04090265 CITY OF CUPERTINO
BUILDING DIVIs1 ON PERMIT CONT CTORINk'O.RMATIgN. '
BUILDING ADDRESS: PERMIT N b 4 0 9 O 2 6 5
OWNER'S NAME: PERMITLSUEDATE
KENNETH & MARY rHEW Nny to
E: SANITARY NO. CONTROL NO.
ARCHI7 (ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
apZ' LICENSED CONTRACTOR'S DECLARATION lob Descri t100
a1 tummy affirm that 1 am licensed entice previsions of Chapter 9(commencing p
iWC wiJh Section 7IXk0 of Division 3.f the Business anProlessieru Code,and my lim.is
« inralIA m enderr«k( P ( EXTER. STUCCO (BACK WALL)
j i LiccnSe,Slns _Lic.
,a,—o nae Conu.ner_ C )NTRACTOR: ANDY HORIUCHI CONSTRUCTION
�dcrsaSh. Cr ECLAR records
u tnd my plans
shellbeuxd as uhlicrecords SUBCON. DOIN IT RIGHT (415026)
tu InLicensed Professional
O< OWNER-BUILDER DECLARATION
<I 1 hereby affirm Nn 1 am exempt room the Contractors License Law for the
0 o following reason.(Suction 7W 1.5,Business and Prefesamns Cade:Any city or county
K m which requires a permit to construct.ala,impmve,demolish,in repair any strumure
prior to its issuance.Stan requieu the applicant for such Permit o rile a signed statement -
t?<
that hcisrimmed purmanUoOn,pmvisioesofthe Contractorilimpose Law(Chapter 9 Sq. Ft. Floor Area Valuation
z�m (commencing with Section 71](0)of Division 3 of the B usiness and Proressiens Cone) or
y5 Nat he is
mmmtherefrom refrom and Ne hasu the for alleged exemption.Any violation of $4000
section 7031.5 by eery applicant for a penal,aebj«ta the applicant to.e_iw penalty or APN Number Occupancy Type
oat more Nan five hundred dollars(SSW).
1.as..of the properly,or my cmploym with wages as Nair ale compensation,
will do On,work.and the.enure u not intended or offered for sale(See.7061,Businessand Professions Code:The Comdmor's Liana Law does not apply to an owner or Required Inspections
property who Wildamimproves therm t,and whodaessuch work himself orthrough his
own employes,provided that such impmvemene,art notinummil proffered forsale If.
howevee,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
❑h as owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7014.Business and professions Code:)The Contractors Li-
ceme law does not apply to an owner of property who Wild..,impro es thereon,and.
who contracts for such projecLl wish a contractor(s)licensed pursuant to ft CpnVaetors i
�Iam eacmpt under See .B&PC far this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hemby eRrm under penalty of perjury one of Ne following declmatsons.
Aaw and will maintain a Cm ficateaf Consent to self-insum for WorkarsCompcn-
Saber.as provided far by Section 3703 of the labor Code,Per the performance of the
work for which our permit is issued.
Q 1 have and will maintain Worker's Compensation beco ance,as required by Section
37M of the Labor Code.for the perform nec of the work for which this permit is issued.
My Workers Compvwuo t Immmres,carrier and Policy number are:
tittle(: 1'WICrh
CERTIFICATE OFENFROM WORKERS'
COMPENSATION ATIONINSURANCE
(Thisuction need notbceomplmed if the Permit is faro«hundred dollars(SIgO
or less)
I cenify that in the peffernomm of thorydk�fomrg11whic�Nis pmmil is issued,I shall om
entploymypermn in any manna Y I ygEfScIMMeWorkers Compensation
Laws of Califo(nhk.Datg VV"1
Appheanl ( V Y
NOTICE TOA ICAWT:tr.Ifter. rmA7ft this Certificate of Exemption,you should
become subject to the Workm's Compensation provisions of the labor Cod,you mind
fom ilb comply with ouch pmvisimas or this permit shall W decreed revoked.
ZO^ CONMUCTION LENDING AGENCY
I hemby affirm that there is a cmatruninn lending agency for the Performance of
gG� the weak I.,which this permit is issued(See 3W7,Civ.C.)
ISOfender's Nemc
6. lender's Address
az
J0 1 cenify that 1 have mad Nis application and sate that the above infom,atiun is
t1.F correct.I agree m comply with all city and county oNlaws relating and SUM lawrelating to
C)U building construction.and hereby amhorne reprtunatives of Nis city to enter upon the
r F17 shove-mendancd Fortuity for inspection purposes.
6. (We)agree to sale,indemnify and keep humless the City of Cupenino against
Frp liabilities.judgments,casts and expenses which may in any way acorec against and City
U z his permit.
APPLICANT UNDESTANDS
g ooming of IAND WILL COMPLY WITH ALL NON-POINT Issued by: Date -
SOUF�[�RA NS.
11 11 _ 427(2-7 Re-roofs
Date
'gnmum of App cH ZARDOUS MATERIALS DISCLOSUREbou — ^_x-- Type of Roof
Will IM applicant or future building occupant store or handle hxnrdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Se❑eY..25532ool All roofs shall be inspected prior to any roofing material being installed.
Will the a (enol ear mlem wildm I ase e I pr dmmes whicher 1111"L
If a roof is installed without first obtaining an inspection,I agree to remove"
pp k occupan quipmen
I hazardous air commitment,.Jcfncd by the Bay Area Air Quality Management all new materials for inspection.
IWWl?
❑Yes Nu
I have read the hrombi.matcrialsreyuiremcnts under Chaper6.9Sof the Califon ..�
ria Health&Safely Cade,Sections 25505,25533 and 25534.1 undersand diatribe building
Joos n currently M10 tenant that it u my rearemihility m nouty the arc mdro of die �s
requ' now eh be pnorwissmn«oraCcNfmateor c[p"aar/ Signature of Applicant Date
own raddium.Jagent All roof coverings to be Class "B"or better
C[TY OF CUPERTINO `pts i? °+d " 177
BUILDING DlvlsfoN PER "CONTRACTOR`LNk�ORM I,ON*
cam. ,. a.,� �
BUILDING ADDRESS: """"64090265
ERMITNfy,4090265
47 CRPRKLILIE DR E
OWNER'S NAME: PERMIT ISSUE DATE
KENNETH & MARY CHEW
NOV 10 20W--E:
SANITARYNO. CONTROLNO.
RR
ARCHITEC IENGINEM: O D BUILDING PERMIT INFO
t\ BLDG ELECT PLUMB MECH
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATIONdelob Descri II00
e C I hereby affirm Ibar 1 Am licensed unr provisions of Chapter 9(commencing p
5 z,a with Section 7")of Division 3 of the Business an PrmfeuionsCode.and my license is
o�„ Lice.1A ceanamrre=hl u ( EXTER. STUCCO (BACK WALL)
O aI? LicenSC.rAhss
&1=n Dam Canwcon CONTRACTOR: ANDY HORIUCHI CONSTRUCTION
RCHITECTS ECLAR N
¢� +,jsWcrsundmyplansshallheusedas ahlicr«raw SUBCON. DOIN IT RIGHT 015026)
Dyer
3 a y Licensed Pmfcssinnal
g OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Comraso's Liecnse Law for the
me following mason.(Section 71131.5,Business and Professions Code:Any city or county
m E' which requires a Permit 1.conswct,elle,improve,demolish,in.,air any structure
Prior m its i.W..also mquims the applicant for such permiuo file a signed storeman
�E< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
lira (commencing with Section 7")of Division 3 of the Business and Professions Coda)of
to _ that be is exempt tWmfrons and the basis for the alleged exemption.Any violation of $4000
Section 7031.5 by any applicant for a Permit subjects Ne applicant to a civil Penalty of APN Number Occupancy Type
AM ream than five hundred dollars(5500).
❑Las owner ortfie property,or myemployvs with wegesas lheirsale compensation,
will do the work end Ne swaum is not imm�deJ or offered forsvle(See.]044,Business
dna Professns ioCade:The ca omaner's License Law dors not apply to an..or of Required Inspections
progeny who builds or immaves thereon,and who dWsauch work himseuarNmugh his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within arc year of completion.the owner-
builder will have the Wide.of proving that he did not Wild or improve for purpose of
sale.).
❑1,as owner of she property,am exclusively contracting with licensed contractors to
construct the project(Sec.7 4.Business and Professions Code:)The Contractor's Li-
ccnse law dose not apply m An owner of progeny who Wilds or improves thereon,and
who contracts for such projects with a consractoKs)licensed pursuant in Ne Contractors
License law.
(,7tivn exempt antler Sea. ,B&P C for this mason
]Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty or perjury one of she following declarations:
I Nva and will maintain aCeni scale of Consent to selbimum for Worker's Compen-
sation,as Provided for by Sttuon 3]00 of she labor Code.for she performance,of the
work for which this permit is issued.
❑I Move and will maintain Worker's Compensation Inwranu,as required by Section
3700 of the labor Cade,for one performance of the work for which this permit is issued.
MyWorkers Compensation Insurance carrier and Policy number am:
7 CERTIFICATE OF E%EMPrION FROM WORKERS'
COMPENSATION INSURANCE c
miisseetion need not N completed iftW permit is formic hundred dollars($100)
M less.)
1 certify that in Na performance of work for which this commit is issued.I shall ret
emPloyvnypeam.m.ray manh n SyblecI to the Workers'Compervation
Laws of Calor m.DAI V T
Appif
NOTICE TO ICA for mak. this Cenificme of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Code.you most
O farrowithmm,ly with such provisions or this permissh.11 W deemed revoked.
Z � CONSTRUCTION LENDING AGENCY
[--c ' IWmhyaffinm our there is.amissucsinn lending e,a.y for the orrumur.a of
E
the work for which Nis permit is issued(See 309],Civ.C.)
W Q Lender'a. s Name
Z Lenders Add.
U C I certify that 1 have read Nis application and state that the Above inf.maliun is
gL f-' cawch 1 agree to comply with all city and county ordinances and sum laws relating to
0 Wilding construction.and hereby authoriac representatives of this city to enter upon the
r d ahovcmcntioned property for inspection purposes.
(We)agree to save.indemnify and keep harmless she city of CApat ino against
Frq Iiabiliuu,judgments.costs and expenses which may in any way same against said City
V Z in cmnsequcnce of the granting of this permit.
m—'
APPLICANT WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REG A NS.
? 2-7 (ox
ignuu,of AMBeanucomraclor c� Data
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
az depned by the Cinnamon.Municipal Code.Chapmr 9.12.and she Health and Safety
Code.Section 25532dy? All roofs shall be inspected prior to any roofing material being installed.
El Yes
Will the a licant or future building
t nae a ui ment or device:which If a roof is installed without firs[obtaining an inspection,I agree to remove
rap g«cmpan q n
emit hazardous air contaminants az dcfned by Ne Bay Area Air Quality Management all new materials for inspection.
District]
❑Yes
I have real the bnzallous materials requimmens under Chapter 695 of the Califor-
ninHealth&Safety Core Sections 25515,25533 and 25534.1 understand that if the Wilding ,f\
data n m,has A enanl,Net it is my responsibility m noury the occupant of Ne ,
mqu' mntsw'Ch IWn priorm issuanceofaccnihcamor paty Signature of Applicant Date
own roc maria=,,sant �� Data All roof coverings to be Class"B" or better
• • Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
OtJPEI�TINO
-Building Department
JOB ADDRESS: `� � PERMIT #
84 CR�� uNC U`fo� oz��
OWNER'S AME: KEN M C, t.J PHONE # $O gke 1417 7f
GENE CONTRACTOR: N0C t FAX 1K (o5b) 4R 20
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing 1 1 S02(o
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
-Paving
Plastering S f} � S A*A 'p—
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
rr - OCITY OF CUPERTIN*
CITY OF PERMIT APPLICATION FORM /
CUPERTINO 0(� D f4b
7BuildA.Address:
PN # ,L l rl 0 t I .2 Date:
T `� 2� 0
Mailing Address (if different from building address):
- Cf-CEkL (-lNC
Owner's Name: Phone#:
KEN W KA-Vf CA uj $ & & q
Contractor: License#:
Nt,JD4 &QZtLKc( F> X83 88
Contact: N Phone: 6Sb $8 `f971 Cupertino Business License#:
F b� 7-02-k
Building Permit Info:
Bldg - - ' Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential E 9-kp( - ST uCC O Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: 66 Occupancy Group: /
Type of Construction: . Please check this box if roject is a
C pyJ second-sto addition: ❑
IF
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> 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
✓' I BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investi ation fee BUILDING
1 of
r'( --- *CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
7 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
BPINfERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Cbeck 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 StomvRain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER WaterHeater/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 Furnace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Nou-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 Appliance ELECTRICAL
2 of 3
�L a0l
9ITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
i 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
PPERNUTFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Change BUILDING AdIlIL
3 of 3