04080112 CITYOFCUPERTINO
BUILDING DIVISION PEAD
avILDINCADDaess: PeaMITNo.
POSSIBILITY KITCHENS 04080112
299 RQPiNIDELL WY
NER'S NAME: PERMIT ISSUE DATE
-TAMP r- Tr)py RERGUSGN PHONE: SANITARY 0 OLNO.
ARCHnECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p l� 0 E! I�
Yo0
LICENSED CONTRACnOR'SDECLARATION JobDescri tion
e I hereby affirm that em fLhc Bd undo;and
Professions
of Chapter 9(commencing p
with Section and
ionJof the Buainea e,b ProfcuVons Code,and my license is
R 4 in full force ad cffcn.
ac Duenaaaav tie.• KITCHEN REMODEL
Dam Contractor
ARCHITECTS DECLARATION
? DEC< I understand my plans atoll he used as public mcnNa
;G Licensed Penfcssiaml
a'y OWNER-BUILDER DECLARATION
of
I hereby affirm that I em exempt from tins COnuaear's License Law for the
p O which ra moon.(Section R)J str Business and vet demolish,
Cade:Any tiny or county
$fLi which roqubes a e.else to canswe,pima improve,demolish,ore a sig ed awaum '
F-�'t^
Prior an issuance,ala rcyulma the applicant for such Permit to filo aligned statement
< that he is liccnsed pursuant to the provisions of the Contracwr's License law(Chapter 9 Sq.Ft. Floor Area Valuatl ❑
cFO e (commencing with Sation]OW)nf DivialOnJ of NC Business end Profcuinns Codo)w
R R that he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 38�n BTB�[00 Occupancy Type
not.oro than five hundred dollars(5500). ..
❑I,u Owner of the property,or my employees with wages as Weir sole compensation,
will do the work and Nes Wave is not inuou ed or offered for sale(Sec.7W.Business
and Professions Code:The Contractor's License law docs net apply m an owner of Required Inspections
property who bulldsorimproves theroomand who doesnsch workhimulfar through his
owe employees providrd War such improvement,iso nal intended oroRcrcd fatale.If,
however.er,the Nc building or improvement is hlo all within one year of ie
mpletion,th
builder will have rd
the buen of proving Wet did cot build or Improv purpose
of for puou Of
ale.). 14 P4;17
®®I,u owner of ct Sec.7 on exclusively contracting with:i The
anuacross i.
fomtme d project(Sec.]014,Business and rty who
Cade:)The Contuouen.Li-
come law dam not apply roan owns of property who builds or improves thetean,and /
who contract,for such projects with aeanmador(s)licensed pursuant in the Contractor's
Lkena Law. 0
❑I am exempt under Sea T- .B&P C For th0 auon
7
ter
Due
WORKER'S COt)dP NSATION DECLARA�TI—OJN
1 hereby alarm under penury of perjury am of the foing dtcluadom:
❑I hw aM will maintain aCeNrtam ofComent Wulf-Insum fm Warws C.mpn-
ation,as provided for by Section 3700 of tite labor Code.for the performance of dee
work for which this permit is issued.
❑1 love and will maintain Worker's Compensation Insurance.u required by Siniou
3700 of Oc Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance Carrier and Policy number em:
Caller. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tho aClion need not ccompleted if the permit is fwn w hundred dollars(SIM)
or mss)
1 certify not in the performance of dm work for which this Iscrmit a found,I shall nm
employ any person in any members u in become abject to the Workers'C.mpcoodon
Laws of California,Dam
Applicator
NOTICE TO APPLICANT.IL after making this Certificate of Exemption.you should
become subject to fee Worker's Campenation provisions of that labor Coda you must
.JO forthwith comply wide such provisions or this permit shall be deemed mwked.
11
Z y CONMUL71ON LENDING AGENCY
F.a 1 hereby grim that them is a Construction lending agcmY for the performance of
Oil
7 the work fon which this permit m issued(Sec 3097,Civ.C.)
W Q Lendces Nurse
a z Lcndefs Addrou
U Q 1 cinify that 1 have read this application and state that the above infoura un is
lr" a" cancel I agme to comply with all city and county ordinances and state rows relating to
building construction,and hereby autharire repraenutives of this City to enter upon the
W shove-mentioned property for inspection purposes
(We)agree in save,indemnify ad keep harmless the City of Cupertino y
against /
f..ty liabilities judgmen¢,costs and .,.a which may in any way....,am,,
a id Cil
UZ in conuqucnce of deo ymn,ing of Nis permil
^" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE R ULATIORS_
a,Q t �A/�� ��.� b Re-roofs
Sign ur.of Appl¢adContrsemr Data
HAZARDOUWMATERJALS DISCLOSURE Type of Roof
Will the applicant or fumes building occupant stem.,handl.h...thme material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
otic.Sc ye25532(.)?
❑ s tNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huardnns air contaminants as dcfmcd by me Bay Arca Air Quality Management all new materials for inspection.
District?
0 yos l Nu
I have reef the hoardaus mawrials mquiremenu under .Chapterd.95 of the Colifor.
nla Hcullh k Safely Coda Sections 25505,25533 and 25534.1 undorstad mmif the building
dons no,currently haw a conal that It is my responsibility w notify du,mcupa,m thc
rcyuimmenu hiahmug be ,pnorwissumccofaCmtifwamo(Ocup,cyX Signature of Applicant Date
C
Ow ariathorivadagent PateI All roof coverings to be Class "B" or better
r
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tot
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V ................................ .J m _
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u�' sS ih ACCl1R0ANCE WITH O E I LACES
P3
CUPERTIN E�SJA
)ATE_,_
i
n
SIGN F'« — ecifications MUST
Thi set of :..Ons and sP times
be on the lob I all
or, alterations Al
lawful to make any ermissibR ttom k
n same without Gity of cupefino.
r q builm i Dept., City cificsdOnv
m in of this Plan and spe
Th " I �T be held to permit ar to be ar«
prn n It the violation of anyP!O)11W 3
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co I.. EQUIRED E1000 .
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CITY OF CUPERTINO
'Ptem 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36219025 . 00
DATE ISSUED. . . . . . . : 08/13/2004
RECEIPT # . . . . . . . . . : 26674
REFERENCE ID # . . . : 04080112
SITE ADDRESS . . . . . : 7899 ROBINDELL WY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JANE & TOBY FERGUSON
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5076
RECEIVED FROM . . . . : JANE FERGUSON
CONTRACTOR . . . . . . . : COURTNEY MCKOY LIC # 25269
COMPANY . . . . . . . . . . : POSSIBILITY KITCHENS
ADDRESS . . . . . . . . . . : 330 B LINCOLN AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95126
• TELEPHONE . . . . . . . . : (408) 924-0204
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 6, 600 . 00 137 . 16 0 . 00 137 . 16 0 . 00
BPFIXTURE UNITS 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00
BPLANCHK PERMIT FEE 137 . 16 183 . 04 0 . 00 183 . 04 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
BPTRAP NO OF TRAPS 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00
BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BPWSVCS WATER SERVICE 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BENERGY PERMIT FEE 137 . 16 65 . 84 0 . 00 65 . 84 0 . 00
BREMAPPLI NO OFAPPLIANC 3 . 00 21 . 06 0 . 00 21 . 06 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BREMFIXT NO. FIXTURES 1 . 00 1 . 20 0 . 00 1 . 20 0 . 00
BREMINHOOD NO UNITS 1 . 00 10 .26 0 . 00 10 . 26 0 . 00
BREMPOWER POWER UNITS 2 . 00 65 . 95 0 . 00 65 . 95 0 . 00
BREMRECEPT NO. OUTLETS 12 . 00 14 . 40 0 . 00 14 .40 0 . 00
BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00
BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 .26 0 . 00
BSEISMICRE VALUATION 6, 600 . 00 0 . 70 0 . 00 0 . 70 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 756 . 74 0 . 00 756 . 74 0 . 00
THOD OF PAYMENT AMOUNT NUMBER
-------------- ------------ ----
H --------------
ER 756 . 74 VISA
TOTAL RECEIPT 756 . 74
/ 1
ItITY OF CUPERTIN• (� o
• CUPER0 PERMIT APPLICATION FORM
APN# 36.2 /90�5 Date:
/ �� 01 'clTX�
Building Address: Mailing Address (if different from building address):
76'926061M061-& wu A l CU PCP- Tirvo CA 95014
Owner's Name: IPhone #:
PW61 --r-06Y 1--6k(Gusoki IkQ& a5D- Q73
Contractor: PG1SS/8/L /TY K/7CHE�/ icense #:
C0�k-"i✓E y.
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg El Elect Plumb ElMech El
Job Description:
Residential AeMO Q — L X TG EN Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: J ` 5 Occupancy Gro r
Typeof Construction: Please check s bo ' project is a
second-storyaddition: ElPro'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<-- 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <-- 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<--200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
I of 3 ( ,
7 Y7 �f
CITY OFCUPERTINO
BUILDING DIVISION PERMIT _ (`UiRACTOR TNF!l)1tMA"CTON'��.
BUILDING ADDRESS: POSSIBILITY KITCHENS PERMrr NO.04080112
OWNER'SNAMPBID�DBLL Wy PER OMISSIRDATS
g; SANITARY 0 OL NO.
ARCH17ECr/ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o
IOC LICENSED CONTRACTOR'S DECLARATION Job Description
V I hum
hereby affirm that I am licensed under pm ms of Chapter 9(commencing
a� with Sudon70(kBaf Dlvaion3of We Busineuand PmressionsCode,andmylicenscis
in full force and effem.
L�? License Clas Lle.M KITCHEN REMODEL
G Dau Conuacw.
ARCHITECTS DECLARATION
>S I underm nd my pits titan booted M public mccurda
Z U
1.G Licensed Prefrsei...I
y OWN ER-BUILDER DECLARATION
i�f 1 hereby affirm that It exempt from the Convectors License Law for the
r O O fallowing mason.(SMUon RD 13,Bucnss and Profrsdns Code:My city ar county
aj$e! whish requires a Permit to conatmcL almr,hnprow,demmon.m reps,my nmclure
td mi.iiaasnce,also.".iwpe+p ..fartuchpermisu.men Lm,(uummt -
C < thuhelaI.SwiLpuranent70DWofv ionfafftBusinm l3conselaw(Chaptor9 Sq.Ft. Floor Area Valuers n
�s (co=me,exempt
ith genlo se,and of Danis for
Of oto sled.sand Pro(my A l[too of
out he a exempt aa:rtfrom roti We baa for the+IlegW europeen.MY All[too of
Seaden 7031.5 by troy applisnt fora permit mbjecu We applicant m a cidl penalty Ilk a 9,�
oat mart Nan ftw hundred dollars($300). BSI 0 0 Occupancy Type
❑1,ummrofaupropeny,mmyempla3 withwagesa Wel,roleeempewao
willdo Wework.and Mostructues a=bounded w offered for agile(Sec.70N,Bme=
and Profetolona Code:The Centimeters License Law does not apply in an owner of Required Inspections
property who bulldsorlmprows Wemon,and whodecesuch werkhimself orthrough his
own employes,provided that such imprewmenu art not intended aroRered forule.lf. JAN J 2005
however.the building or impmwment is sold within one year of completion,the owner.
builder will haw W burden of proving Wt be aid not bald u improv for par f
ole.). pec ttong�`s^L(T�
I,to awn.of the So..7 y,am=elusively contractingrcoldos with Iieerbsed rnmnc
onILDIN
es La the project(Sec.706x,Bufnss am property
who
C. The Con
who few dos not apply m an owner of property who builds or impmw thereon,roti,
who contracts for such pmjecu with acontractor(s)licensed punsuu the e ConpseM1
to
L
License few.
❑lam exempt under See .B@PC for this
OwneN l�I/lQ. - Y�.CJ fret��l Dau
WORKERS COTP NSATION DFLLARATTIION
* 1 hereby 1111=under penalty of perjury aw of the f—ng deolantbu:
...ad will mainuln•CaNfisto of C...I u scir-asure for Workers Compco-
n.As provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit Is intent.
t.
❑1 bow and will maintain Workers Compensation Inummes,As required by Section
37M of M Labor Cade,for We performance of We work for which this permit la Wood.
My Worker,ComPemadon Inmrame carrier and Policy number are:
Cartier: Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMsautlon need Out becompleted Ran permit I+forow hundred dollars(SIM)
urleso)
I ceNfy that in the performance of We work fm which this permit is issued,I Aall not
employ any person in my manner an As to become subject to oto Workers'Compensation
Laws of 611fomla.Dau
Applicant
NOTICE TO APPLICAT:If.ter making this Ccmlfisu of Exemption.you Mould
become subject in We Workers Compensation prwidons of the labor Code,you most
.JO forthwith comply with such providans or Wu pconk And be deemed revoked.
11
CONSTRUCTION LENDING AGENCY
[y Ihereby affirm Wu them is a construction lending apcmy for the performance of
a We work for which his permit Is issued(Sec.3097.Cih,C.)
WM Q Lenders Name
,=z Lenders Adds
U O I certify thst I haw mad this pplication and sato that the Mow Information is '
14 r".. m=m.I aIIs W comply with all city and county ordinances and sato Iowa relating to
O LTJ' building commotion.and hemby authorise reprexna0w of this city to enter upon Me
W ahovcmcntiuned property for Wpeerlan Pulp..
(Wc)agree m saw,indemnify and keep harmleto We City of Cupertino against
VT liabilities,judgments,eau and espensa which may in any way tome against told City
U 7 in consequence of We granting of this Permit.
�i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N NPOINT Issued by: Date r
SOURCE RgIJULATON,S_
Re-roofs
Sig ort of Applicanuau
VConor Dau
HAZARDOLtIMATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oceupwntstom or handle hamdos mauntl
as de0oed by the Cupertino Municipal Code,Chapter 9.12.and We Health and Safety
Code,Section 25533(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea Ktf4.
Will the applicant or future building accupom use equipment or devicas which If a roof is installed without first obtaining an inspection,I agree to remove
haandnus air cooumi.mus as defined by the Bay Arca Ail Quality Management all new materials for inspection.
rict7
❑YesNu
I have mW the hatoNousmaudals requirements under Chapur6.95 of the Califon
nia HcalW&Safety Code,Sccdms05505.8533md25534.lunWmandthairoo building
dos not comedy how a tenant.Will It Is my Mmonsihility to notify Me acupmt of the
req.moranhs on must Ipdortoissumccof,Ccoificauoro, P-cyy Signature of Applicant Date
ow er naod'rea.en, to All roof coverings to be Class"B" or better