08040037�AVy
Be.)ILDING DIVISION PERMITL�l�,
A� .� _✓L�ky= yl!'.3�
sU11.g2irgf.UURo1R�S
AN, JUAN RD
TBD — TO BE DETERMINED
PERMIT NO.
08040037
OW NEWS NAME;
PERMPr ISSUE DATE
'r ;AC LECKRONE
04/07/2008
NE:
SANITARY NO. CONTROL NO.
CHITECT/ENGINEER:
BUILDING PERMIT INFO
200 AMP ELECTRICAL SERVICE BLDG ELECT. PLUMB MECH
11 0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nn 1 em license under provisions of Chapter 9 (commencing
^ ^"^^^"^^ ^^ ^^ ^"^ .dBb.DesCrlpUOn
with Section 70110) d Division 3 afore Eudnssaand Prefectures Code, and my license is
in full fares and a KL
''-
Lie. 1 a Lic. N 3fyzc sea
DamConuecbI �— �Y
ARCHITECT3DECLARA, i
1 mMmsianJ my plane shall ba uses as public rtcorJs
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm Nm 1 am exempt from the Common's License Lew far the
fallowing mason. (Section 71131.5, Business and Professions Cole: Any city or county
which requires a permit he construct, almr. improve, Jcmollsh, or mfWr any sawtum
prior to its issuance, also requires the applicant for such permit to Ole a signed sincerestserest
Ft. Floor Area
Valuation
that he is licensed pursuant m Ban provisions of this cantracters License Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business end Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any viohthon of
APN Number
Occupancy Type -
Section 7031.5 by siry applicant for a permit subjecle the applicant in a civil penalty of
net mom than On hundred dnllara ISM
[11, ae owner of the pmpemy, or my m rployeas with wages as their sole compensation,
Required Inspections
e ns
will do don work. and the sticture It not intended or offered formic (See, 7ON, BWIOCY
and Pmfeadons Cade: The Committees License Law dons not apply m an owner of
q p
pmpertywha builds wimprovvtheroon, andwhn dassuchworkhimWfar threats his
we employees, provided that such improvements are not inmoded oro0ered Intents. If.
however, the building or improvement is sold within ane year of completion. gas awner-
builder will have the burden of Proving Nat he did Trot build or improve for purpose of
sans.).
C 1. as awucr of the property am exclusively..raising with licensed cormemss m
constrvt the project (See. 70,14. Business and Precool Coda:) This Comnctars LIS
cove Law docs not apply in an owner of property who builds or bromvv thereon. and,
who woman for such projects with a conuacmr(s) licensed personal in he Committees
-
Llce. law.
C lamaxemptunaer See .B&PCfarthiamawn
Owner Date
WORKER'S COMPENSATLON DECLARATTON
I hereby a01mr under penalty of perjury one of the following declarations:
and will maintain a CcArrcole ofConsent to self-ivum for WmkebCmrpen-
kban
n, as provided for by Section 3700 of the Labor Code. for the performance of the
h for which this permit is issued.
71 1 have and will maintain Worker's Compensates Insurance, as required by Section
3700 of the labor Cade. for the performance of the wort for which this outmit is issued.
'
My Warkees Compensation hourmco wrier and Polity number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(rb s section wed not M completed lithe Permit Is formic handed dollars (5100)
'
lir leu)
I certify that in the performance of the work for which this permit Is issued, I shell not
employ any para. in any mamleJrsq�lahccom'e subjaLm the Worked Compensation
Laws of California. Dam 44 tamom- lam
r
Applicant
NOTICE TO APPLICANT: If, offer making Lh aOcam of Demotion, you should
become subject to Na WmrkcYs Campcvktia p2simss of the labor Cadc, you must
forthwith comply wit such provisions or this permit shall an deemed revoked.
CONSTRUCTION
NLENDINGAGENCY
I hereby thi Nat there u a emmmc. 3s. lending7.Ci.agency [m the Performance of
co
ich
the work for which this permit is issucd (Sec. 3097, Civ. C.)
'
Lender's Name
tartlet's Address
j 1 certify that I haw mad this application and sue des, the above information is
'
Comm 1 agree a comply with all city and county ordinances and scale laws relating to
Wilding construction, ad hereby authonze nu m iumauves of Nis city an enter upon the
shave -mentioned property for inspection purposes
(Win) agree to an, indemnify and keep harmless the City of Cupertino against
j liabilities. Judgments. costs end expenses which may in any way acme against said Cityin
conuence of the grossing of daii Permit.
I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued byi . Date y
30 E R LAEyU FTIO_N_5,
ti
SignofApplicamiContsmator Data
HAZARDOUS MATERIALS DISCLOSURE
Re -roofs
Type of Roof
WIII rt or forum building or hanand
havNoand
,
de. Chapter Surety
az tle0vd by this Cupertino Municipal Cade. Chapter 9.11, mtl ore HnIN and Safety
y this Cupertino the
Code, Section 35531(.)7 a. �{
CYv gBnm
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment W Jcvicv which
It humorous air contaminants a defined by the Bay Area Air Quality Management
all new materials for inspection.
sict9
CYas Wit
I ban read the hondousmaerialsrequiremcnts under Chapmr6.95 of the Califor.
n,.Health& SdetyCade, Secumw 25505.25533 and 15534.1 undemmM datifte building
does not,tancr ly hew m mnanl that It u my responsibility m rwofy the accupsnl of be
requil c Must xmatprior missuance ofaCouricamar ca
Signature of Applicant Date
��
All roof coverings to be Class'J}" or better
Gwne remmarivaaagent Dam
Sec: Twp: Rnq: Sub: Blk: Lot:
APN ........: 34217080.00
DATE ISSUED.......: 04/07/2008
RECEIPT #.........: BS000004379
REFERENCE ID # ...: 08040037
SITE ADDRESS .....: 22701 SAN JUAN RD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: SylviaM
COPY # : 1
OWNER ............: MAC LECKRONE
ADDRESS ..........: 22701 SAN JUAN RD
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3932
RECEIVED FROM ....: RINGO RANNAVESKI
CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096
COMPANY ..........: TBD - TO BE DETERMINED
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
• --FEE-ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
------------------------- ------- -------------------
'1BSEISMICR VALUATION
1,515.00
0.50
CITY OF CUPERTINO
•
3
ITEMS OF 3
PERMIT RECEIPT
Sec: Twp: Rnq: Sub: Blk: Lot:
APN ........: 34217080.00
DATE ISSUED.......: 04/07/2008
RECEIPT #.........: BS000004379
REFERENCE ID # ...: 08040037
SITE ADDRESS .....: 22701 SAN JUAN RD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: SylviaM
COPY # : 1
OWNER ............: MAC LECKRONE
ADDRESS ..........: 22701 SAN JUAN RD
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3932
RECEIVED FROM ....: RINGO RANNAVESKI
CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096
COMPANY ..........: TBD - TO BE DETERMINED
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
• --FEE-ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
------------------------- ------- -------------------
'1BSEISMICR VALUATION
1,515.00
0.50
0.00
0.50
0.00
1EPERMITFE FLAT RATE
1.00
40.79
0.00
40.79
0.00
1TRAVDOC FLAT RATE
1.00
40.79
0.00
40.79
0.00
TOTAL PERMIT
82.08
0.00
82.08
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
0
AMOUNT
---------------
82.08
---------------
82.08
REFERENCE NUMBER
--------------------
VISA
•
�.- CITY OF CUPERTINO
0
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #
Na /-700.00
Date:
/E;Jn
Building Address:
-7c1 `-AIv j'./Aw
Z2
Mailing Address (if different from building address):
Owner's Name:
Phone #:
N,AG L�C4 P -ON
Contractor:
Phone: c 3 > (6 �gy
f.AF1i ('S (.(3iJ^,7'rrUta i�,ly - )&141193.5-K
Fax: I>, 1J �
Contractor License #: 3(
Cupertino Business License #:
Contact:'KA KN h �J( .� kt
Phone: �/ j r !75-1!, \5
Fax:
Residential WT Commercial
Job Description:
of
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1 FR, 11FR ❑ 11, 111, V-1HR [—]11, 111, 1V V -N
! 2,'-�'
Valuation: Square Footage:
Project Size: Standard ❑ Large ❑ Major ❑
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf
Fee ID
Fee Description
Fee
Permit Type
Group
1GENRES or
1 GENCOM
1BTEMPPER
Temporary Building Permit (good for
B
30 days)
1BBOILERI
For the installation or relocation of ea
M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h 29.3kw
1BBOILER2
Installation /relocation of ea
M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption ss over 100,000 Btu/h
1BBOILER3
Installation/relocation of ea
M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1BBOILER4
Installation/relocation of ea
M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1BBOILER5
Installation/relocation of ea boiler or
M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH
For ea appliance or piece of equip
M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
IELECINSP
Other Electrical Inspections (per hour)
E
1MECHINSP
Other Mechanical Inspections (per
M
hour)
1PLMBINSP
Other Plumbing & Gas Inspections
P
(per hour
1MEETINGIHR
Application Meeting
B
•
•
C,
WTYCUPI,TINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
IACOUSFDW
SFDWL/Duplex New
B
IACOUSRESAD
SFDWL/Duplex-Addition/Alteration
B
IACOUSCOM
Multi-Family/Commercial
B
CHIMNEY'S
1 CHIMNEY
Chimney
B
1 CHIMNEYR
Chimney Repair
B
FENCES
IFENCE>6FT
Non -masonry, over 6 ft in height
B
1 FENCEMAS>6
Masonry, over 6 ft in height
B
FIREPLACES
1FIREPLMAS
Fireplace Masonry
B
IFIREPLFAB
Fireplace Pre-Fabricated/Metal
B
1FLAGPOL>20
Flag pole (over 20 ft in height)
B
1MODUSTRU
Modular Structures
B
FOUNDATIONS
1FOUNDREP
Foundation Repair
B
1PILECAST
Pile Foundation Cast in place concrete
B
1PILEDRIV
Pile Foundation Driven (steel, pre-
stressed concrete
B
3of5
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1 GENCOM
RETAINING
WALL(CONCRETE
OR MASONRY
1RETSTN
Standard (up to 50 ft)
B
IRETSP310
Special Design, 3-10' high (up to 50 `)
B
1RETSP10
Special Design, over 10' high (up to
50'
B
1RETCRB<
Gravity/Crib Wall, 0-10'high (up to
50 ft
B
IRETCRB>
Gravity/Crib Wall over 10' high (up to
50 ft
B
SIDING
1SIDEST/BK.
Siding, Stone & Brick Veneer
interior/exterior
B
1SIDEOTHER
Siding all other
B
SKYLIGHTS
1SKYL<10 SF
Skylight less than 10 sf
B
1 SKYL>I OSF
Skylight greater than 10 sf or
structural
B
1STAIRS
Stairs -first flight/ea addt'1
B
STORAGE RACKS
1SRACKS<=8
Storage Racks 0-8' high (up to 100 sf)
B
1 SHACKS>8
Storage Racks over 8' high (up to 100
st
B
1STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
4 of 5
19
0
a
CUPERTINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows
B
1WINMEWSTR
New Window -structural shear
wall/masonry includes plan ck fee
B
1EPERMITFEE
Electrical Permit Fee
E
1MPERMITFEE
Mechanical Permit Fee
M
1PPERMITFEE
Plumbing Permit Fee
P
lELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
1PLMPLNCK
Stand Alone Plumbing Pln Ck (hrly)
P
1 STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourly -stand alone
B
IBSEISMICR
Seismic Residential
B
1BSEISMICO
Seismic Commercial
B
/
ITRAVDOC
Travel & Documentation
B
IBUSLIC
Business License
B
E
5of5
CITY OF
CUPERTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
PERMIT #
SUBCONTRACTOR
OWNER'S NAME: MAC
PHONE # 413- 5-33 tc,-70
GENERAL CONTRACTOR: R A.fl S
FAX #
I am not using any subcontractors: 411/7 -AP
/ Signatur
17-
Signature Date
Please check applicable subcontractors and complete the following information:
/
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
)4V:t a :: Ce>h.nv •c3yycv
�'a7d�l �^
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/ Contractor Signature Date