05120063 CITY OF CUPERTINO
BUILDING DIVISION PERMIT hCONRAG'CQR I1VF �2M,e1'TIOIY r•:
BUILDING ADDRESS: T J JOHNSON CONSTRUCTION ""'IM"�NO'05120063
10411 LANSDALE AV
OWNER'S NAME: PERMIT MUE DATE
DAN GORDON 7146 GRIMSWOOD CT 12/13/2005
NE: SANITARY NO. CONTROL NO.
(408) 218-8994
ARCHITER/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
h�oo LICENSED CONTRACTOR'S DECLARATION Job Description
O�F 1 hereby afRmn that i am licensed under pmvitimu of Chapter 9(commencing P
with Sation 7")o(DIv1Yoa 3of the Business and PrefeuloN Code.and my license it
n� infbforce andeffect, INSTALL NEW WINDOW .(® W i IDE)
Z� Llcenw Cleo Lk.N /R gt �®
fk.. Da¢ Con=lot AL
? Q ARCHr1EC1'S DECLARATION
S�j cy7 1 understand my ph.shall be uteri u public rtcords
Licensed Professional .111N
II�� �oo�
5 OWNER-BUILDER DECLARATION
Con cos
a I heresy affirm on 1 am attempt from the Conrom Co License Law for the
p o following reawa emir 17 o I.S,Business and Professions Cade:MY do as county
$ which its ores a permm ra construct,titan improve,de Permit
t at repair any atmcture 12(]0
Sex Met heor INI hammer'aatsnn,to atha inion of forsuch Conustrmiuomoss,e. Law(Chapter
�< thatmencigwit purwant to%aof Division
of the Comrsemfand Proelaw(Chaper9 Sq:Ft. Floor Area I
zC p that he is
(commencing withternon and
the
bss 3 of the Buslnea omit on.Anyavi Chan or
3$ 0W he h exempt ihemfrom and Ne beau for Ne alleged assumption.Any Nohtion of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty or r Occupancy Type
not marc Nan five hundred dollars(5500).
❑L a owuer of the property,army employees with wages u theb sok compen xtion,
maid Naffassiam Code:TIeCom Communities La does Out
aplyy.to an toa/.��of 9 P
Required Inspections
Property who builds or i m proves thereon,and who does such work h imself or through his
Own employees,provided that such improvements are not Intended ar offered for We.if,
bawever,the building or improvement Is sold within aro year of completion.the awaer
builder will have the burden of proving that M did not build m improve for purpose of
sate.).
❑1,as owner of the property,am"elusively conuuting with licensed convamss to
contract the project(Sec.7044,Business and ProfeWoa Cade:)T1s Conbamor's U-
cave Law does not apply b an owner of propeny.wha builds or improves theteon.orb,
who contracts fm shell,projects with a contrssmr(q licensed pursuant m the Conuacmft
License Law.
❑I am exempt under See. ,B k P C for this mason
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby aBirm under penally of perjury are of the following decluuioa:
I haw end will maintain a CeniOmmaf Consent m selfdaure far Wortrfs Comp"•
sation,u provided fu by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Wmkces Compensation Inauranm,a required by Section
37110 of the Labor Code,far the performance of the work for which this permit is hand. -
My Worker's Compensation Inwnnm artier and Policy number am:
Cartier. ert.�l Policy No.:
CERTIF�PTION FROM WORKERS'
COMPENSATION INSURANCE
(Thtssmlim nerd tetbecemplemd Uma permit Is fa=hundred dollen($100)
or less.)
1 certify that in the performance of the work for which this permit is broad,I shall not
employ any pervert in any masaliK l ""Moo
the Workcn'Compemadon
laws of Califorah Dam ll,,II
Applicant
NOTICE TO APPLICANT:es atom making mm hse of Exemption.you should
become rvbject y the Wmh provisions
ermvl nt or me labor Code,you must
Oforthwith comply with such provWnu orthis permit shall bcdamcd rewtrd.
„Z,h hr
CONSTRUCTION LENDING AGENCY
("h^ Ihcrebyalfirm that Nen isaconwuctimh leading agenry,far do,performanceaf
Ri the work for which this permit is issued(Sm.3097,Ci,C.)
Q Lender's Name
=z Lsnder'a Add=
U Q I mnify that 1 Moe read this application aha tam that the above Information Is
IL f" correct.I agree b comply with all city and county mcnanees and some laws misting m
Q V building construction,and hereby authoHm representatives or thischy so enter upon d1w
`.� ahow-mentioned propcny for inspection purposes,
tF'y'gy (We)agrm m taw,indemnify and kap harmmss the City of Cupertino against
y liabilities,judgments,cosh and etpcaa which may In any way accme against said City
U 7 in consequence of the granting of this permlb —
F7 APPLICANT,,����tttttt111111NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date Q
L��,3
SOURCEATI
Re-roofs f
Signature ofAMlican' ctor Dam
HAZA OUS MATERIALS DISCLOSURE Type of Roof .
Will the applicant or futum building amupantporc or handle harallou material
as,de0ned by the Culanko Municipal Cade.Chalder 9.12,and tie Health and Safety
We.Section 23532(4)7❑ All roofs shall be inspected prior to any roofing material being.installed.
Yes Nu
Will the applicwt or future building maupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haudnus air conta",hams"defined by de Bay Area Air Quality Management all new materials for inspection,
uiW \
❑Yea
I have read the haabaut materials mWinneem under Chapter 6.95 arae cdifor.
n6H"Ith etYCode.Sm9mts25505.25533atb 25534.1 uMemard dw,irate building
docs nm c tY eve a mnmL dot 16 my responsibility m hm ify the meopant of me
reyulremc hi tha etpdormM"`ccQr'cc"""`OfOccp y. Signature of Applicant Date
(� l i b5 All roof coverings to be Class"B"or better
Owo"m inahmbcd s cm nm
t ne Bordon s 4Ud-2b/-bb49 p.1
YD/VL/GVVD IV.iv rhA VVD III 4444 6111 LVrcmitmu I$f VV I/VVI
Community I lewlop=VM
10300 T=m Avcwe
Cuperdmn CA 95014
Tetephone(40B)777-3228
t U
Fax(400)777-3333
.IOU PEI`TINO
�uilding De artmer I
Jos ADDRESS: PF-RM1T#
04 1 l Lck^ d Ic Avrkn0 5-1 zC06 3q o s ISS i
OWNER'S NAME: ave o- n.•1 ✓ — PHONE# 7 S 1 6 S
GENERAL CONTRACCOR^ o nsnr. 1 t; FAX N 0 Sr- J Sl 6 T 9!�
I am not using any subcontract rs. _ _ u1
Signature Late
Please check applirable subco_ntracb rs and complete the followinx inforinati in:
SUBCONTRACTOR BUSINESS NAME BUSIP FESS LICENSE #
Cabinets &Millwork —
Cement Finishing
Mectrleal
Excavation
Fencing
Floorin . Carpeting
i Linoleum/ wood
Glass / Glazing
'• Heating
• Insulation
Lamd9caPing
Lathing
Masonry 1
Ornamental Sheet Metal. _
qi Painting/ Wallpaper ISL4.S.Ac PA. / CA 2t 4- o o i -i -TZ
Paving
'✓ Plastering '� _ C c P ir~5} v;'n o W9 S_30V
Plumbing
Roofing
Tank _
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Sign .iure Date
•
1,10 1,Oil, 11 4E 'PRM,7`11,
I aelpo-
St ffi-��'TP
CUPERkTINO
Assessor's Parcel Number:
Name of owner. L70.
Project address. 1) "Ns �k e 1:4%1a !:J
Contact person. ler, Phone. x140 - Lt
Fax.
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage?
• Is privacy protection planting required for the project? Y\
On what floor(s) is work being done? )eA �( Or
Y Brief description of work. PUT 11, INQW IN x. nq . V N Si Nhi,e
Code editions:2001 CBCIff) N)2001 CFC (Y -N)2001 CMC (Y-N)
2001 CPC (Y -N)2001 NEC (Y -N)
Effective 11/1/02
Plan Review Process Work Book Page-8-Revised 4/28/04
PLOT PLAAS
CHECKED BY
SEC j 32005 D DATE
v�.
PLANNING EPT
DATE_ ZZ--f 7' 0(—
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4qI -
ERTINO
CITY OF CUPERTINOCUPPERMIT APPLICATION FO1W
, b
N # / 0 0� Date: I a 4 O 5
uilding Add ess: Mailing Address (if different from building address):
m
Owner's Name: o� Phone#:
Contractor: 11 1 r VLicense#: L 1 g q3
o
Contact: Phone:�1 ' Cupertino Business License#:
I Fax: V-v.9 +
Building Permit o: ,� ��\ Naw Wu �� W�S� S t Dt- Wb,
Bldg Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Proiect: Occupancy Grouro:
Type of Construction: Please check this box if the project is a
b QA Wye second-story addition: ❑
ro'ect Size: Standard ® Laze ❑ a'or ❑
uant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBQILER3. 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
3 23 7JP
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4c 1 wo CITY OF CUPERTINO
CUPEIZTINO
PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
f BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERT24E 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 rinklerBackflo 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 PLnIBING
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 Fumace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREM-MAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREhQMC 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 Appliance ELECTRICAL
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CITY OF CUPERTINO
CUPEI�TWO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
13REMTHEATR 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
BTFIAPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMTTFEE Elec Permit Issuance ELECTRICAL
MPERM.FEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG
Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Commel Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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