05050051 CITY OF CUPERTINO ' '" °
BUILDING DIVISION PENT CONTR'ACTQRgINF®R1�TION.
� « rr�aw.s4 �-: ,spate
I�LDING ADDRESS: KEISER, ROSS GENER CONTR PERMIT N%5050051
PTT.M AV
OW NEWS NAME: PERMIT LSSUR DATE
A
PHONE: CO TR
SANITARY OL N0,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
2Oo CONTRACTOR'S COIDACTOR'S DECLARATION
C 1 bemby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
UU with Section 70M).&Division 3 ofthe Business and Professions Code,and my license is
mfull esmaClical "' REPLACE BATH TUB/TITLE/FIXTURE
j yaz Licensercea L'm.s
,F,ga Dam Contractor NO ELECT. /EXISTING PIPES TO REMAIN
ARCHITECTS DECLARATION
Sv a< I undoon nd my plans shall M used as public records
JnoU
O Licensed Pofi ssi...I
vs 3 OWNER-BUILDER DECLARATION
I hereby affirm Nat 1 am exempt from Ne Contractor's Uncross Law for the
m O following reason.(Section 1031.5,Business and Professions Code:Any lily fir county
K which requires a permit m(enatroel,alter.improve,demolish.or repair any structure
y�1, prior N its issuance.also requires the applicant for such permit o file a signed statement
—�< Nat he is licensed pursuant lo the provisions of the Counselor's License law(Chapter 9 Sq.Ft. Floor Area Valua io3rb00
as (commencing with Section 7000)of Division 3 of the Business and Profusions Cod.)or
,c $ Nat he is exempt Ncrefrom and the basis for the alleged exemptian.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of APN Number Occupancy Type '
not mom Nan five hundred della.($500).
ID 1,as..or of the property,.1 my employe¢with wages as their talc compensation, 35704015 . 00
will dothcwork,ands: h,cture Contractors
tors Licens,ded offered s not apply 7044,Business Required Inspections
and Professions Codd:The ctun is roti License law dose not apply man owner of p
property who builds or improves thereon,and who doessuch work himself or through his
own employees,provided that such improvements are not intended muffled forsale.if,
however.Ne building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of �/
sale.). �6 /Po
❑1,ru t ft p of the Sec.7 ,am exclusively confessions with licensed ennaacmrs i.
construct tlm project(Sec.7014,Business and Profesproperty
who Wilds
Cade:)prom the
od. nd
cense law docs not applyte an with
a of property who builds rs improass Neuron,and
who concocts for such projects with a convumr(s)license pursuant to she Contractor's
m Law.
1 am exempt under Sec. .B d:P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury an of the following dcclurations:
❑I have and will maintain aCenifiam of Corvert to self-insum for Waddles Camper-
sasion,as provided fm by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insu.na,as required by Suction
3700 of NC Labor Cade,for he performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu secdsnt need not M completed if the permit is format hundred dollars(SIM)
nr loss)
1 certify Na in Ne perfurmence of Ne work for�yMch Nis permit u issuc.d l shall not
empty any person in any manners. aMoo [subjcum NC Workeri Compcmauon
Laws of California-
Applicant 0 f C, / Ilio
NOTICE TO AP LII after makin'fibia—Ccirdificall of Excmpuon,you should
Meome subject to the Worker's Compensation provisions of tM IaM1nr Code,you must
.Jz forthwith comply with such nowisimes or this permits hall M deemed mvakcd.
Z O CONSTRUCTION LENDING AGENCY
Ihereby affirm that there iso mnswctinn funding agency for the performanaeuf
C Nc work fur which this panto,is Wood(Sec.3097,Ci,C.)
QUndcrs Name
IL
IL z Leadn.Address
U Q 1 cenify that I have fend this application and slam that the above info rradon is
W H correct.I agree to comply with all city and county ordinances and auto laws messing to
�U building construction.and hereby authorise representatives of this city to enter upon the
,r W ahov.-mentioned mo,,ty for inspection p.,a..
Q. (Wc)agree to save,indcmni fy and keep harmless the City of Cupart no against
nF.lin liabilities.judgments.costs and expenses which may in any way see=against said Cily
U in consequence of the granting of this permit.
t—' APPLICANT UN DE RSTANDS AND LL COMPLY WITH ALL NON-POINT Issued by: Date
SOVRCE REC A` ONS. J
stgnamra of vpl1Canvcontra fir _ `/ /3 Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building occupant some or handle hsaardous mammal
defined by the Cupertino Municipal Code.Chapter 9.12.and she Health and Safety
Code,Section 25532007
E]Yea A(_yN��IIa All roofs shall be inspected prior to any roofing material being installed.
Wilt the applicant or future buildingoeeupant use equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
emit havardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District]
❑Yds A.
1 have mad the hatindnus materials requirements under Chapter 6.95 of Ne Cali for.
nia Health Safety Cod.,Sold.v 25505.8533 and 25534.1 undersand thm if the building
does not currently have a tenant Won is my res ovihility m nn.1. 1M aeupan of the -
rcyvimmcnt, helm tMmnpri ssaan fJc.nifeamoracap_ancy,. Signature of Applicant Date
Z� T)t "`��-- " ' All roof coverings to be Class"B" or better
Owner m:.usbonmd agent / Date
h mr �3*4• ��y s 'Y±r. d.+y.. , .A ^sW2v 'G "1� Z
Am
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y..�d„� e � w"'ki�.t�.'c',� •� s i .. xv,S'x hyw q�n � xy�Y s'";
CUPEkTINO
..�'Jr4 atrwL• sA��'z-_c. .� •^.,c z _.s cn„ s� ,...y E �3.,,_ 3i '�. �F1�'
Assessor's Parcel Number 3 S7D yv/r v p
Name of owner.
Project address.
Contact person. Phone. 9��3/
Fax. a
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? Y N
Is privacy protection planting required for the project? Y N
On what floor(s) is work being done?
Brief description of work.
Code editions: 2001 CBC (Y -N)2001 CFC (Y -N)2001 CMC (Y- N)
2001 CPC (Y -N)2001 NEC (Y- N)
Effective 11/1/02
- O
OFFICEz
RECEIVED
MAY 1 0 2005
Plan Review Process Work Book Page-8-Revised 4/28/04
i
CITY OF CUPERTINO
Item 2 of 2 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub : Blk: Lot :
APN . . . . . . . . : 35704015 . 00
DATE ISSUED. . . . . . . : 05/10/2005
RECEIPT # . . . . ... . . . 29618
REFERENCE ID # . . . : 05050051
SITE ADDRESS . . . . . : 22432 PALM AV
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER ARIL GILBRECHT
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2710
RECEIVED FROM . . . . : ROSS KEISER
CONTRACTOR . . . . . . . : KEISER, ROSS LIC # 1404
COMPANY . . . . . . . . . . : KEISER, ROSS GENER CONTR
• ADDRESS . . . . . . . . . . 22430 PALM AVE
CITY/STATE/ZIP . CUPERTINO, CA 95014
TELEPHONE (408) 446-4372
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---- - -- --- ------------- -------- - - ---------- ---------- ------- - - - ------ ----
BPERMFEE VALUATION 3 , 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00
BENERGY PERMIT FEE 83 . 16 39 . 92 0 . 00 39 . 92 0 . 00
BSEISMICRE VALUATION 3 , 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
PPLBG SQUARE FEET 50 . 00 4 . 00 0 . 00 4 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- --- - - -- -- - - - - ------- --- -------
TOTAL PERMIT 165 . 95 0 . 00 165 . 95 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
-
-^ -------------- ----------- - ------------ - - - - - -
CHECK 271 . 21 144
TOTAL RECEIPT 271 . 21
•
CITY OF CUPERTIA
CITY OF PERMIT APPLICATION FORM
CUPEI�TINO
APN# OS��v ,5 Date:
Building Address: / Mailing Address (if different from building address):
ZZ EK;?—
Owner's
2Owner's Name: Phone#:
Contractor: License #:
e ZT 30 73
Contact: Phone: Y �072- Cupertino Business License#:
Fax: 5/0o• f� G
Building Permit Info:
Bldg ® Elect ❑ Plumb 5 Mech ❑
Job Description: A' OZi�.4 •i a ,' f
Residential ❑ e;�j-v�.v i ' S qi Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
ype of C n truction: Please check this box if the project is a
Azlolz second-story addition: ❑
Project Size: Standard ❑ Laze ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K 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
Ask / BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of
CITY OF CUPERTIl`*
CITY0 PERMIT APPLICATION FORM
. CUPERTINO
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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 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
BRENUHMAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL 77
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
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,-v Ary OF CUPERTINO
CUP
EI�TINO PERMIT APPLICATION FORM •'
QuantityFee ID Fee Description Fee Group
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 Inspection BUILDING
BSWIM 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 Issue PLUMBING
J PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
•
3of3
CITY OF CUPERTINO '* aw5,2xi+.� `�
BUILDING DIVISION PERMIT 'CONTRACTOR INFORMATION:`
au1LDING ADDRESS: KEISER, ROSS GENER CONTR PERMITNo05050051
4-12 PALM AV
OW NEWS NAME: PERMIT ISSUE DATE
A
E:
SANITARY CO OL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EUCr PLUMB MECH
0
non LICENSED CONTRACTOR'S DECLARATION Job Description
ZF 1 hcuby affirm Nn 1 am licensed under provisions of Chepur 9(commencing
on<on with Section7")or Division 3 of the Business and Piefessiusu Code,and my license is
��„ in Lic.m me andeffecREPLACE BATH TUB/TITLE/FIXTURE
z License Class Lk.
^- Dem ARCHI ContractorTS TION NO ELECT. /EXISTING PIPES TO REMAIN
i I understand my plans shall W used as public records
J e.
3 G t; Licensed Professional
5 OWNER-BUILDER DECLARATION
1 hereby affirm that I am eump,form do Contractors License Law for the
00 following moon.(Section 7030.Business and Professions Code:Any city or county
$9 which requires a permit m construct.Simi,improw.demolish,or repair any stricture
z i prior m its issuance.also squirts the applicant for Such permit to rile a signed statement
FSG
that he is licensed pursuant to the provisions of the Commctma License Law(Charter 9 Sq.Ft. Floor Area Valua� 00
yF$ (commencing with Section 7")of Division Sof NC Business and Professions Code)or
Nat he u exempt dciefmm and She basis for use alleged exemption.Any violation of
Section 7031.5 by cry applinnl for a permit Subjects the applicant in a civil penalty of APN Number Occupancy Type
not mac than five hundred dollars(5500).
01,uowncr ofdc pmperty,amy employers with wageas theirmlc compenutlon, 35704015 . 00
will do to work and Nelmocturt is no,intended or offered forade(Sec.7064,Business
and Professions Code:The Conuazmrs License Law dues not apply In an owner of Requireedd Inspections
property who builds orimprows thereon,and who does such werkhimulf or through his a,�+Q
own employees,provided Nat such improvemm s are not intended oroffered forsak.It. 1/t//�
however,the Wilding or improvement is sold within one year of mmpletion.the owner. J
builder will have the human of proving that W did net Wild a improve for purpose of F A
sale.), 6t ,a
0 1,u owner of the pmpcny,am exclusively contracting wit licensed mntracmrs to jJAN
M �
concoct the project(Sec.7044,Business and Professions Code:)The Contrawrs Li 9�n
whouse law does not apply m an owner of property who Wilds or impro m thereon,and. LCrus
wcontracts for such projects with a canumn
acter(s)licensed pursuant he the Coctoes CrUD
License Law.
0 l am exempt under Sec. ,B&P C for this reason
Owner Dam LEt IU
WORKER'S COMPENSATION DECLARATION f s' t•ti i ,py,
1 hereby affirm under penalty of perjury one of the following declarations: 4+
1 ham and will maintain a CenceuUuu
iOofnno self-insure fa WorkehCompen-
anion,as provided for by Section 37W of the Inbar Code,for She performance of the
work for which this permit is issued.
0 1 have and will maintain Waters Compensation Insurance,as squired by Section
371 of Ne lobo Code,for the performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.: _
CERTIFICATE OF EXE MON FROM WORKERS'
COMPENSATION INSURANCE
(Thisuctionneed.1 a completed itthe permit is Forane hundred dolun(211)
in less)
1 certify that in one"Formanec of Nc work fa ghich Nis permit is issued.I Shall not
employ any person in any mwoe ••xR becamfsubvesm Ne Wortcrs'Compensation
Laws of California. S-
""'mar,
NOTICE TO AP LICA :II,after making s Ccnirmate of Exemption,you should
become subject u,the Worker's Compensation provisions of the Lather Code,you must
.JZ forAwiN comply with such provisions or this permit Shall he deemed mwked.
z O CONSTRUCTION LENDING AGENCY
thehcrwhich thi that there issued(See.3 7. Bcncy for Ne perfumtanm of
fk 1 Le work for which this permit is issued(Sec.317,Co,Civ.C.)
II]z
Lender's Name
6.
Z Isnders Address
V Q 1 certify that 1 have read this city
ad nun and sou that and
aborc information is
0 F concur 1 agree m comply with all city and county ntaii es of and sum laws relating e
V .1,ovengcontwctionand hereby mNorianspreunutives of this city remorse upon She
erty
1' 4Sl ahovcmenudgments.met
e(an inspection expenses
purposes.
F I]. (We)agree to save,indemnify and keep harmleu the City of Cupertino against
UFq incoitimpjence of s,cwring expcnsumit. may in any wyeccmc agains6uid City
Z in PLICA< of due RSTStarNDS this Permit. Issued by: Date
^
SOURCE
RE 1/NB�RSTANDS AND LL COMPLY WITH ALL NON-POINT
SOURCE REC5y.A5'15�NS. J
S Re-roofs
Signature OfAppliessnVComractor I,- ec
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will She applicant or taus Wilding occupant uort or handleeallous material
as defined the Cupertino,Municipal Cade.chapter 9.12.and NH
e Health and SafetyCode,Scction25532(a)?
❑Yu INu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building acupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants u defined by the Bay Area Air Quality Managcmem all new materials for Inspection.
Diso
O Ycs IDfau
1 have mad the Wx onlous'mlaterials requirements under Chapter 6.95 of Ne Califon
nu Health&SsfetyCo ic.Sections 25505,25533 and75534.I wderswd that ifdc Wilding
does not currently ham a mnank Nath 6 my res rrsihili y m rodfy theW—Signature
rcquirtmcnuw' m timet ori issues aCcnihcam of of Applicant Date
Dwrulmmlori mdagent All roof coverings to be Class "B"or better