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04080101 CITY OF CUPERTINO BUILDING DIVISION PERMITcONTRACTORdINFORMATIQN;; ; BUIL DING ADDRESS: _ ALAN & BETTY JOHNSON PERMIT NO.04080101 OWN' W NF_R'S NAME: PERMIr ISSUE DATE 112 2 E: SANITARY O OL N0. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u00 LICENSED CONTRACTOR'S DECLARATION Job Description a u C I hereby affirm shot I am licensed under provisions of Chapter 9(commencing - !ibw will,Section 7")of Division 3 of 0,Businov arq Promssians Code.and my license is ^.`may mmIt me aanderre"' REMODEL MS . BATH/REPLACE WINDOWS IN MS .BED/BATH Z Lom rc Chis Lie.M 'Fp Dam Contractor 'y ARCHITECTS DECLARATION –r I understand my plans shall he used as public reemds JiU 30� da Licensed Pnssmand OWNER-BUILDER DECLARATION I hereby alirm that 1 am exempt tram the Contractors License Law for the '0 following mavon.(Section 7(U1.5.Business and Professions Cade:Any city or county v 7 K m which rcquims a permit to emuwct,almr,improve,dcroolish,an repair any struclm, prior to its issuance,also inquires theapplicantforsuch Permit o fileasignedmarement that W is licensed pursuant to the pmvismat of thc Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuau n FFG (commencing with Section]000)of Division 3 of the Business and Professions Cade)or 6 i Nal he u exempt demfrot,and the basis for she alleged exemption.Any violation of Sedan 7031.5 by may applianlfor a Permit subjeeu the applicant to a civil penalty of 3.j5Fr3Tftalber00 Occupancy Type not more than five hundred dolls.($508). 0 L u owner of the progeny,or my employees with wages as their into compensation, will do the work and the swcture is not intended or offered for aale(Sec.7Bs6,Business and pormssiam Code:The Conusctora License law does not apply to an owner of Required Inspections propeny who builds or improves thereon.and who does such work himui f or Omugh his own employees.provided that such improvements are not intended oroRered for sure.IL 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 build or improve for purpose of sale.). 0 I,as owner of the progeny,am exclusively contracting with licensed contracors to Construct the project(Sec.7006,Business and Professions Code:)no Contractor's Li- cense Law does not appy in an owner of property who builds or improves demon,and who contracts for such pmjeco with a emurxetor(s)licensed pursuant o the Cor mutons License law. 0 1 sin exempt under Sec. B h P C Tor this mazon ATIJam. WORKER'S COMPENSON DECLARATION 1 hamby affirm under penalty of Penney oa of the following dee mostions: r haw and will maintain aCcnili me of Consent to self-insum for Worker'sCompen- bown,as provided for by Section 3700 of d t labor Code,for da performance of the work for which this Permit is issued. 0 1 have and will maintain Worker's Compensation Insurance,as required by Section 37W of the Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not hccomplcoJ if the permit is for one hundred dollars(g100) or less) 1 amfy that in de performance of the work for which this permit u issued,I shall not cmployany persany manrr�a..sstn�umpecosec subjc�ttoric Wmkcis'Compcnsafior Laws of Califon i - e ^f 1„'d�A Apit.aP t NOTICpTp APPLICANT:if.after making is CeniOcam of Exemption.you should boom tat o the Workers Compensation provisions of the Liquor Code,you mum .,z formwid comply with such provisions of this permit shall be accrued revoked. Z O CONSTRUCTION LENDING AGENCY I hereby affirm dal dere is a construction lending agency for the performunce of Cthe work for which this permit is issued(Sec.3M.Civ.C.) ly Q Lender's Name z Lenders Address U Q 1 corny that I have read this application and state that the shove information it f" coven.I agree to comply with all city and county oolinanas and sok laws relating to U building construction.and hemby audorire mpramenotiws of this city to enter upon the 44 above mentioned property for inspection purposes. (We)ague m save,indemnifrm y and keep harmless rise City of Cupertino against F' h liabilities,judgmen.,comx and expenses which may in any way seem.against so to City U z APPL CANTeof 00 UNDERSTANDSrstriting tnns permit. No WILL COMPLY WITH ALL NOWPOINT Issued by: Date SOUp�Cr�REGULATION L 1 d Q— ( �a Re-roofs S' mwrc of ApplicanUC tractor Date H BeRDOUSMATERIALS tston,(SSURE Type of Roof ed by t e plicant Cupertino future Municipal ode.Chapter tsmm 2.andthandle Heambous rt and Salcry defial ned o do Cupertino Municipal Code.Chapmr 9.13,and the HcaIN and Safny Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. Will the applicant or drum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove .Tit haaardnus air canmmin...as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yea vklu I have mad the huaNsms materials requirements under Chapter 6.95 of tho Califor. nice Hca W G Safety Code,Sections 25505,255]]and 25530.1 undersand out ifthe building does not currently new a truant,that it is my respo mbiliy to notify the occupant of the mqui n.whtchmamberu Hort i uanmafaCemficamaroccupancy. Signature of Applicant Dale L1� 4 o do aedasant Data All roof coverings to be Class "B" or better _ . Y°, ' RINFORM�� CITY OF CUPERTINO V 'sxe, u CONTBUILDING DIVISION pJR� O N . O , r BUILDING ADDRESS: PERMIT NO. ALAN F. BETTY JOHNSON 04080101 ER'S NAME: PERMIT ISSUE DATE 1ARCHFrECT/ENGITNEER: ONE: SANITARY 0 OL N0. BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 toLICENSEDCONIRACfOR'SDECLARATION Job Description iw1 M1ereby affirm he,1 am licensed under provisions of Chapter 9(ommencing eUwith Section 7grip of Division Sof the Business and Professions Codc.and an,iccmc is ^n„ imfull force and effect. REMODEL MS . BATH/REPLACE WINDOWS IN MS .BED/BATH ju�z License Class Lisp Z�G DO - m Cuntracr [fp ARCHITECTS DECLARATION Y C I undersand my plans shall he used as public rtenNa D0.3 C y Licensed Pmfcssinnal g OWNER-BUILDER DECLARATION Contractor's 1 hereby um affirm that1 1. exempt from the Cssions o License Law for the no following reason.(Sector 7(13 L9,Bulinus and improve, de Professions Code:Any city or county / m which requires a permit m cnnaruct,eller,improve,demolish,or rile sig any slmnacut 2 prior m its issuance..1.Mi.i sthc aVidiltm for such permit m Blc.signed sammcnt Valuat n that he is licensed p...art to the provisions of the Comrumri License Law(Chapter Y Sq.Ft. Floor Area D� mHm (commencing wi th Section 7")of Division 3 of the Business and Profusions Calle)or a — But he is exempt therefrom and the 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 3N 9NA31OeF00 Occupancy Type mot marc than five hundred dollars($50y. 0 1,as owner of Ne pmpony,or my employees with wages m their sole compensation, will do Professions and the he Camis oar's Lnthetle Law dA favor apply to an owner of Required Inspections and Professions Code:The Csnmcton,Liana law uses not apply ff an owner of q I) . property who builds or ed than Neuron,and er.mwhodoessush work himself edIAmugh his own employees,provided that such improvements arc not intended.,offered the O e.r hu .the building orimprovementishat withinone year of completion,the ownc> sae)builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with liamed contractors to connruct the project(Sec.7D .Business and Professions Code:)The Conuacmh Li. Moue law thou not apply to an owner of property who WiMs or improves thcmon,and who contracts for such pro cox with a contraaor(s)licensed pursuant m Ne Cooluum fs License Law. 1 am exempt under Sec. Date= WORKERS PSC for this�rcazon WORKER'S COMPENSATION DECLAR&4dH 1 hereby annm under penalty of perjury,one of the following declarations: 1 have vad will maintain a Cenifteam of Consent m self-insure for Worker's Corn pen- eoiom,as provided for by Section 3701 of thth One labor Code,for e performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the labor Cade,for the pcdomanee of the work far which this permit is issued. My Wolach Compensation Insurance artier and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEM MON FROM WORKERS' COMPENSATION INSURANCE (This section need entire completed if the Permit is rnr tmehundred dollars nHKB or less.) 1 terrify that in the performance of the work for which this Permit is issued.I shall not cmPloy any perzny mFsn^w.bgdomciJjcr,'t mthC Wahcrs'Csmprnsaton Laws of Californi cbKm '-!! Applicappl three. �T¢APPLICANT:If.Curr making Pr Provisions Of or Exemption,code, you should m boom )mp to the Worker's iSmpcnsat is permit imu ter the Labodeemed Codc,you moa .Jz foMwith comply with such Proviaiam Or this permit shall ba deemed rooked. ZO^ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a concoction lending agency lot the Performance of Psi the work for which this nmil is issued(Sec.3(97,Civ.C.) W ALends,Name C6 Lender's Address V C 1 comfy that 1 have rod this application and sale that the above information is W F' correct.l agree no comply with all city and county ondinaa as and shot laws rotating m pU building concoction,and hereby aurbome mprescnativu of this Miry m comfupon the r W alcove-mentioned property for inspection purposes. /l (We)agree to save,indemnify and keep harmless the City or Cupertino against liabilities.judgments,costs and expenses which may in any way accrue against said City / V Z in emms omm of the gaming of this permit. I/ '^ Date APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOU�C�jREGULATION A ( � (h4 Re-roofs S' nawrc of AppI inn tractor Dam HA ARDOUS MATERIALS DISCLOSURE Type of Roof Will thcapplicame"tuure buildingoccupantsmrcorhandlcharardousmaterial thcfibe,by the Cupertino Municipal Code.Chapmr 9,12,and the Health and Safety de.Section25532(.)? All roofs shall be inspected prior to any roofing material being installed. ❑Yee t Ntr 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 7domr it haordous air conmminams as defined by the Bay Arca Air Quality Management all new materials for inspection. arist] ❑YM 0.'u I have mad the haoardous materials requirements under Chapter 6.95 of the Califon- a Heellh&SafctyCodc.Sections 25505.25533 and 25534.1 undcra.+nd that if the building not currently have a mmol,that it is my responsibility w noury the axupant of the qui mil awmmmunttl,c on tion i aanaofacrmnamoraapaacy. Signature of Applicant Date a-0 Ll- r All roof coverings to be Class "B" or better o atmodxMdagcnt D„ tz� gfaC�a 11 Si J�✓u'✓ Vdtn / close t RE EIVEDF lzlr'u: �UG 12 2004 \ I CITY QF-CURERT@1Q e — N ,,A �,-z ' J I J t � � :, �3UILDIN' DRARTMENT " 5 T- '— 'J 'J; - J, I APPROVED J I I ACCORDANCE WITH THE CITY OA 01.P.ERT:"0 ` DES P ID R ANCES DAT (/ SIGt ED Thi: set of pl and specifications MUST be apt on the job at all times and it is un lawful to make any changes or alterations C-V C�� r.NAJ C on same without written permission from the building Dept., City of Cupertino. The stamping of this plan and specifications S C� o L-0-\)v ^ °" t SHALL NOT be held to permit or to be ar, approval of the violf2'a if anv City Ordnance �r j,tate Lew. 11 SttUw v W 14 L) t (2�� �tit � �7 WiU J J• 13nTL o H 12�Pl �tcti U.1., VLCJ ✓��dEtib t—U o.(.✓i i IL t,'P�8 c� th.: ry Y`^=✓ (a i �2 `1 fv i j-t� G v io �7.-. ✓ t N r n�r to vJ ✓V) C1 � ` Cl / ® i 0� ® CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp : Rng: Sub: Blk: Lot : APN . . . . . . . . : 35928039 . 00 DATE ISSUED. . . . . . . : 08/12/2004 RECEIPT # . . . . . . . . . : 26661 REFERENCE ID # . . . : 04080101 SITE ADDRESS . . . . . : 1054 COLONY HILLS LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : ALAN & BETTY JOHNSON ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5802 RECEIVED FROM . . . . : ALAN JOHNSON CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : ALAN & BETTY JOHNSON ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5802 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL --- --- -- -------- ---------- - --- -- -- --- --- ------ BPERMFEE VALUATION 8 , 000 . 00 147 . 96 0 . 00 147 . 96 0 . 00 BPFIXTURE UNITS 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00 BPLANCHK PERMIT FEE • 147 . 96 197 . 45 0 . 00 197 . 45 0 . 00 BPREPIPE NO OF FIXTURE 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00 BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 BENERGY PERMIT FEE 147 . 96 71 . 02 0 . 00 71 . 02 0 . 00 . BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 PPERMITFEE 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 2 . 00 2 .40 0 . 00 2 . 40 0 . 00 BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00 BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00 BSEISMICRE VALUATION 8 , 000 . 00 0 . 80 0 . 00 0 . 80 0 . 00 EPERMITFEE 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 TOTAL PERMIT 751 . 71 0 . 00 751 . 71 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER --------------- -- ------- ----- ----- - - ----- CHECK 751 . 71 711 AL RECEIPT 751 . 71 az&1;16-En *CITY OF CUPERTINA CITY OF PERMIT APPLICATION FORM 6YOS 0( 6 l CUPERTINO APN # 3 S—� 2e J Date: a —( ;1 ` O 4- Building Address: Mailing Address (if different from building address): Lo s-4- no(b., ►-1-;tIs Lti Owner's Name: Phone #: /44d.h K , \,vtsay 47-i�-6(4-- Contractor: License #: (L J-4KsJL Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: (Mpg�ma C'JXi57-N'49 m6s;, cv- �� w�� , 12e0 dc= B,Z � --x I wHdow , Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential E- Commercial ❑ Sq.Ft. Floor Area: ` u V $/Sq.Ft.: Cost of Project: Occupancy Gro Type of Construction: Please check this ox if the project is a second-star 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> 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 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 7 /�� W