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04050046 CITY OF CUPERTINO am_�o A C-0NTRkCT0RiI R BUILDING DIVISION PERMIT BUILDING ADDRESS: GARY WORKMAN PERMIT N 64050046 �A55 BOIIIDI074R OWNERS NAME: PERMITMUEDATE Ashk C',Z,P V WoPT<MAN o9/o7/2no4 IFE: SANITARY NO. CONTROL NO. ARCHTTECT(ENGINEER: BUILDING PERMU INFO BLDG PLUM MECH Its =8 Met, LICENSED CONTRACTOR'S DECLARATION lumb,.f Job Description 7"fifirm Oat I am licensed under provisions of Chapter 9(commencing A,oc f Division 3.f da,Business And Proficusirms Codic.mul my license I. "A- in full fume and affect. 5�" LhtAxcCI. BATHROOM REMODEL 'p; -Lic.0 a Do.—COftramlo, ,1- ARCHITECTS DECLARATION I understand my plans shall c used as public mcords Licensed ProfiAsainnol I bere" fifirm OWNER-BUILDER DECLARATION Oat I am AAcm,A from do,Contractors License Law for the 3: fell..iiii;reason.(Seaction 703 1.5,Business and Professions Craig:Any city or county X which mi,ma A Permit ,,e.marroul. lm�improve.demolish,or repair any structure '4000 4�� prior to its issuance.also ox,tines the applicant for such Permit to file a signed statement (Chapter 9 Sq. Ft. Floor Area Valuation E,< that he is liecrised pursuant in the ponvisions,of the Contrau,OO5 LmcAsc Law (commencing with Section 7000)of Division 3 of the Business and Proficasions Co,c)or Oat he is exempt duenchrom and do,Wous for due alleged eacm,ton.Any violation of Section 7031.5 by a"Applicant for a Permit subjects the Applicant in a civil Penalty of 3 7A13s5I9dmbei0 0 Occupancy Type not mom dom five hundred dollars(M). 0 willikot the work.and Joe surucuum is notintemind on.1yered fer.ale(Se,.7W.Business and Professions Code:The C.."cAnen License Law does not apply to an owner of Required Inspections pm,norty who builds or improves daemon.and whodoessuch work himsolfor through his own employees.provided that such improvements Are not intended oroffemd for sale.If, howover,Or building.,irrpro�...I I,sold ithi.me,year ixf,cunpudich.be trumer, builder will low the burden of proving Oat An did not Wild or improve for purpose of sale.). 0 1,ass Owner of the,Oopen,am exclusively contracting with licensed connotations to construct do,project(SAc.7044.Business and Prefimimm;Code:)The,Contractor's Lt. rense,Law does not apply to an owner of property who Wilds or improvea thereon,and who contracts for such projects with a contractarx,licensed purmart to On Contractors License Law. 0 1 r ca. , do See 5&P C forties memo ac� ( .R;J 51.1 WrMER'S COMPENSATION DEC=014 A 0 I hereby aff, mer Penalty Of perjury one Of due in,declarathms. I haw And will maintain a Certificate OfCoAscnL to Aeff-insum,forWorkeesCompen- sation,as provided for by S�tmn 37M of due Lwor Code,for due perfoartance of the work for which this Permit is imued. C3 I haw and will maintain Worker's Compensation Instmince,As required by Section 1307W of due Labor Caulk.for On performance of dan work for which this Permit is insured. My Woriker's ComManation Insurance carrier And Policy number am: Carrier. Policy No.: CERTIFICATE OF EXEM MON MOM WORKERS COMPENSATION INSURANCE (This section need not ecomplcmd fda Permit is formic hundred doflars(SIM) ,,a I.S.) I artify Oat in the ocoftirmarec of Oc work for which this Permit In innued,I shall not IM=faI R jfi�y cyl i f"An I U �nomc subject to the Woracenr Compensation A �.*i—t I�e X &0 APPLI�Abl"T:If.After Madril this CAnificuZ Of EXCAIPLIDO,Yen should To jut to the Worker 3 Compensation provisions of due LaWr Code,you must 0 z forthwith comply with such provisions or this Permit shall to deemed mv(ikcd. z CONS`TRUCTTON LENDING AGENCY P1 hereby affirm Oat them is a construction lending apne,Jar On performance of C4> Jul word For which OLA gamut Is usned(Sch.3091,Civ.C3 Undces Namc Under's Address z U 0 1 cattily that I haw mail this Application And mom than th.show eformaLits.is c,P COMCIL I agree to COAAPIY with all city and County ordinances and stam,laws helating to 0 building construction.and hereby Audi reprosentatives of this city to enter upon dic above-menniOned No,crty for insfiecdon purposes. C. (Wr)agree to new.indcmnify ad loccep hami ft City Of CUJpcAimO Against , liabilities,jurignicats.em. Ad Aspe.which may in my way seem against said City U Z in consequence of On gourning of difis Nornit. APPLICANT UNDERSTANDS AND WILL COMPLY WITM ALL NON-POINT Issued by: Date SOURCE REQULATIONS. ' I Sign A'Applican ..r Re-roofs "C' DOE—' HAZ DOUS MATERIALS DISCLOSURE Type of Roof Will On applicant Or future Wilding Occupant store or handle hatandous mawrial !�jcl cdjI.Y.Oc Cugcoir.Municipal Coals.China,9.12.And Ric Health and Safety c. '55" ? G�`N. All roofs shall be inspected prior to any roofing material being installed. .....A.A.Aipmcnt or devices which I If a roof is installed without first obtaining an inspection,I agree to remove It hatardtims air contaminants as defined by fine Bay Area Air Quality Management all new materials for inspection. District' [3 yes 01'No I haw W the hisramoul nom,nuda ret,noornums do&,Chapter 6.95 or On c.firo, Ads ReAffin&SafelyCocc.Sectiont 25505.25533 ard!25534.1 urecomand that irtbe Wilding d.not curmod,how A mA.4 0.it IS my malmosibilli,to Amly On..P.L.1 the requic.7 which must W MCI prior w ixxuanceo��Fusc of Occ.parey 5/7 Signature of Applicant Date Owner to mil PS &AS—It Ibl— All roof coverings to be Class "B"or better hm,,f=4 D \Ij CITY OF CUPERTINO � BUILDING DIVIs1oN P�RM� C0NTRACT0R INFORIVIA'�N:°° - BU ILDING ADDRESS: GARY WORKMAN PERMIT N?J4050046 O W NER'S NAME: PERMIT ISSUE DATE 4 NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 Toa LICENSED CONTRACTOR'S DECLARATION wp e hereby affirm Thal I am Ula,Bd under provisions of Chapter 9(commencing lob Desert n yield in ullforca and efecDlVislOn 3orme BusinessanJ Professions Codc,anJmylicenx is nrrra unaerrtieL BATHROOM REMODEL ca- r Liansc Class Lic.K =� Did Contractor ARCHITECTS DECLARATION 'a a 1 understand my plans shall W used as public records ;wo y o Licensed Professional OWNER-BUILDER DECLARATION a S I I hcrchy.Beet that 1 1. cacmpr from the Cations Co eA License Law for the po frilbWhiwingreason.(ermit to comma5.Business imprand ove. edam Code:Aat,ny city OmGmy K m(ei which myuims n permit m crook LhC altar,improve,h pcmil or repair any anumure 0 cc primoiucensed c.also mquires thovisio anisOf forsuch Law statement cera (Co mecingWARSectantraahepfD sion3theheBusinessan Prof Law(Chapter 9ode)or Sq.F[. Floor Area - Valuation �Fp (commencing with Section)(100)of Div(sionJ of the Business and Professions Coda or to than he is exempt themtrom and the basis for the alleged exemption.Any violation of Section)031.5 by any applicant for a Permitsubjectr the applicanno a civil penalty of 3 7AM,519d1mbe10 0 Occupancy Type not mart Nan five hundred dollars($500). k❑I,as owner of the property.or my employees with wages M their sole compensation, Will do the work sad me structure is not intended or offered for sale(see.)IMO,Business and Professions Code:The Contractor's License law docs not apply to an net of Required Inspections property who builds or improves mention,and who does such work himself or through his own employees.provided Joinder improvements are not intended moRemd forsale.If, however,Ne building or improvement is sold within ane year of completion,the owner- builder will have rhe burden of proving that he did not Wild or improve for purpose of sale.). ❑1,as owner of me property,am exclusively contracting with licensed erntraetors to Consumer Ne project(See.7414,Business and Professions Codc:)The Contractor's Li. cane Law does not apply to an owner of property who builds or improves thereon,and who counters for such projects with a comm ctor(s)licensed pursuant to rhe Contractor's , License Law. ❑l am sxem turtle,See. _ .B&P C for this reason Owner Date > T aY WOR Ea'SCOMPENSATION DEC ON 1 hereby afE oder pcnal11 of perjury one of me g declarations: have and will maintain aCcriGeste ofComenl to self-insure for Worker's Compen- - - lion,.provided for by Section 3700 of the labor Code,for the pe,foout aman of the work for which Nis permit is issued. 1 have and will maintain Worker's Compensation Insurance,as required by Section 37W of the Labor Code,for fee performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Cartier. Policy No.: _ CERTIFICATE OF EXEM MON MOM WORKERS' COMPENSATION INSURANCE (This action need not W completed if me permit is for one hundred dollars($100) or less.) 1 Certify mat in the Oerformanee of the work for which this permit is issued.I shall not CMPloyany sonnt ymappor0 asp�ecMan subtract to the Workers'Compensation Laws of Calif rt, /I)4 A licant �' been O APPLICANT:If,after making this Certificate the Exemption,you should been Comply the Workers o Compensation this oressirens rf thelabor Case.You mull .J z frrthwilh comply with such previsions pubis permit shall W deemed mvnked. Z O CONSTRUCTION LENDING AGENCY t-.4 l hereby affirm that there is a construction lending agency lot the performance or C(.> the work for which this permit is issued(See.3097,Civ,C.) W Q Lenders Name •y, Lender's Address t.7 Q 1 certify mat I have,cad this application and sum that the above tl itiis Correct. agree toComply with all city and county oraand state laws orbiting to Qvbildingconstruction,and rebpresenlatives of this oily toorder upon the aboverineo for a,comnposs. (We)agree to save,indemnify and Mop Iarmkss the City or Cupertino against liabilities,judgments.fthewslsang Of thisexpenses onit. they in any way accmc against said Gly \\1 C)z APLICANT of UNDERSTANDS granting Of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS.,c- n / C/�r> N,-t'r ��A1 Re-roofs Sign of Applin.aU Tactor Da HA DOGS MATERIALS DISCLOSURE' Type of Roof Will the applicant or future building occupant store or handle hazardous material a defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Sarcty Code,section 25532(e)? Oyes QfNu All roofs shall be inspected prior to any roofing material being installed. W roti appreant rt,future building occupant use ewipurest or devices which I If a roof is installed without first obtaining an inspection,I agree to remove emir bavardnus air contaminants as delmed by me Bay Asa Air Quality Management all new materials for inspection. Dinrip? ❑ Y. [s'rNo ' 1 have read the harartlous materials rcyuircmcnrs unJer Chap¢r 6.95 of the Califnr- niaHcalth&Safety Cwla,Sodom 25505.25533 and 25534.1 understand that if fie Wilding does not curemly have a Tenant,that it is my responsibility 0 nrdty the occupant or the myuir7 Which most tin mctpr;r,toi.dma cn mrcaterraeupincy Signature of Applicant Date S -7ozl Owner m aumodueda m Date All roof coverings to be Class"B" or better _(b gITY OF CUPERTINO 0 CUP TYOF O PERMIT APPLICATION FORM PN # 37 D 1 /77 Date: Building Address: 5855 o�jihc�er Mailing Address (if different from building address): Owner's Name: CSA R� Wo AK VA&,moi Phone #: �oB 253 o5'i O Contractor: License#: �El_r Contact: G y Wok KMAn1 Fhoone: yas 218 858(. Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: �, �,� Residential Commercial ❑ Sq.Ft. Floor Are , 1 �� Z $/Sq.Ft.: Cost ofProje t: r J Occupancy Group: Type of Cons ction: Please check this box if the project is a second-story addition: ❑ oject Size: Standard ❑ Large ❑ Major ❑ 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/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 r ��. OTY OF CUPERTINO CUP TYOF O PERMIT APPLICATION FORM Quantity Fee H) 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 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 Pipe 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 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 • 2 of 3 (lM WITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Sips 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 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 Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING • 3 of 3 M rw sg J' I OFFEE Cop? 1 _II1 Y N\I -: moi �.I�NIfL=`�� i I MAY 0-'-QJ04 I o CRY 0'U; CUPERYI IIS® 0PN?r• DEPS+"ITMENT 1 APPROVECIN ACCURDA Wg" T'E Crry C11P.ERTI 0� Co p'S •�;; C�7J ':' —rC . OATFb„®@ �— SIGNED. This set o�f;,a� � and specifications MUST De kept 01, the job at all times and it is urr" InWful to make any changes or alterations CO m ®nnto without written permission from . lh® building, Dept., City of Cupertino. r_ Th® ttsmping of this plan and specifications MAU NOT be held to permit or to bear; - - — — Tprovnlr�fir o vio on of ar, — — — — Y provisions If anv City t)rdmance or )tate law, v ar , i i i J, B A I N U L T R A- OWNER'S MANUAL - THERMOMASSEUR'" • INSTALLATION Z. ALCOVE INSTALLA-noN (BEI WEEN - 2 OR 3 WALLs) (CONT.) 1-3 Pull the Therm_oMasseur'"out _ 1-4 Align the wooden supports .. (at least 1 1/2"(3.8 cm)thick) with markings and nail into _ place on the wall studs. 1-5 Put-iback into place and verify that - it is level. 1-6 To finish the front of the bath Bath Deck with ceramic tile or other TA, materials,a 2"x 3"(5 cm x 7.6 cm)structure is necessary tosupport the ThermoMasseur'm. O Place underneath the deck(A) or the edge of the bath (B) Structure < depending on the desired finish. IS CM,7 6 m I Bath Lip t Q r � 1 � � t �. Structure / �� 2"x 3" � [5m,76=1 Pnnr in Canada.Copyright OJuly 3003 6alnUlva Inc.All rignu reserved.45199950. 10 1 800 463-2157 _ - CITY OF CUPERTINO �m 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 37535017 . 00 DATE ISSUED. . . . . . . : 05/07/2004 RECEIPT # . . . . . . . . . : 25482 REFERENCE ID # . . . : 04050046 SITE ADDRESS . . . . . : 5855 BOLLINGER RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : GARY WORKMAN ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3536 RECEIVED FROM . . . . : GARY WORKMAN CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : GARY WORKMAN ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3536 TELEPHONE . . . . . . . . : &EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---- - ----- ------------- ---------- ---------- ---------- --- - -- - - ------ BPERMFEE VALUATION 4 , 000 . 00 97 . 00 0 . 00 97 . 00 0 . 00 BPFIXTURE UNITS 2 . 00 16 . 66 0 . 00 16 . 66 0 . 00 BPLANCHK PERMIT FEE 97 . 00 82 . 45 0 . 00 82 . 45 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 19 . 98 0 . 00 19 . 98 0 . 00 BENERGY PERMIT FEE 97 . 00 29 . 10 0 . 00 29 . 10 0 . 00 BPVENT UNITS 1 . 00 8 . 33 0 . 00 8 . 33 0 . 00 PPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00 BPWATER UNIT 1 . 00 8 . 33 0 . 00 8 . 33 0 . 00 BREMVENFAN NO UNITS 1 . 00 42 . 02 0 . 00 42 . 02 0 . 00 BREMVENSYS NO UNITS 1 . 00 9 . 50 0 . 00 9 . 50 0 . 00 BSEISMICRE VALUATION 4 , 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00 EPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00 ---------- ---- - -------- - - ------ - -- TOTAL PERMIT 384 . 91 0 . 00 384 . 91 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- - - - --- ------ -- ------- --- OTHER 384 . 91 VISA TOTAL RECEIPT 384 . 91 a