03110109 • CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION a.
BUILDING ADDRESS: PERMIT N99 3 11 010 9
22961 STONEBRIDGE ST
OWNER'S NAME: PERMIT ISSUE DATE
Ig NALD CARTER 11/20/2003
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+Op LICENSED CONTRACTOR'S DECLARATION Job Description
Fu❑ 1 hereby affirm that 1 am limmum under provisions of Chapter 9(commencing P
�W wiNS have 000)oefartivixiOn 3Of ththe Business aRtl messinm ae.anti mylicensc is
a in full forteandc L ✓�.tt BATH LIGHT & FAN
to
j
Zi. Licen s t.i
DaleO �
I I' S CL ATION
f WI understand my plans shell M used As public records
U
e
e�� Licensed Professi n.l
S OWNER-BUILDER DECLARATION
<q 1 hereby affirm that I am exempt from the Contractor's License Low for the
00 following reason.(Section]113IS,Business and Pofessioas Code:Any city or county
5$� which requires a permit to construct,alter,improve,demolish,or repair any Naelarc $550
ti Z< prior In its beuance,also requires the applicant for such permit In rile a signed morment
ss
that hin is licensed Pommart to the provisions c(the Contractor's Livems,Law(Chapter 9 Sq.Ft. Floor Area Valuation
s-3 (commencing with Section 7000)of Division 3 of the Business and Proftessinm Ct or
�.. Nn he is exempt theref oat and the basis for the Alleged exemption.Any violation of
Section 7031.3 by any applicant for A permit Wh ACIS thc applicant to a civil penalty of
Ant more than rim hundred it($501y. a Occupancy Type
❑ I,as net of Ne propert,or my employees with wages As their sole compensation,
will do the work,and the swctum is not intended or oOem l for sale(Sec.7004,Business
and Professions Code:The Contractor's License Law docs not apply in An owner of Required Inspections
property who builds or improm thereon,and who does such work himself or through his
own employcu,provided that such improvements An,not intended or oRemd for ole.IL
however.the building or improvement is sold within one year of completion,the owner.
builder will hove the burden of proving Nn he did not Wild or impmvc for purpose of
ulilde
❑I,as owner of she Pmpony,am exclusively conmctin8 with licensed mnuectors to
construct the pmjcet(Sec.7044.Business and Professions Code:)The Contractor's Li.
cense Law docs not apply to an owner of property who Wilds or improm thereon,and
who contracts for such projects with a comaacmr(s)licensed pureuam to the Contractor's
License taw.
❑ 1 am exempt under Sec. B @ P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
ave and will maintain a Ccnificote of Consent m SCANnute for WOrker'aCompen-
sation,As provided for by Section 3]00 of the Ia Wr Code,for the perfatmonm of the
work for which this permit is W.A.
have And will maintain Worker's Compensation Insurance,us required by Section
00 of the labor Code,for the performance of the work for which his permit is issued.
M Worker's C`o'n on ins r.c artier and Polic bac pay
Kerrier, J + Policy NOY�✓ra 002SL (--0�
CERTIFICATE OF EXEMWION FROM WORKERS'
COMPENSATION INSURANCE
('Otis section rated not be completed if the permit Is for one hundred d011m(gIM)
/yl nrlcssJ
/
employ
Not Person
thein any muncr the work for which this permit is iuucd,I shall not
employ any peron in any mannerw as In become ubjmuo tW Woheri Compussation
Laws of Califomie.Data
C
Applicant -_ ... .
NOTICE TO APPLICANT:IL afmr making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the latinr Cri you must
=O forthwith comply with such prnvisinm or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
j—d I hereby affirm that there is a construction lending agency rot the Performance of
:4 > dm work for which Nis permit u issued(Sce.30AG,Civ,C.)
IIIA Under's Name
z Lender's Address
U Q 1 cenify that I have read this application and shoe dust the shove informaliun is
fL t"' co.en.l agree m comply with all city end county aninanws
ce,and Stam la .1.11.81.
Q U building consuuclian,and hereby aothorirc rcpresenlalim of this city to enter upon the
W ahovcme judgm property,for denies purposes.
gy (We)agree to save,indemnify and keep hArmlass the City of Cupenino against
In incoitius.judgmc In casts and of th rswhich may in any Way acoe again.said City
U inconsequence oNDERST0nCOf lhi permit.
APPLICA NDERST D D WILL OMPLY WITH%LL/NON-P�NT Issued by: Dale
SOURCE GUL � //
SignaorcofApplicano'Contracmr Re-roofs
HAZARDOUS MATERIALS DISCLOSURE �ro Type of Roof
Will the applicant or future building Oacupanl Imre or handle hatamuus material
As defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
ale,$colon 33533(x)? � All roofs shall be inspected prior to an roofing material being installed.
❑Yes Nu P P Y $
Will the. lic.ni or I. iwin Occupant uece equipment If a roof is.installed without first obtainingan inspection,I agree to remove
PP C p y patent or devices which P $
harmdous air contamina as defined by the Bay Arca Air Quality Management all new materials for inspection.
ricff .
❑Yes ON.
t
nix HalIthhrvASgctry Cea .ScNctunuimm3a5505.253q3u3imnd25534.lu nCdcm=d.9w5oiff hNc Wilding
J.not c dy hoc a non 11 is my r• credibility m n,'iilj the txx pant of the s
recut. which I oriontiu of aCAnifcamorO;/, ey. Signature of Applicant Date
Owner or awhorircd agent G AW All roof coverings to be Class "B"or better
11/19/2003 23:21 5105363202 LEGALITIES INK PAGE 05
CG` CITY OF CUPERTINO I
PErtPERMIT APPLICATION FORMMPRT 3 v
# �Z o Z® Date;
1112-o`G 3
Building Address:
Owner's Name: LPhoneE#-
415 /656
Contractor: / /I
Contact; [� _ C:o Phone #:
Applicant/Contraoter• Fax #:
Building Permit Info:
Bld Elect Plumb Mech
Job Descri tion:
Residential: 4eal� Commercial:
Sq: oor.Area: S/Sq.Ft.:
Architect/Engineer: Valuation:
(Construction: Occupancy Group:
_i
J:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER I Other Appliances I MECHANICAL
BBLDGFEE Bld Permit s . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K 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 I BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXB Con. Tax for B Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Ener BUILDING
BENERGYADD Ener Add Multi BUILDING
BINVESTIGA'low Investi ation fee BUILDING
13MITIGATC Corton. Housin Mit. Fee BUILDING '(
lof3 2/
11/15/2003 23: 21 5105363262 LEGALITIES INK PAGE 06
2 �Z
CITY OF CUPERTINO
uCITY OF vo PERMIT APPLICATION FORM
,Quantity Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
0.. BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter HeatingMECHANICAL .
BREMRESAPP Remodel Res ApplianceAL
BREMSIGNAD Rmdl Si Add BranchLECTRICAL.
BREMSIGNS Remodel Signs, MarqueeLECTRICAL
BREMTHEATR Theatrical Lighting FixLECTRICAL
BREMVENFAN Vent Fan Sin le DuctECHANICAL
BREMVENSYS Ventilation Systems ECHANICAL
BSCBLVD Scb S ecific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSF&2FAM Sin le & 2 Famil BUILDING
BSFNA Sin le Famil New Add BUILDING
BSPECIAL S ecialInspection BUILDING
BSWIM Swimming Pool BUILDING
BTENT Temporary Power ELECTRICAL
BTEMPPERM Tem or Bld Permit BUILDING
BTEMPSVCS Tem Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electricals foot ELECTRICAL
EPERMITFEE E.
Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
1 MPERMITFEE Mech Permit Issuance MECHANICAL.
PPERMITFEE Plumbin Permit Issue PLUMBING
PPLBG Plumbin Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
1 62E M r t x T-
J;
3 of 3
04/08/2004 13:50 408-996-2269 RON CARTER PAGE 02
CITY OF CUPERTINO
NG.DIVISION PERMIT `„ ' r :`. •'
BUILDIN^G12J`8i STONEBRIDGE ST PPRMIT"®3110109
OWNER'RW-ALD CARTER P0""�1 9"Z�/2003
E: ,
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: PHONE.! BATH LIGHT & FAN BUILDING PERMIT INFO
BLDOO ELECTO PLUMS MECH
O
•, , ?. '�•rt C/I r ° �"1�IIYt x¢ a ^7 TO ARRANGE INSPECTION JOB DESCRIPTION
CALL 777.3138 MONDAY•FRIDAY 24 HOURS REMENTIAI_:
R l,,v I, `- � x^•+21 + <,% .Is;" U'� a. + BEFORE REQUIRED INSPECTION.JOB ADDRESS ' OSFDWL D KITCHEN REMODEL
>?p AND PERMIT B ARE NEEDED WHEN PHONING. C)ADDITION ❑PLUMBING RE-PIPE
y I UFERFOUGROUN/PIERS/H.D.S.
FER GROUND Cl MVLTI•UNIT D STRUCTURAL
V MODIFICATION
PAD/SETBACK-CERT RESIDENTIAL COMMERCIAL—OTHER_ 0INTERIOR n- CHIMNEY REPAIR
GARAGE SLABS/PREGUNITE IMPROVEMENT D SWIMMING POOLS
HA>.AROOI IS FIRE ARPA 08 ATM REMODEL/ItEPAIR D DEMOLITION
sR4ti)i;NC!'CCSNCR ,tifNTfn9'v@?kiis• 68t�6 -D':>'. 5+;; OOTHER
(+ UNDERGROUND/SLAB DYES Ifyea•lun mUnd O.t.Clm Amofu mhgienvluim&
Eo UNDERGROUND PLUMBING
UNDERGROUND ELECTRICAL ❑ NO Inhitl LC.B.O.s
COMMER[i11
EXISTING ROOF COVERING ❑ NEW BLDG/ADDITION ❑ DEMOLITION
UNDERFLOOR PLUMBING Numhcr of exfRln cevedn ❑TENANT CI FOOD SERVICE
UNDERFLOOR MECHANICAL B V ❑OTHER OIMPROVEMENT
UNDERFLOOR ELECTRICAL To ke romovd To he round
UNDERFLOOR FRAMING VENTS
UNDERFLOOR INSULATION
FtA@$NDS BCI00 t_,•Ii AB AT$.t�l?EN.......... . E, TYPE OF ROOF COVERING
12YISTING, PROPOSED. .
ROOF SHEATHMIAPHRAGM ❑ Built•UP Roof
PLUMBING O Built-Up Roof
TUBS k SHOWER PAN D Asphalt Shin{lee ❑ Alphalt ShinBlee
MECHANICAL E3 Wood Shako 0 Woad Shakes
ELECTRICALJPOOL BOND D Wood Shingles ❑ Wood ShlnBles
MING/STAIRS/E.EGRESS ❑ Other(Spedfy) ❑Other(Spincify)
LATIDNNENTI ATION Provide l.C.B.O.Report No.
,NO>WORKs i 'AB :BHBN f'�NEDii.¢; -_'p}S Provide M(F.installation Spec..
-EXTERIOR SHEAR/HOLD DOWN
INTERIOR SHEARIHOLD DOWN INSPECTION SPECIAL INSPECTION REQUIRED ❑ DATE INSP.
SHEETROCK/SHEEMOCK SHEAR
EXTERIOR LATH/W-SCREED
SHOWER LATH
iNQ=APEORIP "tGPE{� 'Ft#'Ctfr:R9 .. $�
SCRATCH COAT
SEWER/WATER
TEMPORARY APPROVALS
OCCUPANCY
D
Z PLANNING 777.7308
s > GAS TEST IMPORTANT
y p GRADEP.W.777-3354
Z FIRE-CALL(408)378.0010 en a permit has expired,a charge totaling one-half
HANDICAP a fees to obtain a new permit must be paid to
0� ELECTRICAL reactivate the permit.
g' PLUMBING
J MECHANICAL
ENERGY If a permit has been expired for more than one year, a
VISUAL FINAL ONLY chazge totaling the full fees to obtain a new permit
BUILDING ��;: must be paid to reactivate the permit.
�`C RANCYiOFeU 1 y iC3 lr • 'ai F� ❑ Initials
DO,
`vt,,`"vlttfrraa. I A,rsiSSio' P s .
y(Ft'SPECTF�A,r;�r�.i� -I ! 1� h CERTIFICATE OF OCCUPANCY
V-INSPECTION: PLYWOOD: IN-PROGRESS:
SP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION