05010175 (2) CITY OF CUPERTINO
BUILDING DIVISION MOM
`,' P"
BUILDING ADDRESS: PETER LETCHWORTH PPRMITN005010175
OWNERS NAME: PBRMnISSUBDATE
SANITARY NO. CONIROL NO
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Ib Description
I rumeby anm lot I am licensed esenP
mom e
d under prmior Chaper 9(commencing
with Section 70110)of Dividon Bottom an
J often Bottd Profeelom e u
ct Code,and mylicen
I.full faand effect 6 ' DOOR OPENING IN NON-BEARING WALL
IJce ee Clue IJc.a
tractor
ARCHITECT'SCon DECLARATION
I understand my plot our w coed As public records
Licensed Professional
OWNER-BUILDER DECLARATION
1;many affirm shat 1 am,Bust from iM Cmion Co I.ume lar fm the
O S which m3 remora omit A 70comment,a1w. end ,thermi Code:My m m enunly
S which in ling a n.also ro ngtheplea,hiicuum p.,h poser t t fi nam seY suunun
w heisl rosining
`m un imecomnrmweesL�n u�(a Assessment Sq.Ft.Floor Area Valuation
(commencing with Section 7000)af DlvWon 7 of the Bution so PefeWam Code)m
S Ow be Is... pA the ermm and Be basis for the alleged eempJm.Any Nowlm of
Section TRHJ by any applicant fur•permit AubjeN the applicant As a civil peuby of 3 5603taiifinefO 0 Occupancy Type
nm mom dun Bw hundred dollen(5500).
❑LYOYmf erJC plopcety.m my Impleym!with wasu as JYlreme WmpenYJm4
wlBxthrod;and the he Contact Lildedmonudofarubpply An nBmltm
prop er ywhobu Coco:The Cmummrs and
who lar dont week
appy r rt awry of Required Inspections .
properly who elide m Improwa therms,and rho don sorb work huumf m though lois
awnwplolem.prwlded that pre;lmprowmcousac not lnuMed maRered(mole.U,
howow.the building As wprowment Is old widt'vm on year of completion,cite. X�
wilder will naw the burden of proving that he did not build or improv for Purpom of
sale).
0 L sa owner of do pmpenY.am emlmiwly contracting wish limned comm ms in /
construct des pmlmt(Sec.7014.owner
ofs acme y wtoutoui Cade:)The Cnotncm(s L4'
roue lar lima noT Appy on Agar W propmY who w11N m improv.Coleco.end, /C\
who
.
projectsMlcud Frozen,union,Contractor'sWomLa..
]ZIAm /
amp:undogee .B kPCfor this mato
owe ! P Le+c,'1wn-L t C.A. 1 Z.FO
WORKERS COMPENSATION DECLARATION
I beacby affirm under peaellY of perjury ore of the following declarmonmc _ f
haw readwillmmnaiac.Nfmworcomemmcalf.imamfmWmkehCompm
scam,sa provided ren by S=on 370D of she labor code-for the perfatmetm of the
work for which this permit is imnd.
0 1 Mw Anal will main rein Warlock Compensation brume ce,As acquired by Session
3700 of the Labor Cove,for the performance Allies work forwhich thin Permit Is issued.
My Warkda CompemWm Inmrupx carrier we Poky numb.sec:
Greer. Policy Nu.:
CERTIFICATE OF EXEMPTION FROM WORKERT
COMPENSATION INSURANCE
(Thu maim coed not be eurepleted E so permit is for one hundaE dollars(S 100)
As leu)
I eenlfy met In mho part. ca of do week fee which this permit u burned.l mail not
employ my perm in eery mmecre An us bemmasubject endo Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,afar meting this Certificate of Exemption,you should
become whim An the Wortces Compcnmdm provWnos of the labor Cade,you must
O 'knbwim campy with such providoes a Otis permll shall bre Accountedrevoked.
I rCONSTRUCTION LENDING AGENCY
r I Weeby Affirm that then Is a cotwmnim lending Apmerry for the performance of
The work for which IN permit is Inund(Sec.3097.Civ.C.)
1 A Lemuh Name
z Lemurs Admw
)Q ccerilly thaTlww mdesuapplloWmaMtutothis the show usmmmueu
^" builesl l ague m comply wally lily and county pati m of and sou Tara relining a
jF almmmngemmud Property
herby Authon purposes. dws of cob city umur upon the
t W aww-mmJomd ptopeny f1w ImpesOm pl"h
(We)ju ager m mw,Ind exile aced kap ly inm the Ory of Ca Simi splen
r Vj IubiluW.jmOrh,emuan ofteun whim mryln my MysmmsgaluT Wd CITy Z / _O�
A PLICANT of D ERST N of this D WILL
/U\Y
APPLICANT UNDERSTANDS AND WII3.COMPLY WITH AIJ.NON-POINT Issued by: Date
so cE ecuuno I z Ir -5-
Re-roofs
9itnuurt of Applican
HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
WIN the appllcam or fuhuo building Owupmtmam mhmdle hasardoumamrim
As dclbcel by the Cuperdm Municipal Code,Chapin 9.13,aed the Health and Splay
Cox,session 355y3(a)7 All roofs shall be inspected prior to any roofing material being installed.
Oyu j(No
Will de Ipplwntter rotas,wilding occupant age equipment As devices widen If a roof is installed without firs[obtaining an inspection,I agree to remove
Murdnm air conuminmu u defied by the Bay Ana Air QuAl y Mamrement all new materials for inspection.
District?
Oma
I hew mad the hmrdmn materials requirements;umkrcnapur .A93of she Califon
nhamld,k SmeeyCodc Sccd.35S05.3S573 IMMIX 1 undemum thstifthe building
does rot cmmally levea mune this ll u etyres- hility m notify the mospml of Tui'
mgol minNnma m et ren necmrleeeproe�P�^ry Signature of Applicant Date
1/ `Ly ems
Owner or Authorized agent Dam All roof coverings to be Class"B"or better
P CITY OF CUPERTINO
Idem 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . 35903030 . 00
DATE ISSUED. . . . . . . : 01/28/2005
RECEIPT # . . . . . . . . . : 28414
REFERENCE ID # . . . : 05010175
SITE ADDRESS . . . . . : 905 ROSE BLOSSOM DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PETER LETCHWORTH
ADDRESS . . . ... . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4215
RECEIVED FROM . . . . : PETER LETCHWORTH
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : PETER LETCHWORTH
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4215
• TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 200 . 00 83 . 16 0 . 00 83 . 16 0 . 00
BENERGY PERMIT FEE 83 . 16 39 . 92 0 . 00 39 . 92 0 . 00
BPLANCHK PERMIT FEE 83 . 16 110 . 98 0 . 00 110 . 98 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BREMRECEPT NO. OUTLETS 1 . 00 1 . 20 0 . 00 1 .20 0 . 00
BSEISMICRE VALUATION 200 . 00 0 . 50 0 . 00 0 . 50 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 274 . 13 0 . 00 274 . 13 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 274 . 13 5028
TOTAL RECEIPT 274 . 13
•
N11 - • CITY OF CUPERTINO`
• CUPEkTINO PERMIT APPLICATION FORM
APN# 3 S—� 0 .3 O O -7
Date: J /2-S/D'S
Building A dress:: Mailing Address (if different from building address):
90--5: 146Rme NOSSOM
Owner's Name: Phone#:
c.VIV-CY-l- g5-7
Contractor: (j[1116-r— License #:
Contact: SQ�rw� Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg
Elect Plumb ElMech El
Job Description:
Residential QI d �'"'i j` Co mercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
rho second-story addition: ❑
Project Size: Standard ® Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 1 OOK 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 Elee 600V> IOOOA ELECTRICAL
BELEC200 Elee Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
lof3 4r— 7 /�
C
OVE
CUPERTINO
•
RESIDENTIAL-FROJECT-
CITY 0
.
Assessor's Parcel Number: 03 - 0-3 d
Name of owner. ?,+e,,- L4 v--�-K
Project address.
V
Contact person.?Ck Phone. ;Zs 7—7 d, Z9
Fax.
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. "`all-L1,L5,
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 DMCE copy
oval co
CHIS pkAbt SOUL MAIN O�ilM'
SHF, J06- AT, AM TWO RECEIVED
RECEIVED '
JAN 2 8 2005
IAN I 11111
Plan Review Process Work Book Page-8-Revised 4/28/04
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RECEIVED
JAN 2 8 2005
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