04010134 CITY OF CUPEWHNO "' ext a'.Ytje sig %a-•0 '� ria" 'd"
BUILDING DIVISION PER* ,CONTRACTOR,INFORM,i ONM .
BUILDING ADD RESs: JEFFREY D SCHULKEN PERM IT NOD4Ol 0134
1041 1; rAT,VRRT I)R
OWNER'S NAME: PERMIT ISSUE DATE
JEFFREY D
NE: SANITARY NO. CONTROL NO.
I
ARCHITECflENGINEER: BUILDING PERMIT INFO
BLS ELECT PLUQMB MOF.cH
_Op LICENSED CONTRACTOR'S DECLARATION
WUI hereby affirm that 1 am licensed under provisions of chapter 9(commencing Job Description I
with5udon]I]IIU)eDiviuonJof de Busi nand Rorcssium cod<.ana myliccnsc is �G 81{� ALEED
n infullforteand affect. tf`f
,qi Ulcerate,Class Lie.x KITCHEN REMODEL/REPIPE
eth a Dam Canlaemr
ARCHITECT'S DECLARATION
nJUL It 2004
�v to I understand my plans shall he used as public records
JU
;Qy LacnredPmresxional BUILDING
S OWNER-BUILDER DECLARATION
20 I naso alarmort Ilia 3. exempt from the Cammctors License Law for the
p o following mason.(Section 7(53.5.construct.alter, and Proive,de a demolish.
Calc:Any city at roomy
m which its issaaPermit toouionthaline impmsuh Permit
erm fi,ore agia'anyatauctmc
iy that he
slicenadpursu pursuant
(it the lhxvirdi eao for Conincoilmeanse gncdsammcni
-SaIhathcincingwidwrction7W)ofDivision3lhrcomsinssandProchonsCodmr9 Sq.FL Floor Area Valuation
Fes (commencing with Scction)(pO)nf Division Jnf the Business and PmfcssinnxCMc)m --
i that he is script therefrom and the basis for the alleged esemption.Any violation of
Section)031.5 by any applicant for a permlt subjects the applicant to a civil penally of 3'ABIN7,aAiW0 0 Occupancy Type
opt more bus.ave hundred dollera(s5Do). P Y YP
p T,es owner or the panprstr,or my employees with wages as their sole compensation,
will do the work.and the swctum is not intended or offend for sale(See.1064,Business
and Profession,Code:The contractors came Law does not apply to an owner of Required Inspections
property who builds or improves Nation,and who docs such work himself or through his
•own employes,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
bailee will Luse the burden of proving Nu h<did not build or improve(or purpose of
sale.).
CI.L as owner or the property am exclusively contracting with licensed commoners to
convect the pmjen(Sec.7014.Business and Professions Code:)The Crnmctarx Li. .
cents Law docs noI apply m an owner or property who builds or int proves thereon,and
who contracts for such pmjeeu with a conmctoild licensed pursuant to the Contractor's
Liana Law.
Ism eacmW on&,See .B h PC for this on
ORKER5 COMPENSATION DECL%R ION -
I hereby afliam un@r penally of perjury one of Na following declaatians:
I have and will nomedm a Certificate of Consent to self-Insure for WorkeraCompen-
sadent.as provided for by Section 3700 of the Labor Code,for the Performance of Ne
work for which this permit is issued.
Cl I have and will maintain Worker's Compenwhon insetW e,u required by Section
37M of the Labor Cade.for the per rormmce of the work for which this Permit is issued.,
My Worker's Compensation Insurance carie,and Policy num bei an:
Carrier. Policy No.:
CERTIFICATE OF EKEM MON FROM WORKERS' ,
COMPENSATION INSURANCE
mbs section recd tont ba Completed title permit ix forme bundree[dollars(SIM) - -
orleu)
I certify Ural in Ne performance of Ne work for which this Permit is issued.I shall not
employ any person in any manner so as to become subjcn to lk Worknt Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of&motion,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J'Z foMwilh comply with such pmvisiorm or this pc,mit,h.11 he deemed revoked. .
Z O CONSTRUCTION LENDING AGENCY
�. I hereby affirm that there is a conamctinn heading agency for the Performance of .
a� the work for which this permit is Issued(Sec.YN7,Civ.C.)
a] q Under'sName
Lender's Address
V Q 1 certify that 1 have read this application and sate tbar the above information is
D. H torten.I agree m amply with all city and county ordinances and sate laws raising I.
Or, building construction,and hereby authorin reprem
sextives of this city to enter upon the
a. ahovm(We)mentioned I. ,tyadow fee inspection t oce,hx. /
y Wc)agree Ile ave indemnify antl tip hatmlcss the City of Cup nines against
fq Liabilities,judgments.costs and expenses which may in any way acnuc against said City
U Z in consequence of Ne granting of this pcamil.
APP ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
50 CER U TIONS _ )
l LjUI Re-roofs
Slgnmu e o m APP nUeammutor Data
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will the applicant or future building occupant tore ler handle haxaadous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety.
Code.Section 2553$a)? All roofs shall be inspected prior to an roofing material being installed'.
Pres pr+a- P P Y e+ g
Will the applicant ler hours building on:nwnt tree c4uiproamt or drviees which If a roof is installed without first obtaining an inspection,I agree to remove
ah hatomous air contaminants ac defined by the Bay Area Air Quality Management all new materials for inspection.
tricO
❑Yes 0146�
Us mM the henrdnus mamriais nqulmmonu under Chapter 6.95 orthe Califon
nice Health KSafety Cade,Scctium25505,25533and25530.1un4rsund thisirde hoilding. _
ems not curtcndy box a enanL Nm it is my rapnnsihility m nndly the a:cupam rel Nc
nquimm is estbeent"Imfmissaanecnracerdrrama�arapanry. Signature ofApplicant —Date
/ 7 7 lts0!
out oria.cd agcm Date All roof coverings to be Class"B" or better
ge.h
RE EIV3?. )
AN 2 8 L _._.:
---______ I� J
NO
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r
�If f ?,v
�n
��. tirt" I?
W� s
I I ACCORCANCEATH THE CITY Of.
- ^�6ES AND MNANC S
IN
E
i ( NEU - - /
f� s set of plana er . specdicati ns MUS. DATE
kept on the i .at a!I times nd it is un G
lawful to mak, any changes or alteration' YL
• on same without written permission frons
the building Dept., City of Cupertino. DA E C
The stamping of this plan and specifications
;HALL NOT be held to permit or to be ac r t R,gKf-
rovrsronOFFEE
'A ;,,wal of dre violation of any p COR
•r arry GIv Ordinance or State Law. \`"J(
* CITY OF CUPERTINIV
CITY OF PERMIT APPLICATION FORM a ,/ `'� 3
CUPERTINO
APN # ® d Date:
f Zg o
Building Ad cgs:
10 IS CGIVe4 Q Cv -0- _0
Owner's Name: e �U I Phone#: S� -7-7
Contractor: I• ` License#:
Contact: J n C Cupertino Business License#:
Building Permit Info: 4, lea- e,e4T
Bl Elec/6--i Plu Mech ❑ (2'( 4 W/S'
Job Description:
Residential El- Commercial ❑
Sq.Ft. Floor Area: S/Sq.Ft.:
Cost of Project: �-V Occupancy Gro
`4
Type of Constructio
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> l OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1 M Btu MECHANICAL
BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL
BBOILERS 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 > IOOOA ELECTRICAL
i BELEC200 Elec Svcs 600V <=200A ELECTRICAL
U�vBENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
4 �4 7
1 of 3
nd- 10 CITY OF CUPERTIN*
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BOVERTUAE 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 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
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> 1 OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Mise Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
•
2 of 3
I I SIR
OITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUP,PKTINO
ua a(iSy Fee ID Fee Description Fee Group
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, 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 Inspection 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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
BMISCELL Building Misc Fees BUILDING
•
3of3
CITY OF CUPEWHNO > F�•"�"^ ''-
BUILDING DIVISION PERMIT CONTRACTOR INxFOR A�TIION - _
BUILDING ADDRESS: JEFFREY D SCHULKEN PERMITNO04010134
OWNEWS NAME: PERMIT ISSUE DATE
JEFFRE
SANITARY N0. CONTROL NO.
ARCHITECRENGINEER: BUILDING PERMIT INPO
BLDG ELECT PLUMOB MECH
O O O
WOO LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�an with Section 7000)af Division 3nf Bm Busirseaand Professions Code,and my license is
mora concern«t. KITCHEN REMODEL/REPIPE
Dj2?: License Class Lic.0
6;n Da¢ Contractor
ARCHITECTS DECLARATION
�m< l understand my plans shall he used as public records
S
�Wt„ Licensed Professional
OWNER-BUILDER DECLARATION
<y 1 hereby affirm that 1 am exempt from the Contractors License Law for the
00 following mason.(Section 7131.5,Business and Professions Code:Any city car county
K$ which requires a permit to construct.alter,improve,demolish,or repair any structure
e_y prior lrl its issuance.also requires the applicant for such permit to file a signed statement -
z< that he is licensed pursuant to the previsions(if%beContractor a License,Law(Chapter 9 Sq. Ft. Floor Area Valuation
yF$ (commencing with Section 7000)of Division 3 or the Business and Professions Code)or -
y _
that he is eromps themffom and be 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 3'7&N'NL$t®el0 0 Occupancy Type
not more than fin hundred dollar,n!i003. P Y YP
❑1,as owner of the pmpeny,or my employees with wages Or their sole compensation,
will do the work,and the swclum is not intended or offered ror sale(Sec.7054,Business
and Profession Code:The Co osactore License Law does not apply to an owner or Required Inspections
property wh sbuilds or improsss thertoo,a rd who doeuuch work himself or through hisll
own emptoyecs.provided Nm such improvements see not intended or offered for sale.If. V'
however.he building or improvement is sold within one you of completion.Ne owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
ale.). �g�®
,I,as owner of the PropenY•am exclusively conucting awith licensed contractors to
construct the project(Sm.7W,Business and Professions Code:)run Contractor's Li.
entire Laa,docanaI apply m an owner or propcny who Wilds or improves thereon and. 2004
who contracts for such projects with a contactar(s)licenced pursuant to the Conmemh
License Law.
I am exemq under Sec. B&P C for this p
a ORKER'S COMPENSATION DEC 104
I Lanni affirm under Pemlty or perjury one of the following declinations:
❑1 hers and will maintain Section
37 er of he La t l0 Code.for ref SVorkeri Compen-
sation,as provided for by Section 3700 of he Labor Code,for Ne perfo,mana of the
work for which Nis permit is issued.
❑1 bars and will maintain Worker's Compensation Insurance,act requited by Section ,
37W of the Labor Cude,for the performance of the work for which this permit is issued.,
My Worker's Compensation Insurance Carrie,and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEbI7nON FROM WORKERS'
COMPENSATION INSURANCE
(Thuseetiunmed nm BecomdthaliDhe permit isfnronchundmddollars(glNsj - -
or bas)
1 certify that in the performance of the work for which this Permit m issued.1 shall not
employ any person in any manner an u to become subject to the Workeii Compensation
Laws of California.Date
Applicata
NOTICE TO APPLICANT:If.after making this Ccnificam of Exemption,you should
Become subject to the Worker's Compunction provisions of the Labor Code,you must
., Z fmthwi lh comply with such provision or perm i t shall Be deemed miaked.
ZO CONSTRUCTION LENDING AGENCY
�" I hereby alfhm that there is a construction lending agency for the Performance ce( -
t� the work for which this permit is issued(See.3097,CO.C.)
W Q Lender's Name
= Z Underi Address ..
U O 1 certify that 1 bars mad this application and sure that the above information is '
It. P collect.I agree to comply with all city and county ordinances and state laws relating to
OU building Conswction,and hereby ambame representatives of this city to enter upon the
r W shove (We)
property for emnify an keep ha /
y (We)agree w save,indemnify and keep harmless the City n Cupertino against C/
UZ inconsequese of the granting
ex penusWhich may inany Way acerae Initial said City
U z APPo I ANT of tDERST ing cal this per mit.
APP ICAR UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO CER U NS
Re-roofs
Signam o App c nVC000sewr Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or futuc building Occupant store or handle haws material
as dcfirred by the Cupenino Municipal Code,Charter,9.12,and the Health and Safet,.
Code.section 25532lan All roofs shall be inspected prior to an roofing material being El YC' g.N� P P Y g g installed.
Will Ban appncaRtor future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it harardnus air contaminants an defined by the Bay Area Air Quality Management all new materials for inspection.
Distrinl
Yes Usr-�
I have mad the harardnus materials mquimmenu under Chapter 6.95 of the Califon
nice Health&Safety Code,Section 255)5.25533 and 25534.1 understand than if the Building
does not currently here It tenant,out it is my resplmsibildy a,maily the Occupant of the
rcyaimm B mustxmelpdor E.O;OWceotaccmncatc aa��acvpancy. Signature of Applicant "Date
1 JAI
tact ier;andagent Dam All roof coverings to be Class or better