04110058CITY OF CUPERTINO
suluDlnc DIVISIONPERMIT.:,@ONTRACTQRNI
QRS ATION ;
.
BU IMING ADDRESS:
CLEAR OAK DESIGNS
PERMIT NO.
04110058
RS A
_
:723
PERMITISSUEDATE
-
e:
B
SANITARY OL N0.
ARCHITER/FNCINEER:
BUILDING PERMIT INFO `
._
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONPnI
I timothy affirm that 1 am Bmmard under provisions of Chapter 9 (commencing
Job DOSCrlptl0❑; , _
with ecr nllNxgofDivie'onJOf tnc Businus afro LL.Cn c,�eydmylianscix
n° t K
tBaSe
•• L'n�11,
REMODEL 2 BATH- RMS \
DMTJJn
nlracmr OamcRCHITETS
-
lips sluncm d ypbeusedasubig0`,;
'
z -Y-- 79npryry
Licensed Professional
OWNER-BUILDERDECLARATION
I hereby arum Out I are exempt from We Characters License law for the
following Baron. (Sudan 7031.5. Bminces and Professions, Cc&: Any city Or County
any
which requires a permit m construct, altar improve, demolish, of .,air eructurt
! prior to its issuance. also requites the applicant for such Permit o rile a signed statement
Liecrom Law(Chapmr9
Sq. FL Floor Area.
v .
Val
War he is licensed garment o the provisions of the Contractor's
(commencing with Section 7000) of Division 3 of We Business and professions Cnde)or
_ -
'
: that he u exempt Watchman and the basis for We alleged exemption. Any violation of
r I�u bei
Occupancy Type
Section 7031.5 by any applicant fm • permit subjaca We applicant 10 a civil penalty of3
not mote thin five hundred dollen (5500).
0 1, m hero, of Ne pmpany, m my cmploycas wire wage n Heir sole compenudon,
Required Inspections
will do We work and the swmare is not intended or offered forsala (So,, 704, Busiress
and Pmfevioru Code,: The Communes License Law aces not apply te an Owner of
Property who builds or improves thereon, and who doessuch work himselforthmugh his
- - • .,,.,. -
own employes,, provided that such improvements are not intended or Offend for We. If.
however We Wilding or improvement is sold within one year of completion, the owner-
-
huilder will have Lha burden Of proving Nat he did not Wild or improve for p ctosc of
salt:).
0 1, as mane, of the property a exclusively smartening with Ikcnsea emimmten to
summer the project (Sec. 7044, Business and promsexa r Code:) Tie Contracter's Li.
- -
came law docs not apply m an owner of progeny who Wilds or trimmer chance. and
who contracts for such projects with a conuactor(s) licensed pursuant to We Contactors
License law.
0I am esempl under See. . B At P C for this on
owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby alum under penalty of perjury Om of the following dcdsrauoas:
I have and will maintain a Craftiest Of CORXn110 Hlf-insure for Worker] eompem
-
ration. as provided for by Section 3700 of the IaWr code, for We performance of We
-
work for which Nis permit is iasmd.
0 I have and will maintain Wmkers Compewtihn Insurance, as tegoimd by Section
-
3700 of Ne labor Cure, for We performance of Ne work for which this permit is iuuse,
My Work, Compens don summa carie, and Policy number �l
cr. Polity No.: l
'
CERTIFICATE OF EXEMPTION WORKERS'
,SMM
COMPENSATION INS NCE
(rims section need not becompleted if tie permit is for one hundred doluta($100)
tui)
1 unify Nal in the performance of We work for which Of. pctran is issued. )shall nm
employ any peon in any manner sl as m burnous subject to tW Wooers' Compensation
Laws of California. Date
Applicant
-
NOTICE TO APPLICANT: If, after making this ConiOcae of Exemption, you should
-
become subject to We Worker's Compensation provisions of the tabor Code, you must
forthwith comply wit such provinom or Nis rx rte it shall be deemed evoked.
ON LENDING AGENCY
CONSTRUCTION
1 herebyaffirmthi Nat Ncrt Ina construction lending agency Por We perfurtnanu Of
is a c
work for which this permit is named (Su. 3041. Civ. e-.1
leaden Name
La
.
.-
-
Lenders Address
�
5 1 canify that 1 have mad this application and sate Nat We above information is
r'~
comet. I agree to comply with all city and county ordinances and sate laws refiling to
�--/
building construction, and hereby aulhonse representatives or this city to enter upon the
above-mentioned pottery for Inspection parpOXl
y (We) agree to Save, indemnify and keep harmless We City Of Cupertino against
✓/
liabilities, judgments costs and expcvn which may in any way accrue against said City
Z in covegmnce of the granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
/
SOURCE REQULATIONS. (11,A
,
Re -roofs
Type of Roof
Si rah pplica^vcunnalor 1 Dam
HAZARDOUS MATERIALS DISCLOTN
Will We applicant or future building occupant store, or handle hmard^us material
as reined by the Captain. Municipal Code. Chapter 9:12. and the Health and Safety
Code. Section 25532(e]? ``
All roofs shall be inspected prior to any roofing material being installed.
❑YO
If a roof is installed without first obtaining an inspection, I agree to remove -
Will tna applicant or ,tee Wuain t use equipment or deaimr eaten
pp g by Or, B yuipmc
hayardnus air conaminanu as defined by the Bay Arca Air Quality Management
all new materials for inspection.
ist
Disticl? � �
0Yu ®Nu
1 have mad the hvallous matarials rtquirtmcn¢under Chaper 6.95 of Ne, Califon
nia Hcalm& Safety Code Secumc25W5.25533 ud2553a. 1 undersand Natifthe Wilding
does not cuncmly haw a ¢rant, Our it is my responsibility m notify the oscul ant of Ne,
rcquimmcna timertossuanaeoracenara ealla^Cy I
Signature of Applicant Date
cmusLtn Iry
�p in 1 I l�1
All roof coverings to be Class "B" or better
Owner or aulhoond agent 1 `CEc
CITY OF CUPERTINO
"" �€`�°' �`' " 19_91v 'sl'
INFORM ON
BUILDING DIVISION PI;Rl�
CONTRAC�°TOR
BUILDING ADDRESS:
CLEAR OAK DESIGNS
PERMIT NO.
04110058
RS A �.
PERMIT L�SUE DATE
NE:
IAO )4�6 g448
SANITARY OL N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACOut,p DECLARATION
1 Walby affirm that 1 am licensed under provisions of Chapter Y (commencing
Job DOSCPIPh�Di
-
witn$ ,f�on 70X1) of Divii on3of thcflusinen dPmfs'yJ� Cc e. atd my hams ix
in fol�r eantl,(ffcct.
_�ln
Licp3 Clasx Lk.p 9
--��
,
REMODEL 2 BATHRMS r
APR
Da¢ Cumractor
a^
RCHITECTR DEC AT '
iltlal
I untie J yplanx shall he used as pontic recmN
(}�j (I p p h,y�
j 11 Il p 11 \e\ Ipya
IL`fYJ11 N`.)'I
NU
Licensed Pmfuxional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contranor's License Law for the
krySaUU
I furrowing reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit m,croon, niter. improve, demolish, or repair any structure
Prior In its issuance, also require the applicant for such permit m rile a signed smmmcnl
Limits, Law (Chapter 9
Sq. FL Floor Area
Val
that W is hectored pursuem to dm provisions of the Contrecmri
(commencing with Section 70)(1) of Division 3 of the Business and Profcnsions Code) w
Nat he is exempt therefrom and the Istria for the alleged exemption. Any violation of
_
1�I�rlbe60
Occupancy Type
Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of3
not more than rive hundred dollars ($500). _
❑ 1, ha owner of my employees with wages Nei( sole compensation,
Required Inspections
CWRlanor' Inlet. lir offered ( r
anddo,smac ce
vellid0efor Walk. ande:
of apply toBSC,.-.. of
arta Proreamma code: rM Canuacma uanse law oma not apply m an owner lir
he
property who Wilda or impove drecean, and whodoesauch .,it himself or through his
own cmployres, provided thatsuch improvements are not intended oroRered farsah. 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 Wild or improve Tor purpom of
sale.).
❑ 1, as owner of the progeny. am exclusively contracting with licensed moratoria to
consumes the project (See. triad. Buaineas and Professions Code:) Tyro Contractor's Li.
,
cense law door not apply m an ..at or progeny who Wilda or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to oaf Conuacmrs
License Law.
1 am exempt under Sec . B & P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pe.It, of perjury one of the failawing declarations:
❑ 1 have and will maintain a Cenifiam of Coastal to self -insure for Worker's Compin.
nation, an 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 Workers Compensation Insurance. as required by Section
'
3700 or the Labor Code. for the postman.,. of We work for which this permir is issued.
My Work Compen.s1m.on i4s nom artier end Polity num/berr, a_re j
\Yjyl%1, 1110 L
Ll/.A^ vV�Poll, No.: �V /
t CERTIFICATE OF EXENPIONMMWORKERS'
JV COMPENSATION INS NCE
(This section recd nos he completed if the Permit is foronc hundred dollars ($100)
or less.)
I ee rify that in the performance of the work for which this permit is issued I shall net
employ any person in any mamerso as to become sub3oa to rbc Wool Compensation
Laws of calimml., Dam
Applieam
NOTICE TO APPLICANT: If. after making this Cenificam of Exemption, you should
become subject to the Worker's Compensation oncookicas of the Iahm Code. you most
rrrvoLl, comply with such pm rsmns lir this Permit shall W deemed mvnked.
D
j CONST RUCTION LENDING AGENCY
I Mmby.ffirm that there is a construction lending agency for the Performance of
the work for which this pemris b issued (Sec. 3097, Civ, C.)
Lpmdees Name
.
Lenders Add.
'
I certify that I have read this application and sexm that che above information is
Correct. I agree m comply with all city and county corman,cs and stale laws relaxing to
building consw<tion, and hereby authorise ¢prearmaives of this cky m enter upon the
shove -mentioned property for inspection purposes
y (We) agree to save, indemnify and kacp harmless the City of Cupcnino against
n Imbilides,judgments,costs andexper¢uwhich may in anyway acemc agaietsaid City
G� f
in
^' APPLICANT eUNDERSTANDS Aof fine granting of rND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS:_
1 I �A I 6
'
GL_; `
Re -roofs
Type of Roof
Sig reo tmianUCoosmcmrk Dam
HAZARDOUS MATERIALS DISCLOSHRV
Will the applicant or form building Occupant store at handle hasardous material
az defined by she Cupertino Mr kipsl Code, Chapmi 9.12. amt the Health it Safely
Code. Section 25532(x)? ``
All roofs shall be inspected prior to any roofing material being installed.
C] Yes 0No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or furore building occupant au equipment or devices whim
emit haiardnus air coe az mmminamdefined by the Bay Area Air Quality Management
all new materials for inspection.
District?
0Ycs Fd Nu
I have mad the hamohno'smmaterials requirements under Chapter 6.95 of the Califor-
niaHealth &Safny Cotle,Sections 253f15.25513 and 25534.1 undersand thmifthe Willing
docs not ci ndy have a tcnanc Nat it' y responsibility m nouly the occupant of the
rtyuirtmcnu��fir rrustbemlpnar to ns�.naaraccn;riejt,o( Otto y. I
Signature ofA lienor Date
g PP
c1-^ I� I E1 ll!/ l
All roof coverings to be Class "B" or better
owner lir arom..dagent t �Dfm
lom 1 of 1
Ll
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35616051.00
DATE ISSUED.......: 11/09/2004
RECEIPT #.........: 27713
REFERENCE ID # ...: 04110058
SITE ADDRESS .....: 11073 BEL AIRE CT
SUBDIVISION ......
CITY .............: CUPERTINO
IMPACT AREA ......
OPERATOR: conniew
COPY # : 3
OWNER ............:
ALLEN WETZEL
ADDRESS ..........:
CITY/STATE/ZIP
...:
CUPERTINO CA,
95014-4701
RECEIVED
FROM ....:
CLEAR OAK DESIGNS
CONTRACTOR
.......:
ROHRER, ROSS LIC
# 21936
COMPANY ..........:
CLEAR OAK DESIGNS
ADDRESS ..........:
1723 B ROGERS AVE
CITY/STATE/ZIP
...:
SAN JOSE, CA 95112
®
TELEPHONE
........:
(408)436-5448
FEE ID
UNIT
QUANTITY
AMOUNT PD -TO
-DT
THIS REC
NEW BAL
BPERMFEE
-------
VALUATION
----
15,000.00
--------------------
223.56
0.00
----------
223.56
----------
0.00
BPFIXTURE
UNITS
6.00
54.00
0.00
54.00
0.00
BPLANCHK
PERMIT FEE
223.56
298.34
0.00
298.34
0.00
BPREPIPE
NO OF FIXTURE
6.00
54.00
0.00
54.00
0.00
BPSEWER
SEWER SYSTEM
1.00
21.58
0.00
21.58
0.00
BPTRAP
NO OF TRAPS
1.00
9.00
0.00
9.00
0.00
BPVENT
UNITS
1.00
10.79
0.00
10.79
0.00
BENERGY
PERMIT FEE
223.56
107.31
0.00
107.31
0.00
BPWATER
UNIT
1.00
9.00
0.00
9.00
0.00
PPE.RMITFEE
FLAT RATE
1.00
38.37
0.00
38.37
0.00
BREMPOWER
POWER UNITS
2.00
65.95
0.00
65.95
0.00
BREMRECEPT
NO. OUTLETS
4.00
4.80
0.00
4.80
0.00
BRFMVENFAN
NO UNITS
2.00
52.41
0.00
52.41
0.00
13PEMVENSYS
NO UNITS
1.00
10.26
0.00
10.26
0.00
BSEISMICRE
VALUATION
15,000.00
.1.50
0.00
1.50
0.00
I;PERMITFEE
FLAT RATE
1.00
38.37
0.00
38.37
0.00
MPERMITFEE
FLAT RATE
1.00
38.37
0.00
38.37
0.00
'i'OTAL PERMIT
---------- ---
1037.61
0.00
------
1037.61
----------
0.00
METHOD OF
PAYMENT
AMOUNT
NUMBER
--------
CHECK
------------
1037.61
------------------
42565
'eL RECEIPT
1037.61
(D.
CITY OF
• CUPERTINO
•ITY OF CUPERTINO• O
PERMIT APPLICATION FORM l I
APN #
Date: t Ioq
Building Address:n _� ^ Mailing Address (if different from building address):
U 3 O�J� ��Q. ��-- C -TT
Owner's Name:
Phone #
ho �`D
Contractor: � Q '(',L
License #: 5 -�
Contact: Phone: -� pb 4 3w "
��006-
Cupertino Business License#:
Fax: 4y
Boiler >100Kto500KBtu
Building Permit Info:
/
Bldg ®vl� Elect LY Plumb 01--- Mech ❑�
Job Description:
Residential Commercial ❑
Sq.Ft. Floor Area: Rb
S/Sq.Ft.:
Cost of Project:
0
Occupancy Group:
Type of Constr ction:
Please check this box if the project is a
BCONSTAX
second -story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
BCONSTAX
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBOILERI
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler >100Kto500KBtu
MECHANICAL
BBOILER3
Boiler> 500K to 1M Btu
MECHANICAL
BBOILER4
Boiler> IM 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
Flee 600V > 1000A
ELECTRICAL
BELEC200
Flee Svcs 600V <= 200A
ELECTRICAL
I BENERGY
Energy
BUILDING
/ BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
a770
1 of3
��37.
r
L
51%
CITY OF
CUPERTINO
*CITY OF CUPERTINO*
PERMIT APPLICATION FORM
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 Mechanical
MECHANICAL
BNUCOMMP
New Conon 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 Re eat Fee
BUILDING
BPREPIPE
Re i e Of Fixtures
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSPRWK
Lawn S rinklerBackflo
PLUMBING
BPSTORM
Storm/Rain Water
PLUMBING
BPTRAP
Kitchen Trap
PLUMBING
BPVENT
Alt of Drain & Vent
PLUMBING
BPWATER
InstallIAlter 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 Furnace > 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
2of3
ZEN OF
CUPERTINO
WITY OF CUPERTINOO
PERMIT APPLICATION FORM
Quantity Fee ID
Fee Description
Fee Group
BREMSIGNAD
Rmdl 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
Scb Specific Plan
BUILDING
-BSEISMICOM
Seismic Commercial
BUILDING
BSEISMICRE
Seismic Fee Res
BUILDING
BSPECIAL
Special Insj5ection
BUILDING
BS WIM
Swimming Pool
BUILDING
BTEMP
Temporary Power
ELECTRICAL
BTEMPPERM
Temporary Bldg Permit
BUILDING
BTEMPSVCS
Temp Dist Svcs
ELECTRICAL
BUSLIC
Business 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
Plumbing Fee sq foot
PLUMBING
ZADDCHG
Address Chane
BUILDING
•
3 of 3