04060028 (2) CITY OF CUPE[tTINO '�*�"'^�e+�,�.�`�,�Fni, ���+'����'�'�-"`��€
BUILDINGDIVISION PEII�T � COL�ITRt���ORIN�''OR ION��
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BUIL�ING ADDRESS: PHRMIT NOO 4�O C O O 2 B
OW NER'S NAME: PQ��T���AT6
JOSEF & LEA B
NE: SANITARYNO. CONTROLNO.
ARCHITECGENGiNEER: BUI[DING PERMR INFO
BLDO ELECT PLUMB MECN
0 0 � �
�Op LICENSHDCONTRACTDR'SDECLARATION' IObD05Ci7 U00
��+ I I�crcby��m W�I am lirom'cE unJcr pmvisiom of Clupmr v(rommencin{ P
nSj� wiNSccuonlOfUlofDivi�ion]ofNcfiuvneuanEPro(essioniCoAe.��WmYliccnxie .
p ��mum�ao�e�rr«�. ADDITION ON FRONT OF. HOUSE
j y�Z Licenu Cim� Lic.M
�'�� o:� co���.��o, MASTERBATH REMODEL/SKYLIGHT
ARCHITECI'S�ECLARATION �I��p �[�
,�< 1 unEeewnJ my phna ehNl he meJ u puMic rtmrN � � a
�
50� LiccnuaPnifcuionel ��
� OWNER-B111L0ERDECLARATION ' r
r��f I hcrc�y amrtn thel I um cxempi fmm�hc Commnofs Liccnu Low for the 2OOY
O O fallowiny rtuon.(Sccuun)f1316,Busincss mU RuRssium CoJe:Any ciiy nr coumy a{
�$�i which�equims�re�mi�in n+nsvuc�,el�er.Impmve.Eemaltah.or Rpve any�wnuie j�j L /
_Zi Priormi�sissumtt.alwrcquimsiMapplicwformchM�inofilea�i6ncdw¢mcm
,2< �1ai�e�licenttJpmsuenuaiAepmvisiamofNcCanmcmr'sLicnml�w(Ch�piv9 Sq.PL FloorArea ❑ Q,QQ
x❑$ (eommencingwiihSeetlon7W0�nfDivision]afiACBusi�unnUPmfcssionsCwle)ue
�3� Ilut he Ie ecempt Ncm(mm md Ne bssb fm Ue ellegcd evemptlon.Any viohdan of
Scction70]LSbyury�pP��cmtfonpnmltaubJecuNeepplinnuoecivilpcmliyof ppNNumber u ancyType
not mart Nan fiw hundrtE dollu�(SH10).
❑1.n awner af Ih PmpmY,a�my employcu wilh v�5es u NeU mlc cmnpew�lan. � 3 6 2 2���'S . Q Q '
willdoJmwaWmd�heewcwrtisnotin¢ndcdoroRe¢dfonde(SecJ0a4,Buvnw Re uiredIns ections ' -
�nE Pmhviom COEc ihe Canuamrf Licenx faw dam nat epply w en owner of q P
pmpmy wha builds or Impmvee Nercon,enE w�o Joes euch wort himself or Nmuyh hia
own emplaycce,pmvided Nol such Impmromenu ue notin¢ndetl ar o@rtd forwle.IL '
however,Ne�uilEine or impmaxment i�mld wiNin one year af mmpleuon.Ihe ovmer� �
builder will Nw Ne Wrdrn of pmvinp W�he diA no�WiIE ar Impmw(ar pueporc o(
' uleJ.
PJ 1,ae owner af Ihe Ompcny,�m ucluaively conuecting wiN licenaetl romm�on m
consvucl Ne pmjcn(Sec.'l044,Business md Prokesians Codc:)The Canlncbr'�Li� .
ccve I�w Eou no�epply w�n ownu of propeny who Wi1E�or improves Nc¢on,mE
who comneLL(ot such pmjecLL wiN e conu¢ior(q IiuveE pursu�m m Ne Conu¢ml�
Liume I�w. �
❑lemezemp�y(y,n�G�erpSQcc. n � .BhP�C(a�Nurtaon
Ow1er/ /'✓`7� /7"/Qf.Y�"� 'u 1—� •
W RKER'S COMPENSATION OEC RA�ON .
I hcrt�y aRmm unAer pentl�y of perjury orc a(Ihe follawini�luuioiu: ' .
. �1 h�w onE w01 meinuin e Cenifio¢of Comem m xlbinnum fm WohNeCompen-
u�ion,u pmvidce fw M1y Sectlan]]W o(Ne I�bor Code,fm Ne performenm af Nc
work for which Ni�pami�ie iuuctl. .
❑I�ave enA will munlain Waher's Compematlon Insu(eem,u icyvimd by Sccuon
7'100af�helaborCodc.farNeperta�mvrceofNevohforwhlchNupemii�i�lssued. � � "
My Workel�Compenwuon Innwanm euriu md Poliry numbc�ue: .
C�rtier. Poliry Na.: �
CERTIFlCATE OF E%EMPfION FlIOM WORKERS'
COMPENSATION INSURANCE .
(ITis seNan nced m�M comple¢J I(IAe pemili h foronc hundrtA dalhn(SI40)
or Icss.)
I«nily�het in Nc peRoemnnee a(Ihc roh fa which Nie permii u iawE.I��dl not '
employenypersoninmymennersoubEccomceubjcmoNeWorkers'Campema�on '
I.awe o!Celifomie.O�m
ApPlicenl
N077CE TO APPUCANT:If,eMr makin�Nis Ccnif¢e�of Eacmption,you LioulJ
become suEjca b Nc WoheYi Compcwtion pmviuons of Ne lahor CoAe,you muL
.JO (arthwiNcomplywiNwchpmviriaiuorNifpermili�allhtlamWmrokcE.
ti^" � CONSfRUCf10N LENOINGAGENCY '
'N� IherebynRemNanherciaeromwnioniendinga6eneylbriheperfurmem:eu( '
C� � Ne wuek for which Ytif permi�h issued(Sec.NN'1.Civ.C.I
�Q 1<nEchNunc
= z I<ndchAdOve
V Q I ceni(Y Nal 1 hew rted��i�epplicnlon mE sum Nn Nc eEovc infofmulun li . ' .
_D�fff......������ cortccl.I�¢rec b comply wiN A1 city anG coumy aNimnces antl eu¢lawa mle�iny�o
y, builEineconswnion,endhe¢�yemhori'rercprc+enuuresofNi�ci�ywenterupnnNe
Wthovc-mentionWpmpenyforWpeetionpuepoxs
(Wc)�C��^N�.InOcmnilY�^4�p h+^^lev iAc Ciry of Cuprniw��uns�
tiy Iiabiliuu,JuJgmenu,caumEe�puuoWhicAm�yinenyw�yacrue�gunstviECilr
V 7 in ucna af Nc Enmint o(Nis permil.
F' APP CANT fIN�ERSTAN�S AND WILL COMPLY WITH ALL NON�POINf Issued by: Date
0 CE�.GUI.9TION5. ��� �Z
��J��- �D7 Re-roofs
Signai o!A ic�nUCanuecmr Da¢
NA2AROOUS MATERIALS DISCLOSURE Type of Roof
Will Ne�pP��n^�ar fuwrt buildin6 acupent smm or henalc ha'rardous ma�del
az Cefincd by ihc Cupenino Municipal COGc.Chepmr9.1],ma�he Hcalth eM Sefcly
caa�,s��uo�zssaxc.n All roofs shall be inspected prior to any roofing material being installed.
❑r� �wo
� Wdl ihe�pplicem orfuwrt WilEinjoccupm�umcyvipmenl ar@vicm whic� If a roof is installed without first ob[aining an inspection,I agree to remove
emi�ha'urJous nir conuminnnLL u JcfincJ Ay ihc Bry Arta Aie Qualiq M�mpemmt all new materials for inspec[ion. -
Dlsuin1
❑Yce �,Nu
IhorxrtW�hehvinlmisme�crialerequiremcnuunJerCh�p¢r6.95o(IheGliforv '
nuHc�IN&SehtyCadc,Scaloiu25505.355J]enJ 23514.1 unJcrsund Naif Nc FuilJing
Joes noi9urten�ly haw e¢nen4�et i�u my rmponsihilily m noufy ihe accupem nf Nc
rcyvirciFe hmusikmel ao�w�.��«anaNn�.�ora��P��Y. SignatureofApplicant Da[e
��� '���� �y All roof coverings to be Class "B" or better
Ownerun- ome 6em U�¢
� �-�� � � � �CITY OF CUPERTIN�
� Olo��B'
CUPE�wo PERMIT APPLICATION FORM � �
APN# —7 � i Date:
, l�
Buildin�l�flress: Mailing Address (if iffer t from uilding address):
1/0�f /7/LK y Wi4�f ,
Owner�ne: Phone#: �
�c��� L�� �i�►�n€- •L. .�
Contract License #:
Co�pt: Phone� Cupertino Business License#: �
F�: �)�=o
Building P it Info:
�Bl Ele P1w�iK ❑� Mech �
7ob Descript /�.j��/j/OT/ f!�"/✓�T � ��
Residential Rfi�/k�L//✓6 /��'� �`7/���`/ r�
Sq.Ft. Floor Area: � ^ $/S . t.:
Cost of Project: , ._ Occupancy Group: j �
Type of Construction: �� Please c6eck this oz if th oject is a
' second-sto addition:
Pro'ect Size: Stand Laz e ❑ Ma'or ❑
uanti Fee ID Fee Descri tion Fee Grou
BAPPLOTHER Other A liances MECI-IANICAL
BBOILERl Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to SOOK Btu MECHANICAL
BBOILER3 Boiler> SOOK to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOII.ERS Boiler> 1.75MBtu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
' BCONSTAXB Con. Tax for B Zone BiJII,DING
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 Ener BUILDING
BENERGYADD Ener Add Multi BIJILDING
BINVESTIGA Investi ation fee BLTILDING
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��� �ITY OF CUPERTINO � ,
CUPEf�TINO PERMIT APPLICATION FORM
uanti Fee ID Fee Descri tion Fee Grou
BMISCELL Miscellaneous Fee BUILDING
' BMITIGATC Comm. Housin Mit. Fee BUILDING
BNLJCOMIv1E New Comm Electric ELECTRICAL
BNUCOD�IIvIM New Comm Mechanical MECHANICAL
' BNiJCOMR�II' New Comm Plumb PLUMBING
BOVERTIlvIE Ins ection Overtime BUILDING
BPBACI{FLOW Atmos heric Vacuum � PLUMBING
BPCESSPOOL Cess ool ' PLUMBING
BPERMFEE Btd Permit Fees BUILDING
BPFIXTURE Pbl Fixture PLUMBING
BPGAS Gas Pi in S stem Fee PLUMBING
BPINTERCEP Ind Waste Interc tor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BiJILDING
BPLANCKREP Plan Check R eat Fee �BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewa e Dis osal PLUMBING
BPSEWER Sewers PLUMBING
gpgpRlNK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
gpT�p Kitchen Tra PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER InstalUAlter Water Pi e PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reins ection Fee BUILDING
. BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
gRE1vfAIItHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI A liance Install MECHANICAL
BREMBUSWAY Remodel Buswa s ELECTRICAL
BREMFIXT Li tin Fixtures ELECTRICAL
BREMFCTRN Relocation of Furnace MECHArIICAL
BREMFURNOV Relo Fumace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHATTICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc A aratus ELECTRICAL
gREMNRAPp Rem Non-Res A ]iance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/A aratus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BRENIItELOCA Relocation of Hood MECHANICAL
. BREMREPALT Re air/Alter Heatin MECHANICAL
ggEMItESApp Remode]Res A liance ELECTRICAL
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�
, °�i �CITY OF CUPERTIN�
CUPE��No PERMIT APPLICATION FORM
uanti Fee ID Fee Descri tion Fee Grou
BREMSIGNAD Rmdl Si s Add Branch ELECTRICAL
BREMSIGNS Remodel Si s, Maz uee ELECTRICAL
BREMTHEATR Theatrical Li tin Fix ELECTRICAL
BREMVENFAN Vent Fan Sin le Duct MECHANICAL
BREMVENSYS Ventilation S stems . MECHANICAL
BSCBLVD Scb S ecific Plan BUILDING
BSEISNIICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL S ecial Ins ection BUILDING
BSWIM Swimmin Pool BUILDING
BTEMP Tem ora Power ELECTRICAL
BTEMPPERM Tem ora Bld Permit BUILDING
BTEMPSVCS Tem Dist Svcs ELECTRICAL
^ BUSLIC Business License BUILDING
ELECTRIC Electrical s foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical s . foot MECHANICAL
- MPERMITFEE Mech Permit Issuance MECHANICAL
PP.ERMITFEE Plumbin Permit Issue PLUMBING
PPLBG Plumbin Fee s foot PLLTMBING
ZADDCHG Address Chan e BUILDING
•
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� •
i � ; City of Cupertino
;d ' Plan Check Transmittal
Permit# 04060028 Control# 13254
Project ADDN TO E PORCH M Plancheck# 1
Address 1104 MILKY WAY FileDate 6/2/2003
• Owner JOSEF BRONEC
Description RES. ADDTN/RMDL
Plan CheCk Stdtus (attach comments and retu�n to Building with plan set)
Plan •
Dept check# Date Due Date Staff Comment Date Approvai7
Buildin 1 6/2/2004 6/16/2004 POH 6/2/2004 �
Plannin 1 6/2/2004 6/16/2004 COLIN 6/2/2004 n
Assessor 1 6/2/2004 6/16/2004 6/2/2004 n
• I �
' Additional Plan Check Fee ❑ Hours
Plannina Fees � �
' Housing Mitigation Fee Amount �'
Heart of the City Speciflc Plan Fee Amount
•