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04090077CITYOFCUPERTINO BUILDING DIVISION PERMIT ^ CONTRACTTbQR INF,UORMATION .- - BUILDING ADDRESS: PERMIT NOA 4 090 90 0 7 7 OWNEWS NAME: PERMIT ISSUE DATE E: SANITARY C OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Jb Description o 1 amby afflrm Nal I am licensed under pmvWom of Caper 9 (commencing with Section 70007 of Division 3 ofNe Business and Propose. Code. and my license is LiicensefaCassnd effect L1Ca BATHROOM REMODEL (1)' Data Contractor ARCHITECT'S DECLARATION 1 underwnd my plans mall he used As public recnNs Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from to Cobraenor's License Law for the following much. (Section 7031.5. Business and Profession, Codd: Any city or county which requires a permit m const¢¢, alcor, improve, demolish, or repair any structure prior In its issuance, also requires the applicant for such Permit to Glc a signed statement Ft. Floor Area Valu that he is licensed pursuant =she provisions of the Contruta's License law (Chaps, 9 Sq. tion (commencing wish Serum 7000) of Division 3 of the Business and Pmfeuinas Cousin) ser Nat he u eaempt thae(mm and use basis fix, the alleged exemption. Any violation of 3 69MMWtqr00 Occupancy Type Section 7031.5 by any applicant for a perrniuubjects the appllunl M a civil penalty of not mom Nen five hundred dollars ($500). ❑ I, As owner of Ne property, or my employee with wages As their sole compensation, Required Inspections will do Nework.and Nc muctute is not Intended cropland (ormin(SttJB44. Business and Portland.. i.. Code: The Quarantines License law donot apply m an owner of e q p propenywho alldaorimprovn tamon, and who doa=ch wark himself or through his own employ=. Provided that such ImpmwmmU art notinmnded oroRered for We. If, however. Ne building or improvement is sold within me year of completion. Ne owner- builder will have the Was. of proving Nat he did nm build or improve far purpose of 1. u owner of a propeny, am crelusively contracting with licensed commands to As o hunt to projen (Sec. 7044, Business and Profntions Code:) The Co aracmrh Li. acme Law don nm apply to an Manor of property who builds or improves Demon, and. who c.mncU for such pmjecm wish aeontnnor(s) licensed pursuant m Ne Cantnc=ea License Law. ❑ 1 am exam t under Sec. B & P C for NIS tion _ tOwl 4 Dam WORKER'S-COMPENSATION DECLARATION 1 achy affirm under Inanity of perjury one of the following declarations: barn and will mainum a Carolinian of Comem to self-ansa¢ for workerscompcn- ation, an provided for by Section 3707 of the Labor Code, Or to performance of the wark for which this permit is issued. 0 1 have and will maintain Workers Compensation Insurance, a required by Section 3700.f the LearCMde. (a the perfmmuca of she work ferwhich Nis permit is issued. My Worker's Compensation Insunnm carrier and Potle, num er are: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Ibis section need notacomplered If flue permit is Duane hundred dollars (SIM) or less.) 1 modify that in the performance of Ne work for which this permit is issued, l shall not employ any parson In any manner= As to become subject to the Worhri Compensadon LAW, of California. Date Applicant NOTICE TO APPLICANT: IL after making this Cenificem of Exemption, you should become subject to she Worked Compensation provisions of the labor Code, you most foMwith comply wish such provisions or this permit shall the dmmed revand. CONSTRUCTION LENDING AGBNCY 1 hereby o(IUm that there Is a contraction lending agency for the pnformmce of No work for which this permit Is Issued (Sec. 3097, Ci, C.) LmWs Name Lender's Address I certify that I have rand Nis application and SLAM that the show information is Waren. 1 agree to comply with all city and county orcin=ms and sue laws Mining to building construction, and hereby auNorian representatives of this city to enter upon the gave-mentioned propcody for inspcNon purposes. (We) agree m saw, indemnify And hep harmless the City of Cupertino against liabilities, judgments. costs and expenses which may in any way same against said City in consequence of the grantmg of this permit. APPLICANT UN RST DS AND WILL COMPUIVWITH ALL NON-POINT Issued by: Date SOU CE L Re-roofs rt `am igna oa(Applic _ HAZARDOUS MATERIALS DISCLOSURE- Type of Roof Will the applicant or future building ocaupantswm mhandte haramau ¢aerial As defined by 0e Cupertino Municipal Code. Chapter 9.12, and to Health and Safety ode, Seen.. 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Peau If a roof is installed without first obtaining an inspection, I agree to remove Will the Applicant or future building occupam tau equipment or devices which husaodous air comaminamm As defined by de Bay Area Air Quality Management all new materials for inspection. strict? ❑Yes u I have mad the haammas ma mills requirements uak:r Chaperb.95 of the Califor. ni.H.hh&Safety Code,Smmm75505, 25537 and 534.lundcamndthaifta Wilding dors not currently how a ten =4 Not it is my reape ihility m badly the occupant of Nc gyui{C an w me be me prior miuuancco aCertificateOfact ey.� 1 Signature of Applicant Date f / R IDa b All roof coverings to be Class "B" or better V Owner as . o a orizccm Dam CITY OF CUPERTINO tT.�fNP'O,�IA".1 ` BUILDING DIVISION PERNIIT,GON�C2UI, DUILDING ADORES$: - PERMIT NO: �IO9OO%% OWNER'S NAME: PERMIT ISSUEDATE CC8WFOL NE: SANITARY Xcr NO. ARCHr1ECT2NGINEER:BUR.DINO PERMITINPO BLDG ELECT PLUMB MECH LICENSED C'ONTRACTOR'S DECLARATION Job Description 1 heroby afmm the, I me isman" under provWau of Chaps, 9 (cnmaencins with Section 7000) of Division 3 orde Butlrcumd pmossons Code.and my Ikons u I. fall face and e8ea BATHROOM REMODEL (1)' Uv ea ClanLic.I Oak Contractor ARCHITECTS DECLARATION I uderwnd my planslull W used as public reCooa Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm Nn 1 am attempt from the Contractor's Livens IA. for the following mason. (Secoun 71131.5, Business and pro(esslnm Cade: My city or County which squires a permit a, Cement alter, improve, demolish. or repair any structure prim m to issuance. also requires thospplieant far each permit to rile a signed statement Law 9 Sq. Ft. Floor Area Valu GOA ^f the Comtort L.ocmc (Chapter that he is located potassium ties pmWaimuru (Coening with Section 7000)of Division 7 of the Business and Parkmamu Code)ar m that he k attempt thentfrom and the basis fm the almgd emmptmn. Any Omission of $action 7071.5 by A" applicant for a perealtubjeeu the applicant m • -Ill Penley of 3 H lr$ON 0 Occupancy TI pe Dot mos dun En hundred dollen ($500), " ❑ 1, as, awm r of dsa property, or my employer with caapi u their ask Compenvtion. will do the work, and the someone, is Out intended or offend for sale(SeC. 7044. Bumf— Required Inspections q P of and ProfessionalCage: The Contracmn License Lavr den Out appy le an owner Of property who but Ids w improves thereon, and who does such went himself or through hie owncriplo5en, provided thelsuh impronmanusre not intended oroffend for sem. It. did one Sete of cmovefaron. purowner will have Uo burden of proving that he did not build or Improve fu purpose of builder thebuildingthen order of ement is mid proving miimar talc,). 1, u t the p o the property, . B uness andvely contracting with :) The ConnClarS - mast the Profen (See o an Business and Property who i Code:) Too Conuurem- Li- cease {sus does rot apply m m owner of property who balms rr improves thereon, andif's 0 the CovusnoM1 (pat such projethacantncur(a)Ilcensd purswmmR wbo=Law. projects, N Lt.= law, O ❑�T un cumlSee .e&PC(or Nm e anderwo - 1 �sv Oak V RKER� COMPENSATION DECLARATION - I hereby affirm under pamly of perjury aro of the f011ewing deelmsioru ❑ 1 ban ad will maintain a Certificate of consent in telf-inure forwodefscompeo- worn, upro fm by Sidon 3700 of time labor Code. for the performance of the wmk for whichh this penmil is iaswA (:j I ban and will maintain Worker's Compensation Inunnce, as mquimd by Section 3700 of Ne Labor Code. far the performauc of the work far which Ws permit is h ud. My Workefa Compensation Irmuance carrier sod policy number ma: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (Thissection reed onl basau^pkud if de perch k fm use hundred de0an ($100) or int) 1 story that in the perform n of the woh for which thin Permit k issued, L Nall nm ' employ anyp ram in my mannerm as in bemmesubkC110 aworkrn'Compemaden Laws of Callramu. Date Applicant NOTICE TO APPLICANT: IL after making this Oeoneeta of Exemption, you should become subject to the Worker's Compen m on providers of on "her Code, you muss ' forthwith comply with such pmvialnn or this permit Nall W demand revoked. . CONSTRUCIION LENDING AGENCY ` 1 hereby affirm that dart Is, Construction Tending agency on the performance of the work fm which tin permit Is Windt(Sm 309'1, Civ. C.) t I=41e Name Luken Address j I «nify that 1 haw rail this application ad sum d u do abort information is ' m me 1 ape at Comply with all city and county oomuun and suis Iwo relating m building conwcton. and hereby anthorim rtprtsanmivea of this city las man upon der: above-mensiond property for harmakn pugroset (We) Ips to sans, indemnify tad keep harmless de City of Cupertino against j Ilabllrn,judgmenu,cnu andexpeesn which may In my wry acme against saidCity In Coneqmence of the sousing of this permit. �v t • APPLICANT UST DS AND WILL COMPL WITH ALL NON -POINT Issued by: Date �U 8 L S ^ - -r `m/ / Re roofs m un of AppliwrDO �- ase HAZARDOUS MATERIALS DISCLOSURE' HAZARDOUS Type of Roof WIII applicant no fou building e. mase orandle h maerkl Healthsand u de0ned by the Cupertino Municipal Code. Cnpkr 9.13, W the Hulth tad Safety y t ni Chrip Code, Samoa 25532(.)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yeso If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant Or future building occupant um equipment m devices which emit hawdous air Contaminants as donned by the Bay Ass Air Quality Management all new materials for inspection. District? ❑Yes u I ban road the hwardnusma erkk squinmenu underChapur 6.95 of the Califon. nkH.I"SafclyCdc.25533and 534,1 underaundthatifthe building doss vel currently ban 1=72""': is my maps INlity u nmdly the occupant of the u n w Mme prior. I.nwaa I CmiOue of Occupancy. Signature of Applicant Date 1 All roof coverings to be Class "B" or better Owmr a an Dau • City of Cupertino, Qi. Plan Check Transmittal Permit# Project Address Owner Description 02090077 Control# Plancheck# 1 FileDate 9/14/2004 RESIDENTIAL REMODE 7955 SUNDERLAND DR HENRY KIRTLAND REMODEL BATHROM AND CLOSET Plan Check Status (attach comments and return to Building with plan set) Plan_. " Dept check# ,'Date Due Date staff Comment Date Approval? 1 9%14/2004 9/28/2004 POH 9/14/2004 121Buildin Assessor 1 19/14/200419/28/2004 SENT 9/14/200 1%11 I Additional Plan Check Fee 0 ' Hours i' Planning Fees ^� Housing Mitigation Fee Amount Heart of the City Specific Plan Fee Amount 4 I Additional Plan Check Fee 0 ' Hours i' Planning Fees ^� Housing Mitigation Fee Amount Heart of the City Specific Plan Fee Amount WIC - W � Z Z m ; CEI 3 � � o SEP �� E��1��oA1iIG R NT a N O 09 S 10 Ci S WIC - W � Z Z m ; CEI 3 � � o SEP �� E��1��oA1iIG R NT a N O 09 S iao CUPEkTINO CITY OF CUPERTINO `� c q U 77 PERMIT APPLICATION FORM ° PN # 3/Z �/D _ F Date: q /l4 /O J, uildin Address: Mailing Address ((if different from building address): 7g5�s Sow ERy1N10 I CR GtS�014 Owner's Name: HfWQ1 9123 "4 -Az Phone #: 4-G4 cl�: --vrl2- Contractor: LpU15 PIRut)Z License #: �1'lfo$4 Contact: Lot) P I a N t K Phone:4o8 X68 - 3 0o Cupertino Business License#: Fax: slob 323.9906 Boiler > 100K to 500K Btu Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Descripti: S/iTN(Z4oM (2E)vI o fz L Residential Lon� Commercial ❑ Sq -Ft. Floor Area: $/Sq.Ft.: t�1Oo�t L_ Cost of Project: Occupancy Gro BCONSTAX Construction Tax Type of Construction: Please check t s box if the project is a Ind/Off/Comm/Quasi second -story addition: El Project Size: Standard ❑ Large ❑ Major ❑ Con. Tax for BQ Zone 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 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 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING X70 lof3 / ��. 3�%