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05090087 CITY OF CUPERTINOa '?�Ta�s ''� ' BUILDING DIVISION pp+R �CON'�I�p.CTOTU4ORM aN 4 5 :; BUILDING ADDRESS: R.K. BERRETT CONSTRUCTION ITIC'ITNO05O9OO87 21941 COLUMBUS AV OWNER'S NAME: PERMIT ISSUE DATE MAROLYN 0. CHOW 6151 CALLE DEL CONEJO 09/13/2005 E: SANITARY NO. CONTROL NO. I (408) 268-0530 ARCHITECPENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH _Oo LICENSED CONTRACTOR'SDECLARATION SJob Description f6 C 1 thereby affirm dr.,1 am Iimnud under provisions of Ch.,.,9(commencing w with Section 7IXNp of Division3 or the Busirvammd Pmfcssons Code,and my Use.is in mu come and effect. WINDOW REPLACEMENT (13) . Z License Class Lic.If Date Contract., ARCHITECTS DECLARATION a I understand my plans shall be used ae public records JyU so In Licensed Professional S OWNER-BUILDER DECLARATION ef I hereby affirm that I am exempt fru¢the Cm%racmr's License Law for the 00 following reason.(Section 7131.5,Business and Professions Code:Any city Lir county m which require a Permit to construct,alter,improve,demolish.or repair any structure $13000 iy prior to its issuance.also acquires the applicant for such Permit o rile a signed statement < thathcislicenseJPursuanuothe provision o(the Contractor's License aw(Chapter 9 Sq.Ft. Floor Area Valuation (eohcialieovxd Scctien7(I00)nf DivisionJnf the Businessmind Professions Cnde)or y that he is exempt thereGom and the basis our the alleged exemption.Any violation of Section 7031.3 by any applicwt for a permit subjects the applicanuo a civil penalty of _37WFMni8erUU Occupancy Type not mart Nan five hundred dollars(SSW). n 1,as owner of the property,or my employed with wages n their is compensation, will do the work.end fee swaure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does nor apply to in owner of 9 P property who builds or improves themen,and who doessuch work himself or through his Own employees.provided tum such improvements arc not intended or offered for mile.If, however.the building or improvement is writ within one Kar of completion,the owner- Q� ' builder will have the burden of proving that he did not build or improve far purpose of y sale I R-fas owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Conmemrs Li- cctue law docs that apply t.U owner of pfoperty who builds n improves thereon,and whoe Law hprojeei owner of prope ywho Wilds UC Contracton License law. / ❑lam exempt dB&PCfor hhi tefsjm�o�onq �a� vena, Da - • a WORKER-9 COMPENSATION DECLARATION I 1 hereby affirm undo pcnahy of perjury oro of On following declarations: v `. a]1 have and will maintain a Certiftcam of Consenuo self-insure for Workers Compcn- astion,as provided for by Section 37W of the labor Code,for the performance of the work for which this Permit is issued ❑1 haat and will maintain Workers Competnation Iosurwce.as mrmmil by Section 37M of the labor Code,for the pertonnance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number art: Cartier: Pali,,Her: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (This section need not W complemJ if tK Permit is for one hundred dollars(SIM) or less.) I certify that in the performance of thc work or which this permit is issued,I shell nut employ any Per nany manncrw 1�Ifa+�tM Workers'COurpom2uhm Taws or Califo a APPlicant& � •• NOTICE TO APP 1C—�ANr:IL after making this Certificate of Exemption,you fiuuld become subject to the Worker's Compensation previsions of the Labor Code,you mum .JO forthwith comply with such provisions or this Permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY 'pw l hereby affirm that done is a comwction lending agency for the Performance of a 7 the work for which this permit is issued(Sec.3097.Civ.C.) W A Under's Name D+ Lenders Address az U Q 1 cmify that I have read Nis application and Stam that the above information is W E" r armcL l agree to comply with all city and county ordinances and sum laws mlaling to L7(, building construction,and hereby suthofire repret.nmime of Nu city to enter upon the r Lq move-mentioned property for inspection purposes- (We)agsce to save,indemnify and keep harmless the City of Cupertino against F" ,,I liabilities,judgments.costs and expenses which may in any way arrive against said City U in consequence of the granting of this perm it. '—' APPLICANT UNDER T NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULAT19�S ��7� &W 1?T1jt ;;6 Re-roofs Signature of Appli�o mm y a HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will the applicant Lir future building Occupant more or handle haoardous material as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety Code,Section 255324)? V5� All roofs shall be inspected prior to any roofing material being installed. ® 0 Will the applicant or¢tam nnudmg ocapant use equipment or aevmea which If a roof is installed without firs[obtaining an inspection,I agree to remove omit haxardous air contaminants as dcrinee by the Bay Area Air Quality Management . all new materials for inspection. Disuist? ❑Yes I have mad the hurallous materials requirements under Chapter 6.95 Of the Cali foo- nice Health&SafctyCode, 2505.25573 and 25534.1 understand that if the building docs not currently naw a t a'i is my responsibility m notify the occupant of me requirements which mu n P' ' g;aatic of.certific"o�r, 1465 Signature of Applicant Date Owncrmauthorircdagent (v �,� All roof coverings to be Class "B" or better CITY OF CUPERTINO I 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35614035 . 00 DATE ISSUED. . . . . . . : 09/13/2005 RECEIPT # . . . . . . . . . : 31175 REFERENCE ID # . . . : 05090087 SITE ADDRESS . . . . . : 21941 COLUMBUS AV SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : MAROLYN O. CHOW ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4714 RECEIVED FROM . . . . : MAROLYN CHOW CONTRACTOR . . . . . . . : ROBERT K. BERRETT LIC # 23418 COMPANY . . . . . . . . . . : R.K. BERRETT CONSTRUCTION INC ADDRESS . . . . . . . . . . : 6151 CALLE DEL CONEJO CITY/STATE/ZIP . . . : SAN JOSE, CA 95120 TELEPHONE . . . . . . . . : (408) 268-0530 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ------ ---- ------------- ----- --- ---------- ---------- ---- BENERGY PERMIT FEE 201 . 96 96 . 94 0 . 00 96 . 94 0 . 00 BPERMFEE VALUATION 13 , 000 . 00 201 . 96 0 . 00 201 . 96 0 . 00 BSEISMICRE VALUATION 13 , 000 . 00 1 . 30 0 . 00 1 . 30 0 . 00 BPLANCHK PERMIT FEE 1 . 00 83 . 16 0 . 00 83 . 16 0 . 00 ---------- ----- ----- ---------- TOTAL PERMIT 383 . 36 0 . 00 383 . 36 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER -- - - - ------------ ---------- -- --------- --------- OTHER 383 . 36 M/C ------------ TOTAL RECEIPT 383 . 36 a a 3"is �jlCYfTINE • irCl - RESID�NTIAL�P _ OAC ""'M'CO�ER3iriuuj � CUPE�FINO - � yxrc ¢ 7 'ht Assessor's Parcel Number: Name of owner. /zl~,e— Project address.. Contact person. Phone. Fax. Net square footage of lot. Ecistin Proppsed Square footage: First floor: ff Second floor: Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N A Is privacy protection planting required for the project? Y N On what floor(s) is work being done? /-/BST sft91U4 ` Brief description of work. l l/yGXJpIYfS 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 -f Plan 11 " , cclM vvti.. CoeUz J'ficr+d.ard-/' /. �.6;c�`I • Plan Review Process Work Book Page-B-Revised 4/28/04 OCITY OF CUPERTIN* cry I J j 7 / CUCITY TYOF O PERMIT APPLICATION FORM 4RF N # / / Date: ��i31a5 Building Address: Mailing Address (if different from building address): M! 'l 6 Owner's e: Phone#: !IE'D F Cont actor: License#: !6 6581 Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: Bldg Z Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential Commercial ❑ Sq.Ft. Floor Area: q.Ft.: Cost of Project: /4000 Occupancy Group: Typ 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> IOOK 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 031, 7x- 1 of 3 r 1 3411 3_, 3 j^ ;d *CITY OF CUPERTINP CITY OF PERMIT APPLICATION FORM . CUPERTINO Quantity Fee ID Fee Descri tion 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 InstaWAlter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT ReinspecIfion Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMA KHAN A/C Units <= 10,000 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace 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 BREMRESAPP Remodel Res A liance ELECTRICAL 2 of 3 'PITY OF CUPERTINO 0 CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmd] 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 InsectioD 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 I Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING • 3of3 4z O FfVED O SEP 1 3 2005 :LL Oopd ocol/ Cry. CITY OF CUPERTINO '�' �ma�•a-Sw +'�->= 'a�e�°" '% `"° zr- BUILDING DIVISION PERMIT CONTRACTOR INFORMATION _�' BUILDING ADDRESS: R. K. BERRETT CONSTRUCTION I40iMTNO05090087 21941 COLUMBUS AV OWNER'S NAME: PERMIT ISSUE DATE MAROLYN O. CHOW 6151 CALLE DEL CONEJO 09/13/200S NE: SANITARY NO. CONTROL NO. (408) 268-0530 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLOG ELECT PLUMB MECH u00 LICENSED CONTRACTOR'SDECLARATION Job Description C I hereby affirm Nat I am licemed under provisions of Chapter 9(commencing iwith Section 7")of Division 3 of the Business and Profewiom Code,and my licame is imm�fmcenndaffect. WINDOW REPLACEMENT (13) ���� � � _ jI22 License Class Lic.as _ `\ cF❑ Da¢ Controcot l.� Ua ARCHITECTS DECLARATION I understand my plans shall W used as public records g o Lkcnsed Pmfcssianal 5 OWNER-BUILDER DECLARATIDN <F I hereby affirm thus 1 nm exempt from the Contractors License Law for the p 1 i no following mason.(Section 703 1.5.Business and Professions Code:Any city or county ( �( N T fQ1I`,t' <m which m res a t m construct,alter,improve demolish,or re air an sumwm �,' �� 11 \ �1t 3'(]v�Q yui .it pro p y 1 IN t. h _ prior us ita issuance.also requires the applicant forsuch Permit o file a signed statement < Nat he is liecnud pursuant o the provision,of the Contractor'sLicense Law(Chapter 9 Sq.Ft.Floor Area Valuation 'l-a (commencing with Section 7")of Division 3 of the Bushemand Proksdom Cnde)or y`< Nat he is exempt therefrom and the basis for the alleged exemption.My violation of Section 7031.5 by any applicant for a gemma subjects the appy anus a civil Penney or MiQni8er U Occupancy Type not mom than five hundred dollars(S500). ❑I,unwnetorthepmp ay,ormyemPloyceswithwegeavtheirsOleeomp ftULion, will do the work and the structure is not amended ororfered forsale(Sec.7044,Business and Professions Code:The Conuactor's License law docs tat apply to an owner of Required Inspections Property who builds m improves Hereon.and who data suchwark himself or trough his own employees,provided Hat such improwmentt tie notimended or offered for sale If. however.He building or improvement is sold within one ycv of campledon,He owncr- builder will have the burden of proving Nat he did oat build or improve for purpose of sale II. p�s.as Owner of He property,am exclusively contacting with licensed contractors to convect He pmjcct(Sec.7044,Business and Professions Cade:)The Contractor's Li Co.Law dors not apply to an owner of property who Guilds or improves Hereon,and, who contracts for su mjects ro with a coractoKN s)licensed pursuant to e Contractor's Laa om law. t ❑1 am exempt .B&P C for s mason Owner Dam WORKER' `MPENSATION DECLARATION I hereby and under penalty of perjury ane of the,following declarations: - 1 have and will mainu;n a Certificate of Consent to self-insum for WorizesCompen- sation,as provided for by Secuon 37M of He labor Code,for the performance of dm work for which Nis permit is issued. 1 have and will maintain Worker's Compensation Iusmancc,as m,uired by Section "M of He labor Code,for Ne performance of the work for which His permit is issued. My Worker's COM penmHon lnsumnce carrier and Policy number am: Carrier: Pnnry No.: CERTIFICATE OF EXEMPTION FROM WORKERS' .-COMPENSATION INSURANCE (This section reed not W completed if the Irrmit is Pardon hundmddollars(SIM) carless.) 1 certify Nm in the performance of Ne workJor which this permit is issued,I shall nut cmPlays, rm many manncrso 17,ef - the Workeri Compensation Laws of Califs t - rvvittam NOTICE TO APP Ie Worker f,n@r making Hts CcmRs of Or Exemption.Laborre.you became subject ro it WdhR oCompcesauon Permit provisions Of 1de Uedr evoke you muse .J O forthwith comply with such pmvisinm or His permiuhall be deemed revoked. ' '� ayNwCONSTRUCTION LENDING AGENCY [r I hereby RBirnt Nat than is a conswctinn lending agency lot On Performance of C the work fur which this pmmi,is island(Sec.309'1,Civ.C.) lender'sa. Name , z Lender's Add. U0 I certify Nat 1 have read thio application and sate Nm On above information is n. cormcL 1 agree to comply with all city and county Ordinances and sum laws misting in CU building construction.and hereby authorim representatives or this city to enter upon He r W above-mentioned property rot inspccuon purposes. gy (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way name against slid City U z in cmtuquenec of Nc ger ting of Nis permit. '—' APPLICANT UNDER S D WILL COMPLY WITH ALL NON-POI Issued by: Date /,—y,j-- SOURCE REGULATI S 7 Wo Signatures MoiC ucdn °�'U Vat Re-roofs � �1 HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will He applicant or fumm building occupant time or handle ha ardous mmcrial as dchr ed by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety ,dg,Coda,otyOn 35533(x" ,�,�a All roofs shall be inspected prior to any roofing material being installed. win me apphant or m coining dccdpant este egdipment dr deices wren If a roof is installed without first obtaining an inspection,I agree to remove mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. Disu;cl? ❑Yes 1 have read Ne hnrardcaus materialsmquiremcn;under Chapar6.95 drum,Califor- aiaHcnith&Safely COdc,S Ejoa25$ � 5.355y33anu4ndlprodirde Wild ding mpo2 does totcarendy have tymnotify On .1 He Mquimmcnts which Signature of Applicant Date Owner or awomiled agent All roof coverings to be Class"B" or better