04020113 CITY OF CUPERTINO '�
BUILDING DIVISION PERMIT C�AT'C'ItAG'Cf)R z1U;. A'TAON"•`•'•
BUILDING ADDRESS: PERMIT NO
PRUDHON BUILDERS 04020113
OWNER'S NAME: PERMITISSUEDATB
!! E. SANITARY CNTROL NO.
HITIECTIENGINEER: BUILDING PERMIT INFO
' BLDG ELECr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION t Job Description
z� i hereby affirm at I am licenxd under prevision Comer 9(commencing P
n,� wife Sec,O�n,7000)nf Diviaien 3af the Buinras atb Profea,inm Code,and mylicenu is
u«mh`cir. Ili`rf"� tie.a,-- � � BATHROOM REMODEL
Dawe CentTCCf n`��
ARCNI l,7 S O�EpCLA A�TIO'N
rs an ahkll he sed es Alit recnms
Liccnelll'mfcsss al l
OWNER BUILDER DE CLARATION
f 1 hmotor .(Seto that 11. exempt from me Cordons Co License Law for the
p O following mason.(Section 7(131.5, 1.alter, and Professors Cod,:Any city or cemaly
which requires a pertnit as cnns,mct.alien improve,demolish,or repair try awcaum
= L:n prior to its Waimea.also mquims the applicant forsuch permit to file a signed salement
e dot he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter9 Sq.F[. Floor Area Valu hon
be mmctming with Section 7000)of Division 3 of the Businusand Professions Code)or
$ Nat he is exempt therefrom and the baso for tits alleged exemption.Any vlolaeon of
Section 7031.5 by arty applian,for a panni,subjects the applicant to a civil penally of
not more man five hundred dollen($500 3 6°�N Yl@
). IO 0 Occupancy Type
I,m mwmr of the property,or my emple,ces with wages as meGsaw compensation,
will do me work,and fee swaum is notinkn&d m offemd foraale(Sec.7044,Buelnua
and Profusions Cade,The Conuscbm'a Limns Law does not apply to an owner of Required Inspec
propeny who buildsmimpravea hairier.and whodoeaeuch work himself orthrough his j
ownemployces,provided that such improvements arc not intended or oRerrA forage.If, ,dYC
however.the building or improvement is sold within one year of completion,the owner
builder will have the human of proving deal he did no,build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed eommctorn An
consuuct the project(Sec.7W,Businuo and Professions Cede:)The Contractor's U.
Genu law does not apply to an owner of property who Wilda or improves thereon.ad.
who contracts(or such projects with a contractor(s)licensed remain a the Co mouses
License La-
o I Am A.empt under Sm.
aw.❑IAmexemptunderSm. ,B&P C for than names
Owner Date
WORKER'S COMPENSATION DECLARATION '
1 hereby arBrm under penally of perjury one of Om following declarations:
I have end will maintain a Certificate of Co..(be self-insure for Work,r'sCompcn-
smon,an provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will mainawn Worker's Comperomise Insurance,as required by Section
3700 of the Labor Code,forme perfmmarm of Or work for which this permit is named.
My Worker's Compensation Insunnm carrier and Policy number am:
cir;ar�R7_e Pen shit I7Lr�Zh Fe,3
%CERTIFICATE OF ES M Olhl FROM WORKERS'
COMPE4 NINSURANCE
CM ts uctinn toed not bo tom ple W d if the perm it is for one h undmd dollars(51001
or less)
1 certify mat in me performance of the work for which this permit is issued.l shall not
employ any person in any manner sn an to become subject to dm Workers'Compensation
Law,of California.Doe
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should
become subject to me Worker',Compensates provisions of IM laver Code,you mus,
.J O forthwith comply with such provisions or this permit shall he deemed revoked. -
z`" CONSTRUCTION LENDING AGENCY
1hereby aftim mat there is a convection lending agency rot we performance of
C
the work for which this permit is issued(Sec.3097.Civ,C.)
QLender's Name
z Lender's Address
O Q 1 certify that I ban mud this application and slow that the above information is
Fcorrect.1 agree to comply with all city and county ordinances and sure laws relating to
Q V building conswction,an}�hereby authorize representatives of this city to enter upon the
W shave-mentioned pts amqt for inspection Istapowhich s.
f� (W,)agree}}ddaa(•e,indemnify and keep harmless 0e,City of Cupertino against
fJy Ilebilities,judgmerlts.coats and upensu whichmryin any way accrue against said City
f,7 in consequence tilt die%ranting of this permit.
r7 APPLICA NDERS DS AND WILL COMPLY WITH ALL NON-POlyr Issued by: Da
SO R gI
2/1-0 Re-roofs
o ppli onus Dam
ARDOUS MATERIALS DISCLOSURE Type of Roof
Will thea lana or furor,building occupant atom or,snake havardous material '
as defined by upenino Municipal Cade,Chapter 9.12.and the Health and Safety
ode, E] es s NE? All roofs shall be inspected prior to any roofing material being installed.
Yes �Nu
Will the applicant or future building occupant use equipment or Jcvices which If a roof is installed without first obtaining an inspection,I agree to remove
It havamdous air contaminants an Jefired by the Bay Area Air Quality Management all new materials for inspection.
Muriel?
❑Yes Nu
(have made a.1r amaterials mquimmcna under Chapter 6.95 of the Califon
ria Hcal"Isa t adc.Sdtions2 5.25533 end 25530.1 undersand thoifthc building
Dees not cummntlM1avon w m i,ts my mspomibility w notify the acupant of the
requireme ch r mat mwiamanaeuracenificamof0eapanry�. Signature of Applicant Date
0w mauthodseJ gcn �Dow All roof coverings to be Class°B°Or better
CITY OF CUPERTINO ' yyrnx .y7��TTs
BUILDING DIVISION c PE TA1t1k`'T;',0 A
BUILDING ADDRESS: TPRUDHON BUILDERS PERMIT NO04020113
OWNER'S NAME: PBRMR ISSUE DATE
NE: SANITARY0. C NTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
y 0 o LICENSED CONTRACTOR'S DECLARATION
I hereby Affirm Nat 1 am licensed under previsions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of the Busis�an1d Professore Code,and my license is area w. aa....
intents% fife v sea.✓ 77(��7T/p BATHROOM REMODEL FINALEM
z License CIS'
k Dere CCntmcln
rat d� ana'n'aRlbhell heCAijamlDis�p hl rccnOr�J JUN 0 7 2004
OEEEU �..-i /- / f
uQ Licensed sf, e
OW NE.BUILDER DECLARATION BUILDING
I belch affirm that 1 em exempt from the Contractor's License Law for the
Ea0 following Mason.(Section 703 1.5,Business and Professions Code:Any city or county
m which requires a permit to Contract,atter.!.Prow,demolish,or.pair any Struclurc
FZe prior I.its issuance.also mquims the applicant for such permit to Glc a signed statement
�thn he is licensed pursuanunthe previsions of Va. License Law 9 Sq.Ft.Floor Area Valu [Ion
N
$ (commencing with Section 7")of Division]of the Business and Professions Cnde)ur
�.. Nat he is exempt therefrom and Ne basis for Ne alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicann0 a civil penalty of 3 6d( Qro 0 Occupancy Type
not mom Nan fin hundred dollars($5031 O CY
❑1,as owner of die property,or my employed with wages as their ole compensation,
willdo the work,and Ne swnure u not amended araQcred ruled.(Sec.7041,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to m e owner of q P
property who bu ilda ar improves thereon.and who d oes such work hi msel f or through his
own employed,provided Net such improvements AM not intended Clattered for tile.if,
however.Ne building or improvement is sold within one year of compledon,the owner-
builder will have the burden of proving that he did not build or Improve for purpose of
.M.).
❑1,as owner of Ne property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contracter'a L.
cense law don not apply to an owns of property who builds or improves daemon.and.
who contracts for such projects with a eommcmr(s)licensed purauanun Ne Contractor's
License Law.
❑I am exempt under S. .B&P C for this Main
Owner Data
WORKERS COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury one of tiue following declarations:
1 have and will maims.a Certificates of Consent to self-insure fm WorkefsCompcn-
1307M
tion,
An provided fat by Section]700 of Ne labor Code,for the Performance of the
rk for which this permit is issued.
I have and will maintain Worker's Compensaaon Insurance,as required by Secdon
of the Labor Cod ,for the performance of Ne work for which this permit is issued.
y Work``e_r'sAC.ompensation Insurance carrier and Policy number am:
rrier.�%Alt7 RIIJI. policy No.: I7G/7Zfi I�3
( / CERTIFICATE OF E)CE OONFROMWORKERS'
J/ COMPENSAYIF)NINSURANCE
(Thissectian ncetl not he completed if the permltlsfa....hund.ddoll.($IW)
nrldaJ
1 certify that In the performance of the work far which Nis permit is heated,I shall at
employ any person I.any manner so as to became Subject to the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certincam of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
70Q foMwith comply with such p..indent or Nis permit shall he deemed revnked. -
q ti CONSTRUCTION LENDING AGENCY
[—t I hereby aRvm that there iso construction lending.puwy for Ne performance of
ai > the work(ser which this permit is issued(Sec.3097,Civ.C.)
U(„)Q Lender' Names
Z Llakus Add.,
1 1 certify that 1 have mad this application and sum Net the about information is
LL F coned I agree to comply with all city and county ordinances and Stam laws Totaling to
f, building conswetion,an�(hemby ouharise representatives of this city m enter upon She
�a ahovnmemianc0 proodr) for inspection purpnus.
(Wes)agree ttddSaw,indemnify and keep harmless the City of Cupertino agdnst
wF"a to liabilities,judgmgrlts,costs and expenses which may in any way acerae against said City
(„)'� in consequence of the granting of this permit. ,
F-t APPLICAbLTIONDERSTA740S AND WILL COMPLY WITH ALL NON-PC IyT Issued by: Dat
SOUIRTSRIqpUA 1 NS rI
2/7-a Re-roofs
.1 or' ppn 'mIlIX Dme
L/ ZARDOUS MATERIALS DISCLOSURE Type of Roof .
Will thea tan,or furore building occupant score or handle hasardou5 material
as defined by th upenim,Municipal Cade.Chapter 9.11,and the Health and Safety
Code,Section 1 532(a)T All roofs shall be inspected prior to an roofing material bei. installed,
❑tiYeaon t�Na P P Y g g
Will the applicant or future building occupant use equipment or dcvicd which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air Contaminants as dcGned by the Bay Area Air Quality Managcomm all new materials for inspection.
isuiclT 11
❑Yes // Nu
I have mad dhd,4 rdaus materials requirements under Chapter 6.95 of the Califon
ria Hdlth&SAT t.Cmk,Seeder.2x5 5,155]3 and 25534.1 undcrsund this num building
Jori not currant hove ate. thit is my reapansihility to..dry the occupant of the
rcyuimmcrosw.ch.mun l�C met anaiaavanca ora ceniGeme of aapancy. Signature of Applicant Date
G —I All roof coverings to be Class"B"or better
Owbe or authori'rcJ gen Date
Community Development
10300 Torre Avenue
Ite Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
a PEkTINO
Buildin Department
JOB ADDM79& PER11T # �f
OWNER'S N : -557
GENERAL CONTRACTOR,/ T2-)✓ FAX #
I am not using any subcontractor :
1 ate
Please check applicable subcontractors an complete the followin information?"
41,
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
He
caner/Contractor i e Date
10/28/03
a4PITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
E
CUP RTINO
N# Date:
36grao , 3 . C)a
Building Address: Mailing Address (' differ t om building address):
381 ,j P c
Owner's Name: Phon #:
`2- 70c )
Contractor: 0 License #:
r�n Gt �, 0y)
Contact: Phone: 390 - 7ySl Cupertino Business License#:
5cgn f Nd1 on Fax: 393- o91y 0 1-Do
Building Permit Info:
Bldg ❑ Elect ® Plumb J Mech ❑
Job Description: n
Residential act room a rvi ocQ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
C) o0
Type of Construction: Please check this b ect is a
Oo 40-gm e second-story addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHEROther A liances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K 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
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDJNG
z
1 of3 { J�
ATY OF CUPERTINO i
.CUPEf�F PERMIT APPLICATION FORM
AMIL
uanti Fee ID Fee Description Fee Group
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
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 rinkler/Backflo 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
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 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
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
2of3
! 'PITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
uant' Fee ID Fee Descri tion Fee Grou
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation S stems MECHANICAL
BSCBLVD IScb S ecific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL S ecial Ins ection BUILDING
BSWIM Swimming Pool BUILDING----
BTEMP Tem ora Power ELECTRICAL
BTEMPPERM Ternnnrnry Bldp Permit BUILDING
BTEMPSVCS Temn 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
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F 2004
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APPROVE
ffU ACCURD E WITH CITY /
UUP A INA ;
DATE
SIGNED 38 21"
z'��
This set o plans and - ecifications MU T
be kept n the ' at all times and it is 4( "
lawful to ma a any changes or, alters ns
on some without written permission fr_
the building Dept:, City of Cupertino,
The stamping of this plan and spodificationt
WILL NOT be hold to permit of to be at,
appf"I of tho violation of any pfoylolon,
.f afly city ofdinanca of stela Law.
All dimensions_size designations given are 20' This is an original design and must not be Designed:2/17/2004
subject to verification onjob site and released or copied unless applicable fee has Printed:2/17/2004
adjustment to fit job conditions. been paid orjob order placed,
bath layout Fp 1 I Drawing#: I Scale:0 1/2"—1'