04060230 CITY OF CUPERTINO
BUILDING DIVISION PERM
BUILDING ADDRESS: v PERMIT NO 04060230
21115 LAURETTA DR
ER'SNAME: PERMIT ISSUE DATE
KEN KISHI 4
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Bipp LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter (commencing Job Description
rlto� with Section 70Y))of Division 3 of the Dusincssan fcssioes Codc,and my license is
oEin a eeandcffem. Dz BATHROOM REMODEL (3).
jnZ Lie s Lk.p4
i-4Dam mL camraemrCONTRACTOR: SUNRISE BUILDERS
3 AR HITECI.S DECLAR19M
�i I understand my plans shall Ise used as public records
DyU
Licensed Professional
3
OWNER-BUILDER DECLARATION
a1 hereby affirm Ibat I am exempt from the Contractor's o License Law for the
i O O following Tosco..(Sectiur 8131.&Bonitompr and ver de professions Code:Any city s county
x$ which mquires a permit o cnnswcs alter.improve,demolish,or repair any xwcwm
riyprior to its issuance.also mquires the applicant for such permit to rile a signed statement
�sao that he is licoutod pursuant to the provisions of the Connector'sLianas Law(Chmmr9 Sq.Ft.Floor Area Valu$da000
on-$ (commencing with Section 7000)of Division 3 of NC Business and Professions Code)or
�..
that hem exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit StOpc0 the appliCML 10 a civil penalty of APN Number Occupancy Type
nut more Nen 0w hundred dollars(250)1 - 32655012 . 00
0 I,usowner of the property,or my employees with wages as their sole Compewion,
will do the work,and the stmctum is not intended proffered fonathe(Sec.7044,Business Required Inspections
and Professions Cade:The Contractor's Licume Law does not apply o e an owner of q p
properly who builds or improves thereon,and who Coast such work himself or through his
own employees,provided that such improvements are nm intended moRemd for sale.It.
however,the Wilding or improvement is sold within on year of completion,Ne owner.
builder will have Ne burden of moving that he did not build or improve for purpose or
sally
❑1,as owner of the property,am exclusively contracting with licensed conoaciass to
construct On project(Sec.7044,Business and Professions Code:)The Contracmr's Li-
cense law does not apply to an owner of properly who builds or improves thereon,and
Who eontmcss for such PID3CCLe with a Coatramar(.)licensed pursuant to the Cmunac or'a
License Law.
❑1 am exempt under Sec. B&P C far this mason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby all..under penalty of perjury one of the following declarations.
0 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compete
nation,as provided for by Section 37W of the Labor Code,for Ne performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as requited by Secdon
37W of the Labor Code,for the performance of On work for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Polity number art:
Carrier. Policy No.: I
CERTIFICATE OF ID EMP ION FROM WORKERS'
COMPENSATION INSURANCE
(TMs section need nothecompleted if the Permit isfoone hundred dollars(21x)
or less.)
1 certify Not in On Performance of the work for which this Permit is issued,l shell not
employanyperspni anymannerm phaco dsubject to the Worland Compensation
Lava of Califoryj�am
Applicam
N077dEd0 APPLIC .IG off9"making this CcmOcatc of Exemption,you should
bees object In the Workers Compensation previsions of the labor Code,you most
.J O forthwith comply with such provisions or this permit shall be deemed rawked.
.Zi h CONSTRUCTION LENDING AGENCY
'rr I hereby alTam Nat Nem is a construction lending agency for the performance of
ai Ne work for which this permit is issued(Sec.3097.Civ.C.)
QLender's Name
D z Lender's Address
U Q 1 certify that I have read Nis application and state that the above information is
V4 H correct.1 agree On comply with all city and county ordinances and slam laws misting to
0 building construction,and hereby suborn mpresenmtivcs of this city to crc"pon the
f31 enow-rommi.acd property for inspection purposes.
G (We)agree to save,indemnify and keep harmless On City of Cupertino against
fir W Iiabilities.judgments,costs and expenses which may in any way accoe against said City
in of the grantiof ts rmit.
U rzr APPLICANTCUNDERSTANDS AND WILL COMPLY WITH ALL NON-P INT Issued by: Date
SOQRCE REGULATIONS.
6 1� Re-roofs
\,,gignature ofAppificanvuormemporam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanlstom or handle hazardous material
az natured by the Cupertino Municipal Code,Chapter 9.11.and the Health and Safety
Alii�cxhc,SectiYcson 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑
Will the app cam ar mtam building occupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Di3lllfl?
❑Ycs Th,
I have mad the mut dous materials requirements under Chapter 6.95 ofthe Califor-
niaHcalN&Safety Cade,Sections25505,25533 amd25534.I understandthiiNhe building
does not currently how a tenan4 that it is my responsibility to notify the occupant of the
mq.mentenb which most be met poor to issuance of.CCmf,Cam of Occup cy. Signature of Applicant - Date
owner rap arixed ag n '" stab All roof coverings to be Class"B"or better
CITY OF CUPERTINO
lom 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng: Sub: Blk: Lot :
APN : 32655012 . 00
DATE ISSUED. . . . . . . : 06/28/2004
RECEIPT #. . . . . . . . . : 26094
REFERENCE ID # . . . : 04060230
SITE ADDRESS 21115 LAURETTA DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER KEN KISHI
' ADDRESS
CITY/STATE/ZIP . . . : MARINA DEL REY CA, 90292
RECEIVED FROM . . . . : KIN CHAU
CONTRACTOR . . . . . . . : LIC #
COMPANY
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
• TELEPHONE . . . . . . . . : .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 23 , 000 . 00 287 . 00 0 . 00 287 . 00 0 . 00
BPFIXTURE UNITS 8 . 00 66 . 64 0 . 00 66 . 64 0 . 00.
BPLANCHK PERMIT FEE 287 . 00 243 . 95 0 . 00 243 . 95 0 . 00
BPREPIPE NO OF FIXTURE 8 . 00 66 . 64 0 . 00 66 . 64 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 19 . 98 0 . 00 19 . 98 0 . 00
BPVENT UNITS 1 . 00 8 . 33 0 . 00 8 . 33 0 . 00
BPWATER UNIT 1 . 00 8 . 33 0 . 00 8 . 33 0 . 00
BENERGY PERMIT FEE 287 . 00 86 . 10 0 . 00 86 . 10 0 . 00
BREMFIXT NO. FIXTURES 3 . 00 3 . 33 0 . 00 3 . 33 0 . 00
PPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
BREMPOWER POWER UNITS 3 . 00 77 . 70 0 . 00 77 . 70 0 . 00
BREMRECEPT NO. OUTLETS 6 . 00 6 . 66 0 . 00 6 . 66 0 . 00
BREMVENFAN NO UNITS 3 . 00 55 . 02 0 . 00 55 . 02 0 . 00
BREMVENSYS NO UNITS 1 . 00 9 . 50 0 . 00 9 . 50 0 . 00
BSEISMICRE VALUATION 23 , 000 . 00 2 . 30 0 . 00 2 . 30 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
EPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
MPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 1148 . 04 0 . 00 . 1148 . 04 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 1148 . 04 VISA
L RECEIPT 1148 . 04
PITY OF CUPERTINO • /
CUPS TINO PERMIT APPLICATION FORM 6 6 Z-? CD
APN# _ / �^ d Z- Date:
Building Address: Mailing Address (if different from building address):
m / 5- C 4 uit D/Z CA n
Owner's Name: Phone#:
Contractor: License#:
/L/SG / G 3 gel-lo >
Contact: Phone:0-10 ga3V Cupertino Business License#:
/eia/ Ce/^ Fax:
Building Permit Info:
Bld Elect ❑ Plumb ❑ Mech ❑
Job Description: /20-rrol2c3 73 5
Residential L pL.q C G _, T Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: o� Occup Gro
,)- 3 /000,
Type of Construction: Please c s ox if the project is a
Ba--9N5 Re-f+vv &-L- second-story addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BB0ILER2 Boiler> I OOK 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
BCONSTAX13Q Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of 3
*ITY OF CUPERTINO
cuPERTlIvo PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMIvIE 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 PbIg 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 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 cfm MECHANICAL
BREMAHU-AN 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 Mise Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platfonn 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
40CITY OF CUPERTINO
CUPEI�TINO PERMIT APPLICATION FORM
{
QuantityFee ID Fee Description Fee Groupi
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 Insection BUILDING i
BSWm 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
il EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL i
MPERMITFEE Mech Permit Issuance MECHANICAL '
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
s
i,
i
I
3 of 3
r
i
CITY OF COPERTINO t`"'°"'nz=
BUILDING DIVISION PERMIT �CONTRA.C'�TORINFORMATION
9"..ate' Xr?* ^!az? ,
BUILDING ADDRESS: PERMIT NOO4O60230
21115 LAURETTA DR
DW NER'S NAME: PERMIT ISSUE DATE
KEN KISHI 06/28/2004
NE: SANITARY NO, CONTROL NO.
1
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
app LICENSED CONTRACTOR'S DECLARATION of CON �Y Y�L O O
240F Ihcmby affirm that NS1nm ON7T1Aunderprovisionsof Chapter (commencing
Job Deseri �`VY,,/P`®`
Aiy� with amn]Ih90)mDivixion3of NCBushumm�fcaslou Cnde.endmyliccnacis
�e G in a fid erre.t. a x.3.66 Z2 BATHROOM REMODELLzzz (3).
Y Dam I e�conlraawr� CONTRACTOR: SUNRISE BUILDER
�UG 2 3 2004
Y 7W< AR MTfELIt DELLA
I uncontested my plans shall be used as public records
D�U
302
LicensedProfessionalBUILDING
3 OWNER-BUILDER DECLARATION
1 onar o0i,m Nil I am exempt from tW Corn.Co e:Any c Lew for the
p O which re moon. ancon 1 703 L5, t.ager. and improve,
decona Code:Any oily n,manly
$fLi which requires a permit re Inns;tet,a@n Improve,demreent t fi mash ed monument FZNe,
prior u)its issuance.
ensedpalmn to be the applicant far such Commour s Ucureo file a signedw(Chamcm
s< thrumomm�gwitpunSection70hepmviviouofNcConuin..nanulamusCooger9 Sq. Ft. Floor Area Valu$l$3000
,F$ (commencing pt storefront
dth Division]ofthceged exe ancon.My violation
of
that he u exempt tbemfrom and Um buil for tiro alleged exemption.My violation.f
Seedon]031.5 by airy applicant fora permit wbjecu de applicanaso a civil penalty of APN Number Occupancy
not more than five hundred dollars(S50B). 32655012 . 00
- p y Type
❑I,uowmr of tiro prpeny,mmy unpl.yces with waguu Nelr vele c.mpenaatlon,
will d.tim work,and Limsc umufe beat intended oroffe ad fouale(Sec.7004,Bushm"
and Profusion¢Code:The Cmmactor's License Law dos not apply m an owner of Required Inspections
property who buildsurimpr.ves Ihem.n.and whodoessuchworkhimself orthrough his
own employees,provided that such improvements art nm Intended croRered forsale.If.
however.the building or improvement is veld wim m one year of eompledon,the owner.
builcer will have the burden of proving that M did not Wild or improve for purpmae of
ark.).
0 1,u.west of the property,am exclusively conmacting with licensed...mum.m
concoct the project(Sec.70x4,Business and PmfcWou Cada)The Conmwmts U.
cense law dost not apply at an owner of property,who Wilds or improves demon,and
who contracts for such projects with a contractor(s)licensed pursuant In the Conmutms
License Law.
❑1 am exempt under Sec. B 9 P C for this mum
Owrmr
Data
WORKER'S COMPENSATION DECLARATION
I hereby union under Penalty of perjury one of the following declarations:
❑ Ihave nit will mainuln•Cenificate of0mosm,.self-insure for WmkmsCompen.
ution,u provided for by Section 3700 of the Ubor Code,for the performance of the
work for which this permit is issued.
0 1 hove and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Cole.for the performance of the work for which this permit is issued.
My Workers Compensation Insurnce carie,and Policy number are:
Carrier. Policy No.: v
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rlbb section need not W compit m l if tlm permit is(crone hunemA dollau(SIIXO
or]us.)
1 certify That in to perrormmme of the work for which this permit Is issued,l shell not
employ any persona any manners.aym b�ecot 'subJen mtIm Woroms'Compeneatimt
Iawa.f Califory t /fin=�I
Applic m �'�—.-
NOTI E APPUC�fT:Ir,argy"makinj this CemEcam or Exemption,you should
bcco object m to Wotreri Compewtion provisions of Ne U Wr Code,you mous
.JO forthwith comply with such provisions or this Permit shall W deemed revoked.
z 7 CONSTRUCTION LENDING AGENCY
iN+ Ihereby sRnm Nu W.is.commode.lending agency for Nepe,frrmMce of '
Cithe work for which this per it is issued(Sec,3047,Civ.C.)
CL,
Q Lender's Nemo
z Lender's Address
V 0 1 comfy that 1 have rad Nis application and tote the the aWw information Is
F' C.ML I agree m comply with all city and county ordinances and sum haws missing to -
O U Wildingc.nswcti.n,and hereby authonon mpresenuttim of his city to eager open the
fJd shove-memimed property for inspection purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupertino against
N Ifibilides,judgmumut,uts and expenses which may In any way amour against Mid City
C.7 z in consequence of the granting of this permit. s
'-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- INT Issued by: Date
50 RCE REGULATIONS.
Re-roofs
t urt.fAppliem onlnemr am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding acupant atom or handle haundau mamdsl ^
u defined by he Cupertino Municipal Coes.Chapter 9,13,and the Health and Safety
Cut
S., ,m 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
Yu
L Will the applicant or fut/u�WUNng occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,mit in...Nnus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑jet
1 have mW the Wastrel materials requirements under Chapter 6.95 of the Califor.
nu Neild,g,Safety Codc.Savona 35505.25533 and 23534.1 undersand then ifdm Wilding
dost not currently haw a mnanL that it is my responsihility at not ry Lou occupant or the
requirements which mus W met poor on issuance of a CeNOcus of Dec.ray. Signature of Applicant Date
X16
Ownsr Dosed ag All roof coverings to be Class"B"or better
am '