04120096F,
L
CITY OF CUPERTINO..Fa
DIVISION PERMIT
CONTRACTOR INFORMATION
"
BUILDING
BUILDING ADDRESS:
PERMIT NO0 4 12 0 0 9 6
2266 N DE ANZA CL
NER'S NAME:
PERMIF ISSUE DATE
STEPHEN DERMAN
12/15/2004
PHONE:
SANITARY NO. CONTROL NO.
ARCHITHCTENGINEER:
-
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION -
lob DesA
1 hemby affirm Iha, I am licensed under pmvisions of Chapter 9 (commencing
with Section 1") of Division 3 of the Business and Professium Cuba. and it, license is
�j
in full force and effect.
REPLACE CONCRETE IN
License Class l -mil
Dam Contractor
.YARD
JUN t— 2005
ARCHITECT 5 DECLARATION
I undersand my plans shall he used as public records
[Qp��]
LkcrtscJ Professional
OWNER -BUILDER DECLARATION
1j�aI1[jt'�f(//��$�
I hereby .('Seco l License Lew for the
exempt from the Gasiona
LTA®� Y V r:✓'
reaso on 1. Code; Any airy county
ire reason. (Section ]II3str Business and Professions
demolish.as
ere
which enn9mn, ahca improve, repairanysuuemsc
which myuims a permit
hparmia
prior to its censed o, also eequit the applicant for such permit to riles signet autamem
re
Ft. Floor Area
Valuation
mathe a
pSectio uomc pro visions of theeBusies iii
Sq.
mencimnsed
Code) or
Division s of the Business and professions Code) of
(cothat
vi
I Thal he is exempt therefrom and the basis for ase alleged Gumption. Any violal(on of
hes examwith hereon] and M on. Any
'
er0 0
Occupancy Type -
Section 7031.5 by any applicant for a permit Subjects the applicant to a civil penalty of
not mom than five hundred dollars ($MO). -
❑ I, as mond of art proper, or my cmployces with wages as licit so lc compensation,
Required Inspections
will do Ne work. and Me awmum is not intended of offered for sale (Sec. 7044, Business
and Professions Code: The Conmcmr's License Law docs not apply to an owner of
q p
progeny who boilN or improves thereon, and who does such work himself or through his
Own employees, provided that such improvements am not intended or offered for gala IL
however. the building or improvement is sold within one year of completion. Ne owner,
builder will have me burden of proving that M did not Wild or improve for purpose of
sale.).
I, as owner of the progeny, am exclusively contracting with licensed contractors in
contused the pmject (Sec. 7064. Business and Profwiom Code:)The Conmcmri U.
rise saw dors ...apply in an owner or pmpeny who Wilds or improves Marriott. and.
who contacts for such projects with a eontranor(s) licensed pursuant in the Conuanor's
License Law.
i�qm ason
Bte1-71L1J
.-U
�I//xa Date Z 5t
WORK 'S COMPENSATION DECLARp
I hereby affirm under penally of perjury one ofth slowing declarstien5:
I haw and will maintain a Certificate of Cement to self-Insum for Worker's Compen-
Sudion, for provided for by Section 3700 of the later Core, for the Wormmance of the
work for which this poem it is issued.
❑ 1 have and will maintain Worker's Compensation Insurance. as mquimd by Section
37W of the labor Code, for me performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance career and Policy number are:
Carier,Poll, No.:
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(thissection need not W completed if the @'.mil is foroae hundmd dollars (SIM)
or less.
1 Ger iN that in the performance of the work for which this permit is issued. I shall not
employ any person in any mannerso as to become Subject o the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: It. after making this Godficam of Exemption. you should
b`:ome subject to the Wodcr's Compe o ion pmvisions of Mac LZWI Code, you muse
forthwith comply with such provisions or this pohniuhall W deemed ranked.
CONSTRUCTION LENDING AGENCY
hereby that there issconswctinnlending agency 1'nr the perfurman¢of
which his
the Werk for WhIC111h19 pCnllll if limed ($ee.307, G1V. e.)
jLender, Nene
Lender: Adams
I ceniry that 1 have read this application and state that thc above information is
cofrccs. I agree to comply with all city and county ordinances and state laws minting to
Wilding construction, and hereby authorim mpeeaenutivu ofthis city to enter upon the
above -mentions property for inspection purposes.
(We) "ho' to save, indemnify and keep harmless the City of Co,aino against
/ ♦,
j liabilities,judgments, costs and expenses which may in any way accrue against said City
\\)
/
in consequence of the grand ag of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Date
Issued by:��kL
50 EGULATIONS.
Re -roofs
Type of Roof
—Y
Si store of ApplicanVComracmr \ ata
HAZARDOUS MATERIALS DISCLOSUR
Will the applicant or ruwm building occupant store at handle ha,um us material
defined by Ne Cupertino Municipal Code. Chapter 9.11. and the Health and Safety
nue, Section 255320)+ /'
All roofs shall be inspected prior to any roofing material being installed.
❑Yes (.O No
If a roof is installed without first obtaining an inspection, I agree to remove
Will mea ficanl nr rumen Waam wed anI air equipment er aemres saffron
Split s v
emit hatardnus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District!?
❑Yes Nn
I have mad me hanrdnus materials mquimments under chapter 6.95 of Me Califm
n' Health tit Safety Cale, Sectiorts 25505.25531 and ]5536.1 unJersun I'ftW Willing
0(.. not emmmly haw a mnam, out it is my respomihility m nod l y the fine
re u cont o hluhmustMmetpriorWIssuanceuaccnifieau,pracomeny.
Signature of Applicant Date
'�`—S ��_ i " �S 6iY
All roof coverings to be Class "B" or better
ncr of autharimd agent Data
Item 1 of 1
CITY OF CUPERTINO
PERMIT RECEIPT
OPERATOR: suem
COPY # : 2
Sec: Twp: Rug: Sub:
Blk: Lot:
APN ........:
35602019.00
DATE ISSUED.......:
12/15/2004
RECEIPT #.........:
28051
REFERENCE ID # ...:
04120096
SITE ADDRESS .....: 22266 N DE ANZA CL
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: STEPHEN DERMAN
ADDRESS ..........:
CITY/STATE/ZIP .... ,
METHOD OF PAYMENT
-----------------
OTHER
TOTAL RECEIPT :
AMOUNT NUMBER
497.90 AMER EXP
497.90
RECEIVED FROM ....:
SJ
DERMAN
CONTRACTOR .......:
LIC #
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP ....
,
TELEPHONE ........:
FEE ID
UNIT QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
BPLANCHK
PERMIT FEE 147.96
197.45
0.00
__
197.45
__________
0.00
BPSPRINK
NO OF SPRINKL 1.00
13.19
0.00
13.19
0.00
BPSTORM
PER DRAIN 1.00
9.00
0.00
9.00
0.00
BPERMFEE
VALUATION 7,500.00
147.96
0.00
147.96
0.00
BREMFIXT
NO. FIXTURES 2.00
2.40
0.00
2.40
0.00
PPERMITFEE
FLAT RATE 1.00
38.37
0.00
38.37
0.00
BREMPOWER
POWER UNITS 1.00
47.96
0.00
47.96
0.00
BREMRECEPT
NO. OUTLETS 2.00
2.40
0.00
2.40
0.00
BSEISMICRE
VALUATION 7,500.00
0.80
0.00
0.80
0.00
EPERMITFEE
FLAT RATE 1.00
38.37
0.00
38.37
0.00
TOTAL PERMIT
497.90
0.00
497.90
0.00
METHOD OF PAYMENT
-----------------
OTHER
TOTAL RECEIPT :
AMOUNT NUMBER
497.90 AMER EXP
497.90
• Yard:
Install 451 sq. ft. concrete 4 inch slab, then install poured, stamped 2-3 color concrete
Install 4 inch of base rock class 2
Install #3 steel rebar 18 inches on center, grid pattern
Concrete footing 18 in. diameter
Bonding wire connection to pool
Stairs:
Install 9 steps of 7 inch height, 2 landings concrete 4
poured, 2-3 color concrete,
Install 4 inches of base rock
Install #3 steel rebar nosing continuous
Tread is I foot
Haul dirt, concrete
•
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Mis
t.
ttE-IG- TO 2� ftivC � d L P
PLOT PLANS
CUECKED EM
70PLA 4 c dLP
�L�I
Cy
it
PROVED
iN ACCORE
ANCE WITH TH , b[TY OR
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it
cu p
-ERT17
WDR N A
YJ
_
DATE 1
SIGNEO
This s 0 p
et
3ih
cl ications MUST
itis
no Writ
a in at atl-fl as and un
K7,
Vfull
to
ki n a,
tion
,
-on
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It
itt Or
issi
fl;0T.
7 77'�—�
th,
I b
ild ln�
apt City,U;
71� j.7
The
per
of chis, pied land s
Tlino!!'
c1lico
ions
331�
A
NOT
el t permit to b
I or.
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p ro
2
al: 0 tt
e violation of any prove
unn—,
I
City
dlnHrlCe or state 1I
r
2 777 IT�
ZI)
ttE-IG- TO 2� ftivC � d L P
PLOT PLANS
CUECKED EM
Cy
(�y,,
arr of
CUPERTINO
CITY OF CUPERTINO
PERMIT APPLICATION FORM
K
APN # 27 6�/ O
O
Fee Description
Date:
Building Ad ess:
Mailing Address (if differ t from Wilding addr ss):,
Owner's Nai, �� mp
2 e-..
+�„ t
-7.5'0 rs x 2 I V
Contractor::®',
BBOILER2
Boiler > 100K to 500K Btu
Contact: Phone:
Fax:
BBOILER3
Cupertino Business License#:
Building Prinit Info:
Bl Ele ❑
Plum
Mech ❑
Jo Descn ion:
Residential iZ I c n me, { vk)
),h 7a rd
e o n m e t e Commercial ❑
Sq.Ft. Floor Area:
MECHANICAL
S/Sq.Ft.:
Costsfrp jecl:
WW o0
BUILDING
Occupancy Group:
Ind/Off/Comm/Quasi
Type of Construction:
BCONSTAXBQ
Please check this i6ox i ect is a
second -story addition: ❑
Project Size: Standard ❑ Lar;e ❑
Major ❑
Hotel and Motel
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
BELECI001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Flee Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
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CITY OF CUPERTINO -'-"'. . --
_` Adm aia.;+";b- � "" s wzz"" `� �
BUILDING DIVISION PERMIT •
�CONTRACTORJNFORMATION a
.rgsY
s .".m. ,>.,;__au•.$.a4$3'>aTn,..5".
- -
BUILDING ADDRESS:
PERMIT NOO 4120096
22266 N DE ANZA CL
OWNER'S NAME: -
PERMrr ISSUEDATE
STEPHEN DERMAN
NE:
SANITARY NO. CONTROL NO.
ARCHITE(71ENGINEER: I
BUILDING PERMIT INFO '
BLDG ELECT PLUMB MECH
.
0 0 0 0
LICENSED CONTRACT'OR'S DECLARATION
Job Description -
P
I hereby affirm that I am licendd under provision, of Chapter 9 (commencing
- -
"
with Section 7") of Division 3 of the Business and Professions Code. and my license is
-
infull to= and affect.
REPLACE CONCRETE IN
Liccnu Class Uc. N
.YARD
Dau Conuacsor
ARCHITECTS DECLARATION
.0'
1 understand my plans shall he used as public roebrds
L
Licensed Professorial
OWNER -BUILDER DECLARATION
1
1 hereby affirm that 1 am exempt from to Conractor's License Law for the
following mason. (Section 7fn 1.5. Business and Professions Code: Any city or county
V
which .,aims a permit to consumer. almr, improve, demolish, or repair any swnum
! prior it, its uumirec.alsorequim5 theapplicam forsuch permilmfcitaigncd summer,
Cmaracm:sUmem< Law (Channel y
Sq. Ft. Floor Area
-
Valuation
matheisEeen,edparsaanttothepmvismorof the
(commencing wish Sectimn 1000) of Divuioa3 of the Bmarverli Profession Code) to
that M u exempt therefrom and the hssu for like alleged exemption. Any violation of
J WFINgrge—ro 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not mom man five hundred dellen ($300).
❑ I,uawne of the progeny,mmy,mployas win, wagesar their sole compcnsatlon,
Required Inspections
will do me work end me.heron, is notiamnd,U m nffcrcd far sale (Sm.7044,11mm:sa
and Professions Code: no Contncmrs License Law does not apply to an owner of
-
property who builds orimproves meeon, andwhodoessuch work himselfor through his
- -
own employees, provided that such improvcmentsare not intended oroRemd forstim. If.
however. the building or improvement is sold within one year of completion. she owner-
.
builder will have me burden of proving Nat he did nos build or improve for purpose of
-
s tim).
x El 1, au awrmr of dim property, am coclusively contracting with licensed command. in
_
cmumat the pmjecs (Sec. 70x4, Business and Professions Cade) The Conmcuri U.
cense Law dors not apply to in owner of property who Wilds or improve demon, and
who connacls for such projects with a eoulraesor(s) licensed pursuant to me Convacmr's
`
License Law. I I -
❑lamecmpsrcrSec. .B& P C for this reason
.w am d
WORK S COMPENSATION DE�CCLA,�R/AA7JON :
I hereby affirm a idcr perW tY of perjury ane urdiF211owing declarations:
❑IM1awand willmainuinaCenifcam of Cansenuosel6inxum for Worker's Compere
sasion, to provided for by Section 37M of the Labor Code, for me performance of me
work for which this permit Is Issued. —�
Fl I have and will maintain Worker's Compensation Insurance, as required by Section
_ _4
370(of me Labor Code, for one perfmmsnce of the work for which this permit is issued.
-
My Worker's Compensation Insumna carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mm; section need not W completed if the Permit is (arum, hundred dollars (SIM)
..
or loss.)
1 car i(y that in she performance of the work for which this permit u owned. 1 shall nut
employ any person in any manrerso to to become object to the Workers'Compensation-
Laws of California. Dam
-
Applicant
_ -
-
NOTICE TO APPLICANT: IL after making this Ccrtificam of Exemption. you should
become subject to me Worker's Compensation provisions of the Labor Code, you most
'
forthwith comply with such provision n this pemiu sha11 be deemed ranked.
CONSTRULTON LENDING AGENCY
1 hcrehy affirm Nat mire is lending agcl,cy par de Performance of
sed(Se.construction1)
' me work for which this permit is issued (Sec. 7097, Civ. C.)
Lender's Name
I<nder's Address
1 certify drat 1 have read this application and sum met the above information is
• conics. I agree to comply with ail city and county oNinsmes and sum laws relating to
building convection. and hereby aumorim mp camountiv*s brims city to cavy upon me
a above-mentioned propcny for inspection purposes
(We) agree to save• indemnify and keep harmless ted City of Cupertino against
Iiobiliuu.judgments, costs and expenses which may in say way neem, again said City
\J
/
in consecutive of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SO EGULATIONS.
Re -roofs
Type of Roof
—
uroof ApplicanUConBacmr \ am
HAARDOUSMATERIAIS OISCLOSU
Will the applicant or future Wilding orcupans store or MMIC hazardous mammal
u defined by me Cupertino Municipal Code. Chapur 9.11, and the Health and Safety
Code, Seniors 35531(x)? /
All roofs shall be inspected prior to any roofing material being installed.❑Ye
jzNo
0vol
If a roof is installed without first obtaining an inspection, I agree to remove
me applicant or future building occupant use equipment or devices which
mit haeardous air cbmaminarta so defined by that Bay Area Air Quality Management
all new materials for inspection.
Disuia?
0Yes Nu
I have mad the IunNnus mamrialeriquimments under Chapur 6 95 of the Califor-
maHcalm&SidesyCode. Sameon 25305.25533 aM 25534.1 undirs xtfthe Wilding
dLT�- t cunindy hoc a enn4 rent it is my rnponibility m notify me f dao
re immmnR NcgmuxWmetpriormissusnaofaCcruhi vbfQcup r.
Signature of Applicant Date
S OY
All roof coverings to be Class "B" or better
cr tar aumbriacd agcm Dau