04120043CITY OF CUPERTINO -
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- . • —
DIVISION PERMIT
CONTRACTOR INk'RMATIQN
nulcmNc
.' �;.. . , . _
BUILDING ADDRESS:
ALAN JOHNSON
PER11N`b4120043
1054 COLONY HILLS IN
OWNER'S NAME:
PERM)TLSSUEDATE
ALAN JOHNSON
117,1
JE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description.'
1 heeby .from Nat 1 am licensed under provisions of Clapmf 9 (commencing
wide Sectitn]pk1)afDivision]of the Budrry aM Profeasium Codc. arWmYliccsLs is
I �� /� [�
in full fame and effect
' Lit.
REMODEL BATHRM (MAIN BATH)
License Class
... - - 1. ✓: (,.J . - ..— -
r
Date Contractor
ARCHITE.CrSDECLARATION
_na
(^
I undcrsund my plans shall M used a public recat
_
v 37
t7 � (I�
Licensed Pm(cssl i...-�
OWNER -BUILDER DECLARATION
Law for use
1 hereby .Rom io n I em ucmpt from Nc Camme, Any
C
Code: Any city comtty
following massa 8131.5. and o Co :
� _
V I`I` [j ��a�
t, alms.
improve. de l s
which requires a permit m construct, tler. impmw, dcroslsh, Or repair any swnum
Poch O
/ b i� 0
prior mitt issuance, also requims the applicant for such permit to Glc. signed satemem
FL Floor Area
_
Vahlatioll✓
that he is licensed pursuant to the previsions of the Contractor's Ueeax Law (Chapter 9
_ .Sq.
(commencing with Section 1") of Division 3 a(Ihe Business and Prafca ions Code) or
Nat he is exempt thcxfrom and use bass far the alleged eaempuon. My violation of
3 et00
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant Or a civil penalty of
not more than five hundred dollars ($500).
❑ I,Mo =ofthepmpmy,armycmployaswiNwagwn Vabmlecompertsouon,
_
Required Ins eCt10I1S
will da Newerk,and thcstrocturt is nminarWed oroffened hostile (Sen. 7(1 Business
and Profesvores Code: The Canuact re. Lt.. law ot d. napply to er an owof
' --
p
pmornywhobuildsorimprovestherean. and who doessuchwork himeclfor thmugh his-
Ownemployoes, provided Nmsuchimpmvemenuarcnmintonded oroffered forsale.If,have
Out year of therose
---
improveof
builder will love the bodies of proving that M did oat build o imDrow far purpose of
randid
- -
vle.).
v owner, of the property, 2m exclusively contracting with licensed lummuchm, in
- uuct the project (Sec. 7014, Business and Professions Cade:) The Contractors U.
true law dos not pply man owner of propeny who builds or impruve, Vemon. and.-
whocontractsfor such projects with a comeactor(s) licamed pursuant to the Contractors
- - - - -
License Lew. . .
O I exempt undco Sea . B & P C for this m•ion-
O _ Dit"--7—U4-
YORKERS VMPENSATION DECLA0. TION
I heeby .Rum under penalty of perjury ox of Ne foltowm antions:
-
eJ Iham and will maintain a Certificate of Conxnuo serf -insure! taker's Compen-
"-
sation, az provided for by Section 3700 of the lahor Code, far pertormance of the
work for which this permit is issued.
❑ I have and will m&imain Workers Compensation Insurance, m eyvied by Section
-
37110ofthe Labor Code, for the performance of the work for which this permit is issued.
My Workers Campcnsauon Inxnoce carrier and Policy months, am:
-
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
flits section need nm be complcad ifft permit is form= hundred dollars ($100)
or Itis.)
1twifv int perfummnec of the work for which this permit is issued, l shall net
-
[s c
c m an onman mannerxazlo bceom b tt cW ri t oration
g..0 jcc fN
-- '
_oakc
vvvso lifard..
A tic �7
this of FLabor o you ould
N TO APPLICANT: If, afterCom
inti previsions of d i Most-
byem subjca m iM1c Worker'. Compensation provisions of the tabor Code. you mon
for, iwith comply with such pmviuom or this permit shall M dmmcd invoked.
CONSTRUCTION LENDING AGENCY
'
I hereby.Nitre Nat there is construction agency for Nc performance of
s 7. Cit.
' the work for which this permit is issued (Sec. J(19]. Civ. C.)
Lendcr'a Nam.
lenders Atldrus
1 certify that 1 have mad this application and sum Net lie above information is
' cement. I agree 10 comply with 211 city and county ordinances and state laws relating to
building construction. and hereby .0 horim mpresenutives of Nis city to enter upon We
ahow-mentioned property for insPection purposes.
(We) agree to saw, indemnify and keep harmless the City of Cupeninu against
j liabilinos.jodgmcnts. costs and as,.. which may in any way amus.,itint said City
' in consequence of the granting of this permit.
• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU E REGAILATIONS.
Re -roofs t
Type Roof
&lure offApplicano/Canor0orData
HAZAR15OUS MATERIALS DISCLOs
of
Will the applicant or future building occupant shore or handle hanNous material
az defined by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
Ile. section z553zpn .,t''
❑Yes
All roofs shall be inspected prior to any roofing material being installed.
iy.0
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant ar fulue building decorum use equipment or devices which
na hazardous air contaminants as defined by Vac Bay Area Air Quality Management
all new materials for inspection.
Dinner]
(:1 Yes �Nu
I have mad the hotandlinis..Hall myuimmcm under Chapter 6.95 of We Califon -
ns Health & Safety Cale, Sections 35505,25533 am135534.I undersraxI Naz i(the building
d oat eurremly haw a tenant Naz it s my rosponsihility m notify the nccupant of e
ynim entswmhmaatbemet ri tansar.eeNOemeof isn'
Signature of Applicant Date
X-7
All roof coverings to be Class "B" or better
net or authodmd agentif
r
02
Z C
4
CITY OF CUVER'I'INO
s' "_' "'''t
BUILDING DIVISION pF
CONTRACTOR INFOR ON
BUILDING ADDRESS:
ALAN JOHNSON
PERMIT N904120043
1054
NER'S NAME:
PERMIT ISSUE DATE
ALAN JOHNSON
1-2110-7,19 11r) 4
PHONE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION.
i Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
P
with Section?M)) of Division 3 ofthe Busincssand Professions Code. and my license is
Ifbne erreeL
REMODEL BATHRM (MAIN BATH)
License Class Lie. p
Class
DateContractor
_
ARCHITECTS DECLARATION
I understand my plans shall W used as public ¢cords
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby mBrm that 1 am exempt from the Contraaefs License Law for the
-
following reason. (Section 70313, Business and Profession Code: Any city or county
'
which requires a permil to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit a Glc a signed statement
that M is licensed Pmsuantro We provision of the cnmactar: ueante law(Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 700(1) of Division 3 of the Business and Profusions CBM) or
Nat he is exempt therefrom and the buu for the alleged exemption. Any violation of
3 W12440uh9riero0
Occupancy Type
Section 7031.5 by arty applicant for a Permit subjects the applicant to a civil penalty of
not mom dun five hundred dollars ($500).
'
❑ I, As owner of the p.pcny, or my employees with wages as Weir role comPenaauon,
Re ed Inspections
will do We work and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Cneducmr's Licenu Law does not apply to an owner of
_
,.pert, who builds or improves thereon, and whodoessuch work himself car Ih.ugh his
-
moaned for owner,
owncmployecs.providedthatsuch nt is wit in not year tedof the owner.
hutWeavetiebrimprovement is soldnot year of comove
..
,
�/�
lathe did foron,
but later will have the burden of proving that he did not build or improve (car purpose of
later
Sale.,.
/
/
L ax owner o! the am exclusively contracting with liccnud contractors t.
.
Sropcny,
sv tthees not (See n.and ProfusionsThevesthemr's
Lawto an ownBaser ofpropcny who ds or i thereon.and.
And ce nelawdoesr
plyman
-
ecadeddsorimproves
who for Such projects with a contractors) liccnud pursuant m lite Contranar's
such itha
se Laces
License law.
'❑1 eacmplunder Sec. .B&PCfmddx...n
IV
Date,1-7-04-
WORKER'S VOMPENSATION DECLARATION
1 hereby Arm order penalty of perjury one of the follow; �alyla,ions:
0 I ham and will maintain a Cenifica a of Conunt to self-inurefoyWerkefs Compen-
sation, u provided for by Section 3700 of the labor Code. fest a .Iformame of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance, As mquimd by Section
3700 of the labor Code, for the performance or Ne work for which this permit is issued.
. .
My Worker's Compensation Insurance canim and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Seaton need not hceomplewd if th<pe.it is reform huadmd dollars ($10()
lr Ic15.)
"I ecnif th I , crfmmanee of Ibe work for which this P omit is issued, I shad not
mPl an turn y mannerxnnto becomCSubjcetmlM1e Wo�kc s'c nation
apatp,
awso lifamia 1 I 12—! pot�pc
tic
NO TO APPLICANT: If, after king this Cenificode of Exemption, you should
NA
subject to the Worker's Compensation prevision of the Labor Code, you must
r forthwith comply with such provisions or this Permit shall ba deemed invoked,
I-
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the perfurman¢ or
We work for which this permit is issued (Sec. 309?, Civ. C.)
lender; Namc
Lender's Address
j 1 certify that I have mad Ida application and state Nat the above information is
"
' cortecL 1 agree to comply with all city and county oNirwas and sum laws relating to
ibuilding construction. and hereby authome represenutivcs of this city W coder upon the
above-mentioned property (of inspection purposes
(We) agree to save, indemnify and keep harmlcu the City of Cupertino against
j liabilities, judgments. costs and expenses which may in any way accrue against said City
i..i
in consequence of the granting of this Permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 1
SOURCE REG LATIONS.
Re -roofs
Type of Roof
2 --
amts of ApplicantiConfir
HA,AR DorUS MATERIALSSU) Dam
Will Weapplc2morfuture building occupant shomofhandle
material
Asdefined the Cupertino Municipal Code. Chapter 9.12, and the Health anJ Safety
Health
Section
roods. Sc 5532(x)?
CO.Yes �f}blu
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building =upon( use equipmentbrdevice, which
emit hanardeus air contaminants As defined by tits Bay Area Air Quality Management
all new materials for inspection.
District?
Oyes XNu
I have mad the hanedi materials mquimmenu underChapserti of the Caliror-
nix Health & Safcty Codc, Secdats25505, 25533 and2553,1.I undcrstaed thv ifthc building
0. not cumendy have a tenant. that it is my rvponibility ki notify We occupant of c
qmm . mhAuto tbcmet dor auAmAoraceNrwateer cane,.
Signature of Applicant Date
roof coverings to be Class "B" or better /
net aramhmized.,rd DeadAll
Item 1 of 1
•
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35928039.00
DATE ISSUED.......: 12/07/2004
RECEIPT #.........: 27964
REFERENCE ID # ...: 04120043
SITE ADDRESS ......
SUBDIVISION .......
CITY .............:
IMPACT AREA ......
171
1054 COLONY HILLS LN
CUPERTINO
OPERATOR: conniew
COPY # : 3
OWNER ............:
ALAN
JOHNSON
ADDRESS ..........:
CITY/STATE/ZIP
...: CUPERTINO
CA, CA
95014-5802
RECEIVED
FROM ....: ALAN
JOHNSON
CONTRACTOR
.......: LIC
# *OWNER*
COMPANY ...........:
ALAN
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
-----
15 000.00
-----
223.56
0.00
--------
223.56
0.00
BPFIXTURE
UNITS
3.00
27.00
0.00
27.00
0.00
BPLANCHK
PERMIT FEE
223.56
298.34
0.00
298.34
0.00
BPREPIPE
NO OF FIXTURE
3.00.
27.00
0.00
27.00
0.00
BPSEWAGE
UNITS
1.00
67.14
0.00
67.14
0.00
BPSEWER
SEWER SYSTEM
1.00
21.58
0.00
21.58
0.00
BPSTORM
PER DRAIN
1.00
9.00
0.00
9.00
0.00
BPVENT
UNITS
1.00
10.79
0.00
j10.79
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
PPERMITFEE
FLAT RATE
1.00
38.37
0.00
38.37
0.00
BREMFIXT
NO. FIXTURES
10.00
12.00
0.00
12.00
0.00
BREMPOWER
POWER UNITS
2.00
65.95
0.00
65.95
0.00
BREMRECEPT
NO. OUTLETS
6.00
7.20
0.00
7.20
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
15,000.00
1.50
0.00
1.50
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
----------
----------
1058.13
0.00
---
1058.13
0.00
-
METHOD OF
PAYMENT AMOUNT
NUMBER
-------------
4V------------
K
-----105813
10--------
1058..13 108
TOTAL RECEIPT
1058.13
CITY OF
•
CU
PERTINO
d
•CITY OF CUPERTINO•
PERMIT APPLICATION FORM
ofl zJ1�3
APN 97
ate:
Fee Group
BAPPLOTHER
Building Address: Mailing Address (if different from building address):
IDSU-Cow-K y µ;(Is Lvi
Owner's Name:
Phone #:
A\o L11Lc LT01nv^S0 Vj
Gu8-25-7—S61L1—
Contractor:
License #:
Uwr( E7 (Z_
Boiler> 500K to IM Btu
Contact: Phone:
Cupertino Business License#:
Fax:
MECHANICAL
Building Permit Info:
Bldg ❑ Elect JZ Plumb EX Mech ❑ '
Job Description: (2,-vKo8,-I d-t4.1yvow /1.1 H !3. I?,
Residential X Commercial ❑
Sq.Ft. Floor Area:
$/Sq.Ft.: —
,�—V Sr) fiT
Ind/Off/Comm/Quasi
Cost of Project: -g
Occupant roup:
o J
r
Type of Construction:
Please ch ck thF ox_if-th ect is a
BUILDING
second-stor
Project Size: Standard ❑ Large ❑ Major ❑
BUILDING
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBOILERI
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler> I OOK to 500K Btu
MECHANICAL
BBOILER3
Boiler> 500K to IM 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 <= IOOOA
ELECTRICAL
BELEC1001
Elec 600V > IOOOA
ELECTRICAL
BELEC200
Flee Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BI VESTIGA
Investigation fee
BUILDING
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