmploytts with weguastheir sole wmpensetlon,
will do thewod.and Ne sructum is not intended oroRertd forsade(Sec.101W,Business
and Pmfma iots Code:The Comuctori License taw does net appy Mae ownu of Required Inspections
prepeny who builds or improves theroun,end who does such work himself or through his
own employee,provided that such improvements ere not intended indicted forsale,if.
however.the Wilding or improvement is sold within one year of oompledon.the m ner-
Wilder will have the Wmen of proving that he did not Wild or improve for purpose of
sale.).
1,as ower of the properly,am exclusively conuxting with licensed contmLnUr s he
ca tract the project(Sec.7061,Business and Profession Code:)no Contractor's Li.
cone law does not apply us an owner of,so,my who Wilds or improves Mamon,and
who contracts for such pmjeels with a comvnor(s)licensed pate ant to the Contnclafs
License law.
❑lama pl undmsec.
ner .B&PCT Nu n
Da
WORK COMPENSATION DECDRN
I hereby affirm under penally of perjury arse of the following decimations:
1 have and will immune a Certificate of Consent no ul6inure for W arlCompen-
ssnion,u provided for by Section J]W of the labor Code.for Ne performan.e of the
work for whim this permit is issued.
1 have and will maintain Workc/s Compcnsadon Inurana,az rtquimd by Section
771 of Me labor Codc,for Ne performance or Ne work for which this Permit is issued.
My Wurkcre Compensation Insuruce canner and Policy number art:
Came, Polity Na.: _
CERTIFICATE OF EKEMPf10N FROM WORKERS'
COMPENSATION INSURANCE
(Thisscedon need not In complied ifthe Permit Is fmone hundred dollars(S1 W)
or lm.)
1 unify Net in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so a to become subjuuo Me Worldrs'CompenNon
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making Nis Cenifem,of Exemption,you should
become subject to the Worker's ComPcont provisions of the Labor Code,you must
0z roMwith comply with such prrivisinn or Nis Permit shall tic deemed revoked.
Z` CONSTRUCTION LENDING AGENCY
[-+� Ihereby effort that Vert is a construction lending agency lot the Performance of '
Ci the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Landers Nun.
z Lender's Address
U Q 1 cenify that I have read Ws application and sue that the above imfornadun is
fI.P cnr¢cL I agree to comply with all tiny and county ordinances and mule laws elating to
C U building construction,and hereby authmim mpresenutives of this city in toter upon the
above-mentioned property for inpecdon purposes.
(We)agree to ave,indemnify and keep hasmleat the City of Cupertino against
tirq limilidem,judgments.costs and expmai,s which may in any way accrue against sad City
U Z APP Cnsequence of Me grainfing of s Permit.
ANT UN ERSTANDS ArND WILL COMPLY WITH ALL ON-POINT Issued by: Date /
SOU E EGULATIO S �
�G Oy Re-roofs
I aturcof Applian onuactor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy the
Cu,nt ar future ipal Code,
Chapter
scam or handle Heallous madrim
az defined by tM Cupertino Municipal Code,Chapdr 9.13,and the Health and Safety
otic.Section 35532(.)? � All roofs shall be inspected prior to any roofing material being installed.
t]Ye KNZ
Will thea cant or futam building accts of do a If a roof is installed without first obtainingan inspection,I agree to remove
PP g W equipment or devices which P
it haysmous air contaminants as fined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yrs
1 have mad Ne hueardous materials reptimmcnts under CWperb.95 of the Calirom
ma HalM&SmetyCode.Sections 15505,35533 mal 255]4.1 understand that ifde Wilding
docs rpt cunemly have•doom.Me,the,it u my responsibility to notily de occupant the
myuirt�eota. which mu'lW cpn�or inuance r.cerdrad. Oc�u' Signature of Applicant Date
w1(r7f;l�',/,t�/tj/Q�� I— r6 ay
o nr an nrved agent ,d All roof coverings to be Class "B"or better