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05020053 CITY OF CUPERTINO BUILmNG DIVISION PER- CONTRATORIIVFOR ION BUILDING ADDRESS: PERMIT NOO 5020053 W NER'S NAME: PERMIT MUEDATE PHONE: SANITARY NO. 9 CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BO ELECT PLUMB MECH 0 u00 LICENSED CONTRACTOR'S DECLARATION u❑ I Wmby affirm that I am licensed under provisions of Chapter 9(commencing lob Description ZW with Section 7")of Division 3 or the Business and Professions Coda and my license,is L meteor and ell b�i2 Go$ ADD 108 ' (LAUNDRY RM) REMODEL 52 ' �? Liccnx Class _ Lic.M Dace: 1 4 Cantrxtor. ARCHTIECI'S OE ION FINq UI undcmand my plans shell he used u Pu a recfrof /{g�{f�9q® . 6a G LED a;.cep r^ LICC^sCJ Poulton 0naI OWNER-BUILDER DECLARATION <y I he."affirm that 1 am exempt form the Contmcmr's License Law for the O() ipo following reason.(Section?031.3,Business and Pmfessios Cole:Any city or county ��� cAl Zoos which requires a permit ro consumer,alar,improve,demolish,or repair any structure s `< prior to its issuance.alum ox,ires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions or the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area, ©t,7 �r .ate [ (t /jt Valuation biFC (commencing with Section of Division 3 of the Business and Professions Code) q H�� QPt]�t6 jy y $ that he a exempt therefrom and On basis for the alleged exemption.Any violation of NM HH N[E Sl 91 r{L�S,y Section 7031.5 by my applicam fora permit subjects the applicam m a civil penalty.f 3'N&DI4`Glfdtber0Off'U u='�' U D v �Occu ane Type not more don five hundred dollars(S500). P Y YP ❑I.ss..,of Nepmperty,entry employesamth wages u their sok compensation, will do On wort and thestmmum is not intended proffered for e.le(Sec.1044,Business - and Professioes Cade:The Cnnuuwri Lioma Law dues not apply to an owner of Required Inspections property who builds or im proves themon,and who does s uch work him self or ttmugh his own employees,provided that such improvements are not innanded or offered for via if, however,On building or in,no emml is sold within one yrs.of completion,the owner builder will have the burden of proving Nat he did not build or improve for purpose of .1C.). 1,as owner of the property.am exclusively contracting with licensed mnuxtors to construct the project(Sec.7044,Business and Professions Cade:)The Conuacmr's LL cense law does not apply m an owner of property who Wilds of improves thereon,ane. who contracts rot such projects with a eonuacton(s)licemd pursuant to the Cantnctor's License raw. I am exempt under,See fa f� .B A P C for this mason weer C?0 Y&G .Q Dale WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury,one of the following declarations: ❑I have and will maintain aCcrtiGom of Comm to self-insure for Wor earsCompen- sation,an provided for by Section 37M of the labor Code,for the performance of the work for which this Permit is issued ❑1 have and will maintain Worker's Compensation Insurance,an mquimd by Section 37W of the labor Code.for the perfmmarme of the some for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Carrier. Policy No.: , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu section need not W mmplmed if the Permit is form hundred dollars(SIM) or less.) I cenifv Not in Ne performance of the work for which this Permit is issued.P shall not employ any perann in any manner so as to become subjeeuo the Workcri Compcnvdon Law zdicrcalirornbD � Zee t Applicant L/e..DR r:aa.-... NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should become subject m the Workers Compensation provisions of the labor Cede,you must .JO foMwilh comply with such pmvWom or this nornitshall W deemed revoked. z(n CONSTRUCTION LENDING AGENCY rIWtrbyafllrm that then is.constrctim lending alum,for the perfnfrimn of bei '1 Ne work for which this permit is issued(Sce.3097,Civ.C.) QLenders Name CL,r7 z Lender's Address U Q 1 certify that 1 have mad this application and sale Nal lW above informadua is U. F correcL 1 agree m comply with all city and county ordinances and soon laws relating in 0 Wilding consuuclion,and hereby euthorin mpnxnumms of this city to enter upon the shove-memidgm propcny far is peefimrocz Purposes H y (we)agree m serve.indemnify and keep hamnkss the City of Cupertino against res liabilities.JudgmentseCosts and expcesesmit. may in any way eccme against mid City t.),Z, in consequence of the granting of Nu permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOU EGULAT NS. ' C Ig1�o f`i •/ .��R�05 sngnam�uconuBel� � — �— Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the a di ieanl of future Wilding occupant stun or handle havafdous material m defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety We.Sccdon 35532(.)? ❑Yes ON. All roofs shall be inspected prior to any roofing material being installed. Will the applicanlor rutum building occupant sex cquipmcno or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hannious air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes 0N I have read On heard^usmalcrials rtqui¢mcnts t n1krChap e,5,95af the Califon nia Health&SafclYCode.Seedau 25505.25333 and25534.I understand thatirthe Wilding Joe,not emmitly have a tenon,the it is my mspomihility to notify the occupant of the fcul imce owhichmbeme,poortoissuofaCertifiaeorOccupancy Signature of Applicant Date ,c (b _o:.c Owner or suohonrce agent All roof coverings to be Class "B"or better • CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . . 37509001 . 00 DATE ISSUED. . . . . . . : 02/08/2005 RECEIPT # • • . . . . . . . : 28519 REFERENCE ID # . . . : 05020053 SITE ADDRESS . . . . . : 19112 TILSON AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PAUL DECILLIS ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : PAUL DE CILLIS CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , • TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ------ - - - - ----- -- ------ ---------- ---------- ---------- ---------- ----- ----- BPERMFEE VALUATION 15, 500 . 00 234 . 36 0 . 00 234 . 36 0 . 00 BPFIXTURE UNITS 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00 BPLANCHK PERMIT FEE 234 . 36 312 . 75 0 . 00 312 . 75 0 . 00 BPWHEATER PER HEATER 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00 BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00 BENERGY PERMIT FEE 234 . 36 112 . 49 0 . 00 112 . 49 0 . 00 BSEISMICRE VALUATION 15, 500 . 00 1 . 60 0 . 00 1 . 60 0 . 00 PPLBG SQUARE FEET 160 . 00 12 . 80 0 . 00 12 . 80 0 . 00 ELECTRIC SQUARE FEET 160 . 00 12 . 80 0 . 00 12 . 80 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 MPERMFEE SQUARE FEET 160 . 00 12 . 80 0 . 00 12 . 80 0 . 00 MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 PVERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 897 . 89 0 . 00 897 . 89 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ CHECK 897 . 89 1945 TOTAL RECEIPT 897 . 89 0 CITY OF CUPERTINR • CU TY OF O PERMIT APPLICATION FORM U�"a APN # 3}5' 0q— 00 I Date: 2 S DS Building Address: q r Z ILSON Af/E Mailing Address (if different from building address): Owner's Name: Phone #: Contractor: P29 L License#: Contact: hh . Phone: 25+- W_0 Cupertino Business License#: ppoL Vf,: ClU {S Fax: Building Permit Info: Bldg Elect Plumb ,9 Mech ❑ Job Description: �91ZUN��x Residential 0 Yntuoy- ol ) Commercial u Sq.Ft. Floor Area: �11 L . $/Sq.Ft.: ASF 5d2 F to S- Cost of Project: (5' Occupancy Group: Type of Construction: VAIPlease check this box if the project is a second-story addition: ❑ Project Size: Standard Laze ❑ 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 IM Btu MECHANICAL BBOILER4 Boiler> 1M to—1.75M Btu MECHANICAL BBOILER5 Boiler> 1.75M BtuMECHANICAL 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 BUILDNG BELEC1000 'Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BNVESTIGA Investi ation fee BUILDING l of3 X97 87 (Su"-, CITY OF CUPERTINR ' CITY OF PERMIT APPLICATION FORM • CUPEkTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE IPblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Cbeck Fee BUILDING. ' BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Insiall/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNO V Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL AIL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heati-ng MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 1 ' rc CIi CITY OF CUPERTINO �. ' CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING 740 ELECTRIC Electrical sq foot ELECTRICAL / EPERMITFEE Elec Permit Issuance ELECTRICAL NPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change I BUILDING • 3 of 3 • 3t ; 9ktlt, Fk� ik"r' y `, -« r?re rr sfk tY RES, i hiND AL M-ME'C C'OO � s �RjS`HEE F In OF , '� 6" '• _ wry °, `, ° tire} `y^'y `0� CUPEI�TINO ��Q Assessor's Parcel Number: Name of owner. DG GI a4s FAUG AWW �qwa Project address. I9VIZ TL$dA/ Contact person. nf}LIL Phone. Fax. Net square footage of lot. �oX • 9 ��� $F Existing Proposed Square footage: First floor: l y 90 sF' Second floor: ' — W /T/Oi✓•' 1,991514F- Garage: ,9SG Garage: — TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y Is privacy protection planting required for the project? Y On what floor(s) is work being done? 157- Brief 57Brief description of work. /NTE�/O� ��/lJOgrEL/�t/(r ©`CE lfJ7/.rr--1A ,Qin/. 40✓O67A77W� /T i ted�.l�✓f3Tf�2�D/`! ,r/eui �'X/3 ' i�.v. Code editions: 2001 CBC (Y - N)2001 CFC (Y - N)2001 CMC (Y-N) 2001 CPC (Y - N)2001 NEC (Y - N) Effective 11/1/02 PLOT PLANS CHECKED BY! DATE_�v PLANNING DEPT, �TE RECEIVED OFFICE COPY FEB n 6 2005 BLDG, DE"s Plan Review Process Work Book Page-8-Revised 4/28/04 p aow z r mom i O m :2 LLI N O Ckf Of O O .-. 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CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH aft O iJ LICENSED CONTRACTOR'S DECLARATION O O O O C1 hereby if firm Nu 1 un licaucd under provisions of Clmpmr 9(commencing Job Description ^7U win Section 7OX)of Division 3 of NC Business and professions Cade.and my license is .�Jjy a Dran mrtt me ercea t . L i Lima.Chat; Conuacmr ADD 10$ (LAUNDRY 1 a rt�£'Jr ARCHITECTS DECLARATION LED -t 1 underuanJ my phos WII he used as public records (� 'f � licensed Professional �s•T y�N5 3OWNER-BUILDER DECLARATION M 1 hereby mlinn oat 1 am exempt from the Convmmes License law far the 5:00 following mason.(Section 703 1.3.Business and Professions Code:My city or county ) $ which requires a permit to construct.a1mr,improve,demolish.or repair any structure UP t .s prior m its issuance,also mquires the applicant forsuch Permit file a signed smlems v em Y < that he is licensed Norman to lie pmvisionsof the Ctuuium's License Law(Chapter 9 Sq.Ft. Floor Area UU td Valuation as~S (eommewing with Section It")nf Division3ofthe Boammaand Professions CMe)ur 03.- oat he u exempt therefrom and lie buts for lie alleged exemption.Any violation of Sudan 7831.5 by any applicant for a Permit ubjects lie applicant o a civil penalty of 3"} I3�Ifdibet0 0 Occupancy not more nut five hundred dollam(+souk P Y Type ❑1.as owner of the pmpmY or my employees with wages u thew mile compensation, will do lie wall,and lie s nwhou h not imenGA ur.ffmcd for sale(Sea.7044,Business and Pmresumns Code:The Communes License Law does not apply n an Owner of Required Inspections pmpeny who builds or impmwes thermn,and who does such work himself or nmugh his Own employees.provided that such improvements me not intended ororcertd fonsale.If. however.out building or improvement is mid within one year of completion.lie owner- builder will have the burden of proving oat he did not build or improve for purpose of sale.). ❑I.as owner of lie pmpm,,am=elusively contracting with licensed mntrminm to - construct lie project(Sec.7004.Business and Professions Code:)The Commit L6 cense law does not apply to an owner of property who builds or improves Memo,and who contracts for such pmjecu with acomrmmr(s)licensed pursuant in lie C.nummrs License law. I am exemp��t under Sew//s1y� h f3� �� ,B&_PC for.this1 m�ow��n wool V RMY OIR_\J LA> Date�S WORKERS COMPENSATION DECLARATION 1 Mmby affirm under pointyof perjury one of lie following dmluadons: 1 have and will maintain a Certiftcmmof Covent m self-insure for Workers Compere urian,as provided for by Section 3708 of the Labor Code.for the performance of the .,it for which this permit is issued. ❑1 have and will maimain Workers Compensation Insurance,as required by Section 3700 of lie labor Codw for lie performance.(lie work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number tie: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need notbe completed if dr,mordl is fm one hundred dollam(5100) or less.) 1 certify not in lie performance of the work for which this Permit Is issued,I"I not employ any person In my mMner an as b become wouct to BM WaftnGmnpernati.n laws of Gfll(.rri D Z ea t App Cam ` D n&O.i NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption,you should become subject b the Worker's Compensation provisions of lie Labor Code,you most .J z forthwith comply with such provisions or this permit shall M dcemed revoked. Z 1 CONSTRUCTION LENDING AGENCY (~ )hereby affirm that nem is a construction lending agency for lie performanceof C> dm wart for which this permit Is issued(Sec.3097.Civ.C.) 1 p Lenders Name 7,z tenders Add. V C) 1 certify that 1 haw read this application and sum that the aWw information is I9.H cancel.1 agree to comply with all city and county ordinances and state laws relating to Q U buildingcons 1mrs,and hereby amhorim representatives of his city minter upon lie W ahovcmcnuonndpmpeny fariuPenion purposes. G (We)agree to save,indemnify and keep harmless Bre City of Cupertino against rat incoiuequenctmenu,Costs and estimates;which may in any wyattmc agaiut said City l..3 z A APPLICANT UNDof ERSTANDS RSTAgnamig m A Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOU�PEG�U�LAT NS. 1 signmuri col'AppidnVConammr ^ 'Q QL/ �]-�— Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or futum building occupant atom of handle huardou material as dcftned by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety code. y. ❑Na 25s32(a)? CAll roofs shall be inspected prior to any roofing material being installed. Yes If a roof is installed without first obtainingan inspection,I agree to remove Will @c applicmt or future building Occupant tie equipment or dcviar which P mit hasankms air conuminanu as defined by the Bay Area Air Quality Management all new materials for inspection. Disuia? ❑Yes El No I have mad lie huardrms materials mquiremenes under Chapter 6.95.fthe Califor. nice Health&SafetyCode.Seeuoes 25505.75533 and 255}4.I understand ata if Me building does not currently hem a uune nu it h my mspouihility to houfy lie Occupant of the my/uiy/ay�nwhm/hym�aYu be met priornm/fiuumcc of Ccrtifmalc of Occupm. y, Signature of Applicant Date 0wner m mch.n ed agent I Dict All roof coverings to be Class 'B"or better