04080092 (2) CITY OF CUPEWrINO ""``-
BUILDING DIVISION p�-r$jy� CONk'®1,2MA�N
. �$�. Z✓� ..a..xa�,V '.3r ^sof,iO RM
BUILDING ADDRESS: ^\ PERMIT NO.
04080092
"140 UNIT-RD PT_
OWNER'S NAME: PERMITLSSUEDATE
PHONE: SANITARY I ONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
app LICENSED CONTRACTOR'S DECLARATION Job Description
p 1 hereby affirm Nal 1 Am licensed and r proviaiou rf Chapar 9(mmormaeug
OCU with S�Op6]Ofm)rf Divi.ion]af the Burand Pmfcssiuu Code.and mylicenu is
'"?� in fullllf�arce antic
^ 'mar,
manG co�tXaea� Ple(pC� 4 REPLACE SHOWER/NEW VALVE
_ "0e'" ONTRACTOR: KRUEGER KONSTRUCTION .
ARCHI SDEtW1.�ttATION
' d al dot I e 1 he d ea Mbfic records
Oy
30G ens
^ 3 •OWN Exempt frDECe ContrON
3 e E 1 thereby on 11. exempt from the L'anl,emr'b License Law for the
3:2C following moon.(Section RIS syr t.Business And improve,
nu demolish,oc:Any tiny m county
z�m which tequints a pewit a ennstruoL plic imprnw,h permits or repair any structure
Fit prices its issuum,xamoll.netitunesthe theapplieut foe such permit micesaLow(humem
< (commencing
withSeuion7")pmviaiauofNriveBuuuranicenulsw(C ode) 9 Sq.F[. Floor Area Vanua[ 000
a $ (eommencexempt Section and th basis for th the Business and Proon.Any
ladon or
y Nat he r campy thcntfmm and the aper for be alleged exemption.Any violation of
Sccdon]0]I3 by any applicant for apewlt subjects the epplicmuo Advil Penalty of APN Number Occupancy Type
not mom Nan five hundred della,($5Mx v
❑I,uownuaf Ne Pmpeny,emy employee.with wagetu Heir uleemnpenution, 32653023 . 00
swill do NAwah,and Ne Awnttmt n.t intended oroffemd foraale(Sec.]094,Business
.red Pmfossiasu Code:That Canlraamra Lime Law does not apply to an owner of Required Inspections
property who builds mimprovee themon,and who COCA such work himself or through hit
own ver.the
h employee,providedImprovement Np ouch improwmenu tie nal intended araRentd for Gln Ir,
however,oebuildingdethatsuh imissaid mmwithinone yeardcompletion,Neowner•
builder will have she burden of proving But,he did not Guild or improve for purpose of
tile.).
L or owner of du Sec.7 ,am exclusively contracting with Tba ConMAcAmn u
construct thees not apply
Ax in Business and Pmfuoom COCA:)ThemQuetor'a Li•
who orm dope not apply u ts owner of property who builds or improvss centro.and
who con U..for such projects with aconuacyor(q licensed Pursuant to one contractor's
Lice Law.
A,under See ,B h P C you this uazon
Own Dau -
OMP SATIONDECLARATION
w
I hereby eRiunder penalty (perjury one of the following daclaraionsc
I have and will maintain a CeNfieau of Cement to self-inure for Wpkefs Compco-
smion,At provided for by Section 7700 of Ne Labor Code,for Ne Performance of the
we*for which this pewit is Banco.
❑1 have and will maintain Worker's Compensation Insurance,As required by Section
5700of the LaWr Coda,for the po fowmce,of the work for which this pewit is issued.
My Worker's Compensation Insurance canner and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
f@r seeian raced natbecomplcutl R th lewit is!Drone hundred Mr.(SIM)
nr lets.)
I camfy Net in the performance of Ne work for which this pewit is issued,I shall not
emplayany person Moan m.Mpto bcmtpcfubjcct to the Warkeri Compeuadon
Law.of CarirOOD OY
APPHAM,
NQftCE TO APPLICANT:IL after making Nr Ceniacme of Exemption,you shnZ
be �yllt/bjcct to Nc Worker's Compensation proviiou of the Ichor Coda.you mut
co
iwt mply wish such Invariant or this pewit shall he dcemcd revoked.
O' CONSTRUCTION LENDING AGENCY
E-t I hereby affirm that Nem is A cmmmctinn lending agency for the perfurmanm of
C> du work for which this permit r itwed(Sec.3097.Civ.C.)
W Q
Landers Namc
z !mice.Add.1
V Q 1 certify Nat 1 have fad Nis City
and coup and sou Nm Ne above information misting 10
0 f-^ coned I gnte ct comply with all airy and county oNinmtts and sou laws moping to
Q V 1howngcraiMcd construction,and hereby auNon inmpreuntatives of Nis City menur open du
W above-(Weiagree to ave,rty for demnify anpkToua.
gy (Wc)agree m sevq indemnify and keep harmless the City of Cupertino egeinn
y liabilitiesjudgments.costs
�addacapensu which may in My way acme against aid City
V inconugMAUNDerrJ�geeSTppNDS is D WILL COMPLY WITH ALL NON-POINr Issued by:9 Date {
s RC R 4 '( S.
I Re-roofs
new of pplicanUCom or Dem
NAZAR OUSMATERIAlS015CLOSURE Type of Roof .
Will the applicant or future building occupant store orhandic hazardous mourial
at defined by the Cupertino Municipal Cade.Chapter 9.11,and the Health and Safety
Code.Section 1s55xe.j]
❑Yu Na
All roofs shall be inspected prior to any roofing material being installed.
Will the applic t oa rebuilding oavpant ute cquipmcnl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hacsrdous air malaminanIs defined by the Bay Arca Air Quality Management all new materials for inspection.
Druict4
❑Yes No
1 haw mad the huardnus materials requimmenta under Chapter 6.95 of the Califon
duty Cade.Sections 15505,15573 and 15574.1 understand the if the building
,hasnot cow ly ha a tenuk Not i 1 ms ibilitym notify the mcupant of Nc
requirement Bich At etpd tarmtccar ccnifieateoraapaney. /Signature of Applicant Date
own namrriv ant' Date 2tC r 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 . . . . . . . . : 32653023 . 00
DATE ISSUED. . . . . . . : 08/12/2004
RECEIPT # . . . . . . . . . : 26646
REFERENCE ID # . . . : 04080092
SITE ADDRESS . . . . . : 10140 UNITED PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : ALISON MATHIAS
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5712
RECEIVED FROM . . . . : KRUEGER KONSTRUCTION
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 3 , 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00
BPLANCHK PERMIT FEE 83 . 16 110 . 98 0 . 00 110 . 98 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00
BENERGY PERMIT FEE 83 . 16 39 . 92 0 . 00 39 . 92 0 . 00
BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BREMPOWER POWER UNITS 1 . 00 47 . 96 0 . 00 47 . 96 0 . 00
BREMRECEPT NO. OUTLETS 2 . 00 2 . 40 0 . 00 2 . 40 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 540 . 90 0 . 00 540 . 90 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 540 . 90 2381
TOTAL RECEIPT 540 . 90
-, �1 *CITY OF CUPERTINO�
CUPIT EI�F PERMIT APPLICATION FORM
APN#
Building Address: Mailing Address (ifr rent frbuilding address):
D 1 C
0 e Name: Phone#:
I So,J / s Vo733 abs 7
ontr or: Li en #:
2u&C "710110
Contt: Phone:(,57-/0,) Vh?'-0.10V Cupertino Business License#:
D C 2 Fax: c 743-�l i Si
Building Permit Info:
Bldg 2' Elect ❑ Plumb Mech ❑
Job Description: NGv V41,Vii;
Residential PRL % S wei2_ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
to?
Cost of Project: o� Occupancy Group:
30 c —
Type of C struction: Please check this box if the project is a
00 e — second-story addition: ❑
Project ize: Stan Laze ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler>500K to 1M 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
ff
1of3
r.
�� _% OCITY OF CUPERTINOO
CUPEI�TINO PERMIT APPLICATION FORM
QuantityFee 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 Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
At BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check 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 rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM 3USWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace > 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
24 BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance I ELECTRICAL
2 of 3
W
OCITY OF CUPERTIN(*
oo
CUPEI�TINO PERMIT APPLICATION FORM
uanti 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 Inection BUILDING
BSWIM Swinuning Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING,
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
3 of 3
—Ml^tvcr�, VAwP , ZN!STAI( FCZPPROVED
7
Ip ACCORDANC WITH THE CITY Oh
CUPERTI C SES AN ORDINA CES
)ATE CON
)'IGNEU
Thi. ,et sans and specificabons MUST
11 .pt on the job at all times and it is un
lawful to make any changes or, alterations
on without written permission from
ha building �luuvcv! 'nns
u ,,,be he GFS
al f the violati n of any �rovlslona
env Ci rdmanc or )rate
O N
k
00
Shower Tub/Shower
2"L�x35\ 60"Lx30"W j
R
RECIE
/o(VO UA-71 rE 6 pz.Acr�:—O!
CIT, Of pEpA
c o pmt i NC-) I CA a�uppolg