05090186 CITY OF CUPERTINO
BUILDING DIVISION PERMIT* CONTRACTORA FORMAT
Pu"b9 less d.T. ps. "^�,Ha°tefZZ °; .£-
BUILDING ADDRESS: FISCHER PLUMBING & CON 5T PQM N0'05090186
6367 BLACKWOOD nv
PERMIT L4lJE DATE
OWNER'S NAME:
KELM RONALD G AND MARGARET A2766 SCOTT BLVD 09/27/2005
NE: SANITARY NO. CONTROL NO.
(408) 727-2426
BUILDING PERMIT INFO
ARCHMCT/ NGINEER: BLDG ELECT PLUMB MECH
0 0 0 0
jp LICENSED COmZACTOR'SDECLARATION Job Description
C I hereby affirm that 1 am licensed under previsions or Chapter 9(commencing
odwith Section 7")of Division3ofthe Business and prorenios Code,and my license is
Sy mral omen"e e 3356/ MS/HALL BATHRMS PLUMBING & SHEETROCK,
)a Data Clea Can
_� Data - Convamr c, REPIPE, MAIN WATE r7J�Fyp @ F XTURES
ARCHITECT'S use DECublic mAON ''r■ �
1 uintlersunJ my plain shall be used u public records
aV
Licensed Pnsfessianal -
OW NER-BUILDER DECLARATION
f I bereny alum that 1 vin tempt farm the Contractors license Lew far Bic Nnv 2005
h O following mason.(Satan IIA IS,Business and pmfcssiom Code:Any city or county Y J
d E which acquires a Permit to eonstrne4 alvs.'noprove.demolish,or repair any Imuetum
so prior m its issuance,also require the applicant for such Permit f In signed summcm r p rale p ®a ,y
GNatbe is IianseJpursuant uec the PrOvisions the Con Permit License Law(Chapmr9 Sq.F[.Floor Are f{P,t� Itrylgp�Hpl Rp�12`F"p Valui$i1i0000
(commencing with Section 7")of Division 3 or use,Business and Professions Code)or
g$ that he It exempt thmefrom and the basis fm the aheged cacmption.Any violation of
Section 7D31.5 by anyvppgom tor.permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mem than Bae hundred dollars(ML 36918003 . 0 0 -
❑Las owner a the property,a my employees with wag¢n their,cole campensedon,
will do the work.and the soucmm is not intended or offered fanale(sec.70W,Italians Required Inspections
and Professions Coda:The Contncmr't Lt.law don ret apply m an owner of q P
prapeny who builds or imparvesthereon,and who doascoch work himself or through his
own employee,provided Wt inch improvemcnu art not invaded orofferad for tele IL
however the Wilding ar improvement u veld within one year of completion,the owner-
builder will ban the Widen of proving that he did not Wild or improve for purpose of
sale.).
[]1.as owner of the propeny.am cscluelvely contracting with licensed contractors m
cam,.I the pmjnt(Sec.7044.Business and Pmfessi..Code:)'ITe Comraemrs Li'
arse Lew dins not apply as an owner or familiarly who Wilds or improves thereon.and.
who wntracm for such p.j.=with a cantraetoKs)licensed ..at to the Convacmrs
License law.
❑1 am caempr under Sec. .B&P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby ammt nada penalty of perjury one of the following Eeclarmiame
❑1 have and will maintain a CenHcmte of Consent o self-insum for Workcrs Comrcm
scion,u provided for by Section 3700 of the Labor Code,for the performance ar the
work for which this permit is issued.
I ban and will maintain Worker's Compcwdon Insarana,as required by Section
3700 of the Labor Code,for the performance of that work for which this permit is issued.
My Wmksrs(G�o /pansadon lose ntt amicr and Policy number amPoli '
Cartier. ✓/ C FICA O�EMMON FROM WO ERS'
COMPENSATION INSURANCE
Mita section need on,W conpl.md Bdm permit is rm once hundred dollars(SIM)
or Las.)
1 certifv that in the perform.of the work Tor which this Permit is issued.I shall not
employ any parson many manner so as to become wbjat to the Workeri Comfenauon
LIaws of California,Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cci ifiom of Exemption,you should
become subject to the Workers Compcnvdon previsions of the Lehm Code,you most
3 z forthwith comply with such provisions or this permit shall W deemed evoked.
0
y CONSTRUCr1ON LENDING AGENCY
1 hereby ARrm that etre is a convection lending agency far the Performance of
7 the work fur which this permit is issued(Sec.3097,Civ.C.) -
1 Lenders Name '
Unders Addmu
zz
i ceNfY dial I haus read this application and sate eta the Wn infomulum is
correct I agree or comply with all city and county ordinavcei and sum laws relating m
V Wilding tmosruction.and hereby mtharia,oprescti-ins of this city to ental area Be
U alawa-mentioned Property far inspection purposes
(We)agree to an.indemnify and keep harmins the City or Cupenioo against
+ taA lutolifics.judgments,cuts anal..W ¢s which may to any way accrue against said City
z in consequence of the granting of this permit Date `-
^ APPLICANT UNDERSfANFS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOURCE REGULAA]70NS.// �+ 7;L _
g/V GI'Z7Z2 S Re-roofs
Signature fn'Iu5uauhZmm..1 Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of ruom building occupant store or handle hrnrdous material
as dcrmed by the Cupertino Monici I Code,Chapter 9.12,and the Hcale and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or future Wilding occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanardoue air conuminans o fined by the Bay Area Air Quality Management all new materials for inspection.
District?
Cl Yes
I have mad the hanNnus mamrials requiremcros under LTmpter 6.95 or the Califor.
nu Health&Safety Cads.Secures 25505.25533 and 25534.1 undicrsunE Jut ifthe Wilding
dos on,curlemly have a Wont.that it is my maposibility,to had y Ihic occupant of ft
mquimanntrwhiehmntr mc;G? o umsaoracmtifmamorocc")7. Signature of Applicant Date
il C7-Z Dine
All roof coverings to be Class "B" or better
Owner m aueomce again Dam
CITY OF CUPERTINO
gem 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36918003 . 00
DATE ISSUED. . . . . . . : 09/27/2005
RECEIPT # . . . . . . . . . 31372
REFERENCE ID # . . . 05090186
SITE ADDRESS . . . . . : 6367 BLACKWOOD DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : KELM RONALD G AND MARGARET A
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4616
RECEIVED FROM . . . . : FISCHER CONSTRUCTION
CONTRACTOR : . . . . . . : TERRY FISCHER LIC # 23896
COMPANY . . . . . . . . . . : FISCHER PLUMBING & CONST
ADDRESS . . . . . . . . . . : 2766 SCOTT BLVD
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95050
TELEPHONE . . . . . . . . : (408) 727-2426
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - -- - - ---- --------- -- -- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 10, 000 . 00 169 . 56 0 . 00 169 . 56 0 . 00
BENERGY PERMIT FEE 169 . 56 81 . 39 0 . 00 81 . 39 0 . 00
BPREPIPE NO OF FIXTURE 9 . 00 81 . 00 0 . 00 81 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BPWSVCS WATER SERVICE 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BSEISMICRE VALUATION 10, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00
---------- --- -- ----- ---------- ---- -- ----
TOTAL PERMIT 380 . 32 0 . 00 380 . 32 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ----- - - ----- -- - -------------- -
CHECK 380 . 32 43886
TOTAL RECEIPT 380 . 32
•
4Q~`�p SANITgq�,O/�
r
DISTRICT MANAGER-ENGINEER BOARD OF DIRECTORS
MARK THOMAS&COMPANY,INC. " WILLIAM A.BOSWORTH
DAVID E.ROSS DR.JOSEPH F.BROWN
�p
DISTRICT COUNSEL JOHN M.GATTO
FSlABL Is HE'D ��'� CURTIS B.HARRISON
ATKINSON•FARASYN,LLP
HAROLD S.TOPPEL 20833 STEVENS CREEK BOULEVARD,SUITE 104 WENDELL H.KERR,JR.
CUPERTINO,CALIFORNIA 95014-2154
(408)2537071 PHONE 0 (408)2535173 FAX
RF..C~FT ED
NOV 0 8 2005
File: CuSD—MOP
Building Dept. —Cupertino
City of Cupertino
Attn.: Building Department
10300 Torre Ave.
Cupertino, CA 95014-3202
Subject: Residential Remodel/Additions
Name: Ronald G. Kelm
Address: 6367 Blackwood Drive(*)
APN: 369-18-003
Permit No. 05090186
No additional conditio r q 're a is y the District.
Inspector: Carl Beckham ...
Date: ...11-8-2005................... Sanitary Sewer Location:
36' from left property line
cc: Homeowner
(*) This property does not have a property line cleanout.
•
SUPPLYING SANITARY SEWERAGE SERVICES FOR: CITY OF CUPERTINO, PORTIONS OF THE CITIES OF SARATOGA, SUNNYVALE, LDS ALTos AND SURROUNDING UNINCORPORATED AREAS
www.cup eriin o s o nitut ydis it it I.r om
Zrvm I
OTY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
APN# 3 j /Y Date: JZ O
Building Addre Mailing Address (if different from building address):
c7
0Enet's Name: Phone #:
>/
Contractor: n /t Licens33��/G ,V/�e�J(�
Contact: Phone:qO'? 7z7-Z926 Cupertino Business License#:
5 S Fax: 4log 777 - 65V
Building Permit Info: rcpse7odle, 0G /? S4af in on,11 Sliee �aC
�[ J
tap! e � new mala wa�'e�j fe I r ><
Bldg El Erect ❑ Plumb 9 Mech ❑
Job Description: 1 949 Z Vann y/ RQ -rub
Residential Ponc Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
6'0
Cost of Project: �O Occupancy Group:
/of
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard Large ❑ 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
I of 3
32
:mxj:1oapp
Y OF CUPERTINO •
CITY OF PERIVIIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMvM New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINIERCEP 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
BREMAfltHAN 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
13REMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
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 Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERAI Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
l PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING.
PLLONGRNGC Plannin LR Comme/ Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
1
3of3
M� - � �
ARE IDETIAL�pROJEC COVERSHEUT
CITY DFME
CUPEkTINO � ..w .- _ 5s y M.
Assessor's Parcel Number: rr//
Name of owner. Roi'1 Ike/N7/ / f/1�
Project address. C� 7 13LCl� WnOG 1✓(r)
Contact person. Soo# Phone. k!O? 7Z7- Z11Z16�
Fax. —t/O? 77 7—7 20Y
Net square footage of lot. 41
Existing 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 1l f
Is privacy protection planting required for the project? Y N I7/
On what floor(s) is work being done? 1 la;h
Briefescription of work. 4,JJ e. tylL
Code editions:2001 CBC (Y -N)2001 CFC (Y -N)2001 CMC (Y- N)
2001 CPC (Y -N)2001.NEC (Y - N)
Effective 11/1/02
Plan Review Process Work Book Page-8-Revised 4/28/04
CITY OF CUPERTINO ;
LD
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
-'+
BUIING ADDRESS: FISCHER PLUMBING & CONST PERMITN0.05090186
5367 BLACKWOOD DR
'RS NAME: PERMIT ISSUE DATE
KELM RONALD G AND MARGARET A2766 SCOTT BLVD 09/27/2005
E:
SANITARY NO. CONTROL NO.
(408) 727-2426
ARCHITECTENGINEER: BUILDING PERMIT INFO
BLDG ELER PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION JobDescri [loom
FC 1 hereby affirm that 1 am lianeed under provisions of Chapter 9(commencing P I�
U with Section 7")of Division 3 of Me Busing and Professions Code,and my license is ai, ✓:�
+�„ inOnRforceand 3356/ MS/HALL BATHRMS PLUMBING Jai,
SHEETROCK,
j v�? License Class Ue.9
4F0 Dare 9_L�—D Conn.., c REPIPE, MAIN WATER, REPIPE@v FI•XT,URESR,.
ARCHITECTSDECLARAPION
Ss 1 understand my plans shall W used as public records
It
o Licensed Professional
5 OWNER-BUILDER DECLARATION
s<7 1 hereby affirm Not 1 on exempt from the Convactar.s Ueem.Law for the
p 0 following mason.(Sari7031.5,Business and PnRecdnns Code:Any city or county
C.9 which requires a retention construct,slur,improve.demolish,or repair any suucum,
prior to its issuance.also requires Me applicant for such formica 5le a signed suumcon ,y
Our rte isliccnsed pursuant so Ne pmvisinru of the ConvacmrilJcense law(Chaput9 Sq.Ft. Floor Area �py'Valuz$1110000
L�$ (commencing with Sodom 7")of Division 3 of the Businrssand Professions Cndc)or
Nat he u exempt Nen,from and the basis for Ne alleged exemption.Any=of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of APN Number Occupancy Type
act mora man five hundred dollars(SR D1. 36918003 . 00
-
I.asowncr of0rc propcny,ar my employee with wage as their sole compenssuon,
Will do Mcwork,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Conuacmr's License Law does not apply m an owner of Required Inspections
property who builds or improves mercer,and who dos such workhimself or through his
own employees,provided Nat such imprevemenu are not intended oro@sed for sale.If,
however.Ne building or improvement is sold within one yearof completion,Ne owner-
builder will have me t uNrn of proving that W did not Wild or improve for purpose of
sale.).
❑1,as owner of Uu property,am exclusively connecting with licensed convectors to
construct Ne project(Sec.7044,Business and Professions Cade:)The Canuacmr's Li
n..Law docs not apply to an owner at property who Wilds or improve Moreon,and,
who contracts for such projects with a conesanm(s)licensed pursuant to the Convenors
License Law.
❑1 am exempt under Sac. .B&P C for this tcuon
137MData
WORN ER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
and will maintain s Certificate of Consent to self-insure for WoracesCompen-
as provided for by Section 3700 of the labor Code,for the pergorman¢of Ne
for which this pcmit is issued.
ave and will maimain Warker's Compensation Insurance,as mquircd by Section
of the Labor Code,far Ne performance of the work for which this permit is issued.
orker's(f�s /paniatian los doe carrier and Policy numruir. ✓/aCERTIFICATE EXEMPTION FROM WORKERS, �
COMPENSATION INSURANCE
(ThisseNm need mt W camplmd if rk permit Is forma Wndoc dollars(SIOM)
ar less.)
I certify that in me perfo m ince of the work for which this permit is issued,1 shall not
employ any parson in any manner an as to become subject to the Worked Compensation
Laws o(Califomia.Dau
Applicant
NOTICE TO APPLICANT:If.after making mu Certificate of Exemption,you should
become subject to Ne Workers Compensation provisions of the labor Code,you moa
,J z forthwith comply with such provisions or Nis permit shall W deemed revoked.
z Q CONSTRUCTION LENDING AGENCY
I hereby affirm Nat More is a construction lending agency for the perfonnaneo of
fyf the work for which this permit is issued(Sec.3097,Cr,C.)
{Ll
Under'
04
Name.
04 Lcndars Add.
U 01
anify Nat 1 have road this application W sues bon the above infomatiun u
LL F coma.I agree iso comply with all city and county pNinaneas and sou laws Misting to
CV building construction.and hemby mthariae mpmscrimea of this city to cnmr upon tW
C[1 above mentioned intercity for inspection purposes.
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against
N Iiabiliue,judgmenu.cam and expcusix which may in any way accrue against said City
t.)z in consequence oftW granting or this permit �.
^ APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULA ION;. � S4*
z77f' S Re-roofs 0,JA;
Signamne of lrpidr.yCortdmor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fatten Wilding occupant store or handle hazardous material
dc0need by the Cupertino Munia0 1 Cada.Chapter 9.12.and the Health and Safety
.Section x5532(e)?
Ye ,�yg/ All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or future Wading occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
hacardnus air con aminants Ls efmncd by the Bay Arca Air Quality Management all new materials for inspection.
Sri"
❑Yc, u
1 have mad Ne Weadd adoucerisla ocquimmtk
ents unr Chapur6.95,(the entire,.
ria Hcalth&Safety Code,Sections 25505.25533 and 25534.1 unucrstand mw ifthc Wilding
does net currently have a tenant.that it is my responsibility In nouly the occupant of me
rctinnoru whimmast mat ar u,na ora certifieata or Occupancy. Signature of Applicant Date
�-Z z'OS All roof coverings to be Class"B"or better
Owner or authrrtxed agema Date