03030026 CITY OFCUPERTINO
BUILDING DIVISION PERMIT ,CONTRACTOR<INFORMATIQN '
PERMIT NO.
BUILDING ADDRESS: LUCY PASTUSZKA
10 511 MAD RA nR PERMIT tssu
5 NAME:
- ;, LUCY PASTUSZKA
SANITARY NO. LNO.
PHONE:
BUILDING PERMIT INFO
ARCHITEcTlENGINEER: BLDO ELECT- PLUMB MECH
0 t�
IZLICENSEDCON(RACIOR'SDECLARATION Job Description
I hereby off.that l am licensed under provisions of Chapter (commmuing
4 wird SemloLIC.I.7 )of DiA.Mr,3ofdu Businessland Profcuinns GMC,and my license is
in run tars and effen. WINDOW RELACEMENT FUN A- EO
a? License Class
g °ere ARCHITECI-SDECLARATIONuh- MAR 2 5 2003
y+ 1 understand my plane shall M used u public record
6V
Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
etf I Meby.!firm Net 11. essmpt from fles,Contractor's Lune Law for the
aO followingnusnn.permit
IIo comfort
Business and oc.&iues Code:Any city.1 county ,
$to which oquirts.permit to does el.applicant
Impow,h Perlia fi repair ed oomurt
�- pdmwsliccn nc pun�ntLOro Ncapplieantrm Contmioe hers.file A gaed.utamcm Sq.Ft. Floor Area Valuation
< thnheislicensedpunuaooIMofDi.lnes 31Mheealrsiess LifeaeLaw(Chapter9 $3100
$
(Commencingpih Struma]1100)of basis
asi far the
alleged
eund pton.Anyoo.Cod)ser
.. Nm io LL tempi b tang applicant
and the buss far Ne a life eumant to Any viauson of
Section than by any applicant rot a pomp.ubjeeu Ne applicant m a civil pcndty of 3pEl�'3 r 0 0 Occupancy Type
not roam Nen Ow hundred dollen(5500). .
11'ii.u ownm of the property,m my employees with wage u Nek ante compenmlon,
do Ne wah.and Ne..cot.la noHnerWed oroffeed for nlc IS".7W.Busmen 1'01 - FOUNDAM159bg Inspections
and Profusions Cod:The Contractors L)mme Law does not apply to an m`mcr or
property who buildanr lmpmvu Nem.m.rl who d.,a h work Man.dror through his 102 — PIERS
nwnemployeu,prmlded that such lmprowmcus am not intended or offered for gain.If. 103 — UFER
III the building er i powment Is old within ane year of oomplcdon,No owner-
.
budder will haw n of pmHng that M did not wad err impow for wTesss Of 104 — REBAR
sale') 105 - ANCHOR BOLTS
❑1,as awn f Nc p pony.am exclusively conn ting w'iN boned conlracwn w 106 - SEWER & WATER
comtrvet t roject( c.7W.Business Profusions Codc:)The Conuowr'a Li-
C.neltw as not a ply to an Owner of opcorly who Mud.of boom thereon.end, 'ZO2 — UNDERFLOOR PLUMBING
who cam LLfm.0 pwj.WwiNec Mac r(.)Ikensedpuslontwlhe Canuamora
Lknse w. 203 - UNDERFLOOR MECHANICAL
am cm S '' ,okpCiordsiartaon 204 - UNDERFLOOR FRAME
Data i
e W KE COMPE A ON DECLARATION 205 - UNDERFLOOR INSULATION
I reb con uneerpenalty Perju one of herollawingdecuration.: 301 — ROUGH PLUMBING -
711 haw and will melmild Cenlrmu Caruenuo.elf-IesurtlmWmker.Campen-
302 - TUB & OR SHOWER
ndon,n podded for by Section 3700 or the Loon Code,far the perform.of the 3 03 - ROUGH MECHANICAL
wah mr wnicn Ni.permuuiasueG 304 - ROUGH ELECTRICAL
1 hew and will maintain Workers Compensation Insunnce,as required by Section .
7700 of the Labor Code,for Ne pag.or.nce Of the work for which his permit is Issued. 305 — FRAME
My Workers Compensation room=carrier and Policy number am: 306 — HOLDOWNS
C.Mcr, Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
mdisceone need not he Completed if the panni,is fm tae hundred dollars(S IM) 309 — EXTERIOR LATH
or less.) 310 - INTERIOR LATH . w
employ that In No inPerformance
an mu meerr be wort for which IMS permh is issued,l Nall not
employ any person in any mannerouw Mcome subject to tM workers'Compensatmn 311 — SCRATCH COAT
Law.of California.Data 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT:If.Ifer making seaCeniRcata of Exemption,you NouW 501 - FINAL ELECTRICAL ENERGY
become object to the Worku'a Compensation r ovlsiom of Ibe LOW Code.you must
.J,Z raMwith comply with such provision*orthis Permit shall MCovered avnked, 502 — FINAL PLUMBING ENERGY
Z� CONSRUCnONLENDING AGENCY 503 - FINAL MECHANICAL ENERGY
E4E4 IMmbysfnrmOat effect i.a construction lending agency lot heperfwmanccof 504 - FINAL- BUILDING ENERGY
> tM work rte which NLL permit),LLsmd(Sec.309].Civ.C.) 505 - FINAL ELECTRICAL
W5 Lendeh Name
0. Itndrs Address 506 - GAS. TEST
U o I eaai that I ban read this application Nab
on am soon be aw Information is 5 0 7 - FINAL PLUMBING
h.j.., cmrect.I e a comply with all city and county ordinances and sues lawn foisting to
U building as tion,and hereby auNarom represenmi ea or this city to cnwr upno de FIN MECING'
L
L57 awve- endo dproPerty tm lupcetian purpoxs
(We) rte w sew,indemnify and kce0 de Chy a CUpenina agaiml - Q 9 F I
Ntoll u,a gmenu.eosu and eapenss.wIt n any my acetic against said City 5
U AP I Ceof be UNDERST1iNostAapar IL 0 WITH ALL NON-POINT Issued b Dale
Y5
S TIONS.
Re-roofs
ISO reof plicanCones or °ita 'Type of Roof
J AZARDOUS MATER DISCLOSURE
W I�theeicamoilding
or waeeupanl a.m or handle Wadeus material
tic I.'tithe Cupertino Municipal Code.Chapter 9.12,and the Hu1N and Safety
tle,Section 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
❑Yea ❑No
Will the applicant or future building occupant use eyulpmem or devloca which If a roof is installed without first obtaining an inspection,I agree to remove
emit harard... 0 moanu as deriocd by the Bay Am Air Quality Management all new materials for inspection.
Giblet?
❑Y C]No
HE co Nc Mvardnusmatedeu require nu c0 rChaptar6.95 of Ne Celifoo-
nice Hcol Sof yCade,SccYum 25505,25533 d25 .Iundenwd Null Nc Milling
does nor Moo y haw.tan.nl.Net it it pa Nllky w notify Nc acc.p res m um
require ms 1M -IOur u raCertificate oromupaacy. Signature of Applicant Date
ow ra mari,ndegc All roof coverings to be Class"B" or better
Date
CITY OF CUPERTINO °e` '` "�"
BUILDING DIVISION PERMITONTRAC,TOR INk�ORMATIO,s
PERMIT NO.
BUILDING ADDRESS: LUCY PASTUSZKA
10 511 MAD PERMIT 5
OWNER'S NAME:
LUCY PASTUSZKA SANITARY NO. LNO.
E:
BUILDING PERMIT INFO
ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH
jp LICENSED CONfRACIOR'SDECLARATION Job Description
I Mmby in.Jul I am limned under provisions of Chapter 9(commemin{
w�
with Section 7000)of DivUht.3 of to Business and proreulnm Coda nd my license la �m
1.(.11 f...and'fem. WINDOW RELACEMENT r'i Vl�lQ
n�®
az License Clan LIC.0
Da¢ Contractor
FF ARCH—r—mc•s DECLARATION MAR 2 5 2003
Y 1 undeMand my plans Nall he used AS Public retards
U
Liccnme Pmfcuinntl
OWNER-BUILDERexemptDE DECLARATION BUILDING
I hmaso.Rion Net I am,sumps farm to Comncmr'a e:Any c Law far the ® s '• $1$�J
00 w hick m moon.nan dl t 703 LS,Busimu and prewC.de lona Cole:Any city Or county ,
$
which l ns bec •permit re quires the atmc impmse,demolish,ore a sig any momum
y that he lucensede.alae¢gothepr provision
f Consuch rctor'& ienseLaedCaumcte S Ft.Floor Area Valuation
�xx< scar he it cing wait punuate In the provivinu Or to Comncmrk nd Prot lsio(Chapter r 9• $3100
F$
(commencing Is exe exempt
Section 7")and of basis
3 of to Busialleged
exe pt on.Any
Code)or
•• Net he la 31.5 b ammfran and Ju aura far uu alleged eanmled 10 Any it Pen fon of
not
7031.5veany dreddollfor apermit mbJccutoappilcannoadvllpendlyof 3tpl�It�t8n�3gr• 00 Occupancy Type
not mare Nan five hundred d011an(5580).
I,otownerof the proycmy,re myomploym with wageaJtelr Sole 0uta,Balion,
H and muewmiatnot r's License
Law dorarat.pply.toan Owner usfinesi;
101 — FOUNDS BII Inspections
andTrofuilov Cove:The COnuamoe$Lienee Law Ow not apply to an ower of
meem employees.
pdaomlmprawa Juseogandwho deaamhwmk himffeedJuougn his 102 — PIERS
howee,,ancea,pmNm.i tumrmatiS wmenuan nosoundeemoBene fm W.If. 103 — UFER
howd,, Juavlein{aLi pmvemmnuSold hatIM did act
Wild
or mmpledon.Ne Owner-
build,,
we r•
builder will have r�a of proving that he did wl wee ar impraw In purpose of 104 = REBAR
nit.). dJpe 105 ANCHOR BOLTS
❑I.a awn, f Ne P my,am exclusively conuaning with I,=.ad exam m os to
Construct j,I($byE-c.BUS.Business a pfefmaians Cade:)The Conb&cme$Li. 106 — SEWER & WATER
mare Law ms naupplyloanowner Of aperty who builds Of lagoon tcmon,and, 202 — UNDERFLOOR PLUMBING
who cont ¢form projecawit&e vac r(s)licensed pursuant tote Consomme.
License w. BkPCmrtiamaan 203 - UNDERFLOOR MECHANICAL
01. .m arse 204 - UNDERFLOOR FRAME
Dwmr Data
TIO 205 - UNDERFLOOR INSULATION
A
W KE SCOMPE NDECLARAD
I mb munderpemlty, redo oeofte(allowing dcclaodmur 301 - ROUGH PLUMBING
Nw and will nornuina Ceai I cons enitu161nsumfmWnaer.compmm 302 — TUB & OR SHOWER
stdon,as prank cd far by Seedon 3700 of the Isbm Cade,far the perfarmame of to 303 — ROUGH MECHANICAL
work for which 013permit iamcea 304 - ROUGH ELECTRICAL
1 have and will maintain Worker.Competeaion mune,,as reyuind by Sedan
3788 arts lshm Code,for to performame Ofte wart fmwhich tis permit is issues 305 — FRAME
My Worker,Compensadon Insurance limier and Policy number art: 306 — HOLDOWNS
C.mim Policy NO.:
CERTIFICATE OFEXEMPnONFROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(Ths uSeems used not Mcompleue Perm
d lithe is for am hundred dollar(SIM) 309 - EXTERIOR LATH
mica.) -
1 der iry that in the perfam arm or me work for which ibis Fermi,is Issued.I&hall not 310 - INTERIOR LATH
employ any person in any manor an as m become subject o she Worken'Compensmian 311 — SCRATCH COAT
Laws of California.Date
Applicant 313 - ROOF NAIL
NOTICE
suDAPPUCANr:IL.Mrmakingtls Cerins o ofExemption,Labor Code.
you
501 - 'FINAL ELECTRICAL ENERGY
a become subject m the Worker's pr Coons of 01, orath hal of Jte aced Code,you mea
.J,Z faMwit comply with mer.provisions of 01,permiuMll Meecmed mwkcd. SO2 — FINAL PLUMBING ENERGY
z- CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
t..i N., 1Mroh,afore tat tem i.acoocruedn leading agency far Me pohmeece Of 504 — FINAL BUILDING ENERGY
4s > to work rte which t4 permit u issued(Sm.3097.Civ.C.)
u3 p unece.Namc 505 - FINAL ELECTRICAL
undc' Md. 506 - GAS TEST
U O 1 ttN that I have mud this appImmin.and suss tai to above Infmmaiun is 507 - FINAL PLUMBING
U.E. mmmct.I e o comply with all city and county ordinanma and SUM law$CaUdeg to
0 U building na Won,and hereby.utorlm Mpfuenutiwa of this city to enter upon the FIN MEC CAL
Lrl alwvc. endo d pmperty art iepecaan purpo&u.
LL (We) me to Save indemnify and kmp a to City of Cupertino against O 9 FIN
y Ilabil les,a gmcnu,cmuandcapcnm$wid navy waymcrueagaimtssid City 51 NG
(.) T Inc sc cc NDERromi�pN Date
AP 1 UNDERSTV WITH ALL NON-POINT Issued by:5
S TIONS,
Re-roofs
i{n m of plican Conte or Data 'lope of Roof
JJ AZARDOUSMAER DISCLOSURE
W Idn (Irian,or future Wilding accurate amus handle niaAous material
u dente a Cupenlna Municipal Code.Ch.pter 9.13.and the Health and Safety -
Code,Sedmn155311a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea 0 N
Will she applicant or future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
i
omminanu u defnod by the Bay Arm Air Quality Management all new materials for inspection.
❑Nu
tchnardnuamatenalsmquirc nd"Chapterri.95ofteCaber.
yCode,SeeJons 755115,15533 d25 4.y hawa unanl to it Is Coil,w no iiy dw Occupant or tc
1 stbcmmpi., a iscaalfmauofOCcapaner. Signature of Applicant Date
All roof coverings to be Class "B" or better
mt, age Dau
IN ■
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OVWR-BUILDER VERIFICATI O
1. (Check one) I or my immediate family(parent, spouse or child)will perform:
A. ZAll the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work(complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
. portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.,
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Property Owner's Signature: -� N Date: 3- 6- 03
Job Address: _ /OS(/ Mea W-0-v a _Vv Permit# O 3 () 3 00 G
AU changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
•
1
P TY OF CUPERTINO
CIT
CUPEfikT INO PERMIT APPLICATION FORM
�T
APN# n/- " 3s _ 3o Date:
cLIJ
Building Address:
Q51l MA5)E e ZZ . W, EP_JINC, C c V k4
Owner's Name: Phone#:
LUCY Prs7uyvn 40 311 - 3 1 1
Contractor: �1� �llJ) License#:
LJNJE 2L Wt�..
Contact: Cupertino Business License#:
Building Permit Info:
Bld Elect ❑ Plumb ❑ Mech ❑.
-Job Description: W l OZ0L') L Q L R Ce r16 N1'
Residential IK Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Ir
Cost of Project: Occupancy Group:
Type of Construction: iJ VZ PL1(p,rl ty IJ T_
uantit Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK 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
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 BUILDING
1 of
� a
t
i.� CITY OF CUPERTINO •
c'TM
CUPEI�TTINO PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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 eOfFixtures 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 HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BRENWRHAN A/C Units <= 10,000 cfrn MECHANICAL {
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFDZT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> IOK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res App liance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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tTY OF CUPERTINO
n°F PERMIT APPLICATION FORM
CUPEIZTINO
Quantity Fee ID Fee Description Fee Group
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 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
BSWW 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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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