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04070095 CITY OF CUPERTINO ' ` BUILDING DIVISION PERM. - WOY>TRACTORINFORA C NN . BUILDING ADDRESS: AMERICAN BATH IND, INC PERMR"04070095 22445 CUPERTINO RD 9 47 OWNER'S NAME: PERMIT ISSUE DATE SUNNY VIEW MANOR 30987 SAN BENITO ST 02119ir2no4 TONE: SANITARYNO. CONTROL NO. (510) 475-8200 ARCHITECT/ENGINEER: BUILDING PER INFO BLDG ELECT PL PLUMB MECH 0 0 0 0 y w Ll I hereby affirmEdNSEDat I T CONTRACTORS Evans,or Chipmer 9(Commencing LARATION Job Description <Zm with Section]0Xh of Division 3 alone BobactsW professions Code,and my license is ^�„ iOmnmmeAnd err C��E 1 HOWER/SHOWER DOOR ppb? Lfullf Claes Lic.M nF 0 DON Cemoram' ARCHITECT'S DECLARATION ad-ta I understand my plans shall rte used as public reenrds Oats off 'viccnsed Pmfcssionel SEP ZOG4 S OWNER-BUILDER DECLARATION . I berchy affirm than I am exempt from the Comorcmr's License Law for the o O following mason.(!.tion 11031.5.Business and Professions Calc:Any city or county ym which not.a permit to construct,eller.improve,demolish,or.,it any structure f2> prof N its Tuns=.else ox,mr5 the appli[aal for such permit in File a Signed statement p]I Q��� ) Iio that he is li.vm cd pursuant the provisions of the Connector's lJCovLaw w(ChaptuIIL 9 L. flf1bbi-A Valuation e� (commencing with Sccuor70W)of Division 3 of the Business and professions Cmle)or y $ As that he is exempt thurefrom and the basis for the alleged exemption.Any violation of Section]031.5 by any Applicant for A permit subjects the applicant o a civil penalty of erO 0 Occupancy Type not mom Nan five hundred dollen($5W). , ❑i.mmnerofoepmpmy,ormyemploycnwiffimgmu irmlecompcnsation, will do the work,and the structum is not intended oroRered for sale(See.1004,Business and Professions Code:The Contractor's Listree law doe not apply to in owner of Required Inspections property who buildsurimproves thereon,and who doessuchwork himself orthrough his awn employee,provided thauueh impmwments art nut mundled.,.ffered for sale.IL however.live building or improvement is sold within ane year of completion,the owner- builder will have the,burden of proving that he did mot build or improve for purpose of sale.). I,as Owner of d¢pmpery,am exclusively contracting with licensed contractors to cmutmet tk project(Sec.7044.Business and professions Code:)The Contractor's Li. cense Law does not apply to an owner of property who Wilds or improves Neuron,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License law. I nm exempt under Sec. .B&P C f. net�n�/JI f/o.,a ea.-a Dale a f`(� Lf WORKER'S C MPENSATION DECLARATION 1 hereby affirm under penalty of perjury ane of do,followitydiclanadons: ❑l have and will maintain aCcrificale of Covent to elf-imure for W.rtrr's Compere cation,as provided for by Section 3100 of the IaWr Code,for the per ncomm of the work for which Nis permit is iss.d. n 1 have and will maintain Worker's Compensation Imuran.,as tapered by section 3100 of the labor Code,for the Performance of dm work for which this permit is issued. My Worker's Compensation ho uranCo carrier and Policy number am: Cartier: Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Qhus section need not W completed if the permit is fare=hundred dollars($1W) loss.) 1 certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner an u to became subject to the Worlrms Compensation Laws of California.Do¢ Applicant NOTICE TO APPLICANT:If,after making Nu Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the labor Code.you must .J vZ forthwith comply with such provisions or this permit shall W dcemcd revoked. zO CONSTRUCTION LENDING AGENCY �-.4 I hereby effort that Vert is a construction lending agency for Ne performance of fYi> the work fur which Nis pamor is issued(Sce.3091,Civ.C.) W� A Lemict's Name z•Under's Add= U Q I Coolly Nat 1 have.ad this application aha state that the about infotmauun is - Uy F coma 1 agree to comply with all city and county OnEmnsers and sure laws.lating m 0 V Wilding construction,and hereby auNmiae Mpocscnutives of thus city m color upon the } above-mentioned property for inspection purposes. O. (We)agree to save,indemnify and keep harmless the City of Cupertino against n F'p) Iiabibucs,judgments,costs and expenses which may in any way see=Against send City / C.j z APPL CAt f DER!ntt NDS Of AtND.WILL COMPLY WITH ALL NON-POINT Issued by: to (/ SOURCE R U TIO -1� \ �sL Re-roofs UJISigna— moo TApplicanVConwcmr tate HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future Wilding mcupant store or handle hazardous material As defined by its,Cupertino Municipal Code.Chapter 9.12,and thC•F{calth and Safety Cade,Sccuon 255320)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Vo 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 emit bammmus in contaminants ss Fined by to Bay Area Air Quality Management all new materials for inspection. District? ❑Ycs 54, I have mad the hannious materials requirements under Chapter 6.95 of the Califor- iaHmith my CoM,Sections 25515,25533 And 25534.1 mocrsmnd Nat if Nc Wilding Jots not c n ha�a lonan4 Nat it is my responsibility m nntily dlo acupent of Na mqu/'/metswi . met four missuance ofaCertificate ofOccup ex Signature of Applicant Date /, oli c/ ,.".ren= n, �� 4 All roof coverings to be Class "B"or better CITY OF CUPERTINO em 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng : Sub: Blk: Lot : APN . . . . . . . . : 32615130 . 00 DATE ISSUED. . . . . . . : 07/19/2004 RECEIPT # . . . . . . . . . : 26339 REFERENCE ID # . . . : 04070095 SITE ADDRESS . . . . . : 22445 CUPERTINO RD # 47 SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : SUNNY VIEW MANOR ADDRESS 22445 CUPERTINO RD CITY/STATE/ZIP . . . . , RECEIVED FROM . . . . : SUNNY VIEW LUTHERAN CONTRACTOR . . . . . . . : WAYNE CARDELLINI JR. LIC # 24618 COMPANY AMERICAN BATH IND, INC ADDRESS . . . . . . . . . . : 30987 SAN BENITO ST. CITY/STATE/ZIP . . . : HAYWARD, CA 94544 TELEPHONE . . . . . . . . : (510) 475-8200 EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL -- - -- - - - - - - - - - --------- ----- - ---- --- - - ----- -- - - - ----- ---- - - ---- -- -- BPERMFEE VALUATION 3 , 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00 BPLANCHK PERMIT FEE 83 . 16 110 . 98 0 . 00 110 . 98 0 . 00 BENERGY PERMIT FEE 83 . 16 39 . 92 0 . 00 39 . 92 0 . 00 BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00 BSEISMICRE VALUATION 2 , 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00 ------ - --- -- - - ------ ---- - - ---- - - ------ - - TOTAL PERMIT 314 . 30 0 . 00 314 . 30 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------- - - --- - ------- - -------- - CHECK 314 . 30 00003462 TOTAL RECEIPT 314 . 30 • Community Development 10300 Torre Avenue ' } Cupertino CA 95014 Telephone(408)777-3228 CITY Of Fax(408) 777-3333 40:UPEI�TINO Building De artment JOB ADDRES . ax-44S c 6 f �0 2� PERMIT # 040-�- Ddcj5 OWNER'S N PHONE Z43c. xi GENERAL CONTRACTOR:' FAX # S 5 601 t— I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: ba SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting • Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock ' e • l`t on/fa r Signature Dat GE%���' / 100 of C�3� Oa ttlo f \U) i v i 3' APPROVED INF ;: JP ANCE W THE CITY OF ES DOR IN ICES plans and ab dons MUST 1:12 I.: , on the job at all tunes and If is Lmlaw A t make any changes or alferethm on aama J c .Zit written permission from ft 3 S 4 5 k r0nent, City of CuparUm kmping of this plan and 0pm7Wg= n r X 104&uNOT be held to pamtR or tD 178 t n d sov�of the violation of any pmvWom of 0 3 F =s a City Ordinance or State lata Q O 1 D 3 s (1 s Z V) , C6 r) r� 1c) OF]� o � o o � I { 8"1 e01n i� i II �jto E 4ia7 o 6411 wel Addod ...,� A7- 4 L O O m s 9 am ❑❑ a m G S-V •CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM " 7, 0 a CUPERTINO APN # V L o3 Building Address: S Mailing Address (if different from building address): � Owner's Name: Phone #: g.. r„y Vjea Mq'vt/OyZ Contractor: License#: Contact: Phone: Cupertino Business License#: Ci.uY L o OL Fax: SS Lo s Building Permit Info: Bldg ❑ Elect ❑, Plumb Mech ❑ Job Description: (-,9 1-6 �1-a a _� `� 12) I—is E�,I Residential ❑ SF Commercial ❑ "�' ` do Sq.Ft. Floor Area: S/Sq.Ft.: tib 5F Cost of Project: 2S�o Occupancy Group: 5> 0 Type of Construction: Please check this box if the project is a AOL } +o st o-d� Com v. second-storyaddition: ❑ Project Size: Standard 2� Large ❑ Major ❑ 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 <= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec.Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING Ask BINVESTIGA Investigation fee BUILDING I of -3 ? ONE cz_ vg-�� CITY OF CUPERTINO* CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description 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 I 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 cf n MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfln 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 BREN=AT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREND RAP 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 Appliance ELECTRICAL 2 of 3 *CITY OF CUPERTINO* CITY of PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Sips 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 Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING • 3 of 3