04100178 CITY OFCUPERTINO I
BUILDING DIVISION P}..RMIT a >';r` �*T �N '
BUILDING ADDRESS: PERMIT NO.
RUCK CONST. COMPANY 04100178
NER'S NAME: PERMIT ISSIIEDATE
F SANITARY C OL NO.
PHONE:
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
y0o LICENSED CONTRACTOR'S DECLARATION rrr�����P¢¢¢Cf��,pnn o
I hcrcby ef0rm that I em licensed under p as of Chapter 9(commencing Job ®p['gt�as
nod wi Sc I ian7IXNBofDiatI an ofthe Bus t- ProfcuiOf Code e9(com Cenci is IN L
Sig—
in m n reel. 7 REPAIR FOUNDATION
j z Li en IEU
nas Lic.M
zIg�� Da ``` . mnlreclo I
�yau Iurde d ypins shallMumet puhlR [i � 200/.
a T
Licensed Pmfcssional -
S OWNER-BUILDER DECLARATION
Contractor's
ON BUILDING,+� 1 hereby.tfunn(Sec that 1 I.1. exempt from the ConuactCo :License Lew for the rLg■�f^I/p
i p o following reason.(Section 7(131.5,Business and Nvfdmols Code:Any city m county
k m� which mquima a permit Rt construct,eller,improve,dcmrlish, file
repair any sltemot
m—,n prior to its issuance,also mquimsrM1c applicant forsuch permi0oicense Law
��< Par he is licensed pursuant to the provainns of the Contractor's License Law(Chapmr9 Sq.Ft.Floor Area Valua ton
a�$ (commencing with Section 7")of Division 3 of the Business and Professions Cnac)or
..
that be is exempt therefrom and 0e basis for Ne alleged mempthm.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally of 36VTV9Q*e00 Occupancy Type "
not more than five hundred dollars($500). -
. []1,as owner of the pmpeny,or my employers with wages as their mle compensation.
will do the work and the awcmre is nut intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of RCgUICed IDSpeCt10DS -
propertywhobuildsorimpornslhemon,and who does such work himself or through his - ---_=- '
_ own employees,provided that such improvements nenol intended or offered for ane.If. '
however,the building or improvement is mid within one year of completion,the owner-
• builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed convenors to
construct the project(Sec.7144.Business and Professions Code:)The Contractor's Li.
cense law does not apply to an owner of progeny who Wilds or improves thereon,and -- ' — - - - - --
whoconva
Lic
ccnuLawtsfanuehprojeclswiNaconitazmr(s)licensed pumuanlmthe Comm�ar'e . .. ..
. _. . ... ..
❑1 ern exempt antler Sec. .B&P C for this rcazon
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
❑I have and will maintains Ccnificato ofCOnum to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the labor Codc,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of Ne work for which Nis permit is issued.
My Worker's Compensation Inmm se carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPI30N FROM WORKERS'COMPENSATION INSURANCE
(This section need not he completed if the permit is formic hundred dollars(SI W)
Icss.)
1 certify that in thence of the work for which this permit is issued,l shall not
employ any perm in manner n in n u eeuotlu Workers Compensation
Laws of California. at
met TO P ANT:IL after Wi this'Cenifcase of Exempuon,you should
e suhjcet to the Worker's Compensation pmvisions of the labor Code,you must
.JO fo rib comply with such provisions Or this permit shall be denied revoked.
„'Zy
'ra CONSTRUCTION LENDING AGENCY
Ihcrchy affirm that theragency
or Nu performance of
CC .fir the work for which this permit is issued(Sm.3097.Civ.C.) /
Q
Under Na
Le
D z^ Lender's Address ,
V Q 1 certify that I have read this application and show that the above information is
1. H comeet.I agree to comply with all city and county ordinances and stem laws relating Ira
C C.) building construction,and hereby authorize wpmeentildma of this city on enter upon the
u, shove-oreminned progeny for inspection purposes.
(~C (We)agree to save,indemnify and keep harmless the City of Cogent.against
Hy liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of Ne grooming of this permit. v
^" APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ERE LAT% ,` .7JD
Re-roofs
na rcaf Applicxn o actor /Dead -
HAZRDOUSMATERIALSDISCL Type of Roof
Will the applicant or future building occupant store or handle haaardmus material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
om,Section25532o0' All roofs shall be inspected prior to any roofing material being installed.
Wilts t�No
Will the applicant future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit hanodous air contaminants u defined by Ne Bay Area Air Quality Management all new materials for inspection. .
District?
❑Yes
1 have mad the har4NOus mawrials rcquimmcnu under Chapwr6.95 of the Califor-
niaHwlN&Safety Code,Sccdmns25W5,25533 nd25534,1unde,sund NmifNc building
docs not currently have tcnam.Nal it is my rcspmnsi hiI y to notify the occupnl of the
m@fcmcn which u bemelpsi wi uscoMm" cafes ser ata nay. Signature of Applicant Date
Z
n thori.e a eel ate All roof coverings to be Class "B" or better
i
City of Cupertino
Plan Check Transmittal
Permit# 04100178 Control*
Project FOUNDATION REPAIR Plancheck# 1
Address 19743 WINTERGREEN FileDate 10/27/2004
DRIVE
Owner HUCKLE
Description FOUNDATION REPAIR
Plan Check Status (attach comments and return to Building with plan set)
Plan
Dept check# Date Due Date Staff Comment Date Approval?
Buildin 1 0/27/200 11/10/2004 POH 10/27/2004 C,
Assessor 1 1 0/27/200111/10/20041 SENT 1 10/27/2004
Additional Plan Check Fee ❑ Hours
Planning Fees
Housing Mitigation Fee Amount
Heart of the City specific Plan Fee Amount
•
,i
REVISIONS BY
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OCT 2004
sFCTJDAl 2
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E11J 1 ` ifI AROANC W A
l CIWE A
r�catior+s MUST
G be
;"ED
ans
at all times and it is to,
kvAA to make any changes o< a"tim
an same wdhcut wrdten permission ftam
Li the building 1380t, City of Cupertino
catanl
stamping of this plan and speed
SHALL NOT be held to permit a to be, 10 Date l0- Z:>-0_
tpWaval of the violation Of any I>MOM,
�f arrf Cib OMAN""9r.Vreta.Law scale
Drawn
-Job
t
Sheet
\ .
Of Sheets
It%24 PRINrED ON NO.loom CI Rffll T. S
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1CITY OF CUPERTINO
.CUPl y PERMIT APPLICATION FORM o l �� 2
APN Date:
Z Q
1Bth(if7A-Mress: Mailing Address (if different from building address):
Owner's Name: Phone#:
c s z3
Contractor:_ License#:�9 ��
U> Bf
Contact: Phone: Cupertino Business License#:,
Fax:
Building Permit Info:
ld Elect ❑ Plumb ❑ Mech ❑
JobDescription: Gj
Residential ci
Sq.Ft. Floo _Area: ' $/S4. t.:
Cot of roject: mo Occupancy Group:
09
Type of ons c ion: Please check this boz'if the project is a
1
second-story addition: ❑
Project Size: Standard Large ❑ 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 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
1 of .
CITY OF CUPERTINO
CUPERTINO
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 PbIg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
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 rinklerBackflo 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
BREMAIItIIAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL,
BREMBUSWAY Remodel Busways ELECTRICAL,
BREMFIXT - Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV 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
BREMRELOCARelocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
CITY OF CUPERTINO
CUPERiNo PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Si2s Add Branch ELECTRICAL
BREMSIGN& Remodel Signs, Marquee ELECTRICAL
BitEMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
13REMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECLU 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
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE . Mechanicals . foot _ MECHANICAL
MPERMITFEE ._ Mech Permit Issuance ...MECHANICAL
PPERMITFEE.:. _ Plumbin .Permit Issue _ PLUMBING
_ . PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG . .Address Change. _._.,__: ,BUILDING
3of3
•,;CITY OF"CUPERTINO " .; - i x v777777777777777, " � v
BUILDING DIVISION �� "PERMIT•..,
BUILDING ADDRESS: PERMIT NO.. u
.HUCK CONST. COMPANY 04100178
DR
OWNER'S NAME: - FERMRISSUBDATE - - `
NE: - - SANITARY OL NO. -
ARCHnacT/ENGINEER: ' BUILDING PERMIT INFO
' BLDG ELECT', PLUMB MECH
LICENSED CONTRACIDWS DECLARATION _.JOIIDCSCLIption
- 1 hereby affirm that 1 am licensed under pr s of Chapar 9( men
comcing - _
i Se town 7000)of Division 3 of the BestIPhorewska.Code and my license is _
< i f
in and-
11
n fen. "
S� len ,last U. REPAIR FOUNDATION
n
A 1 S OEC R -
I undNR/FJ;/rd
y plans shall W used u pub r
..3a, Licensed Professional -
jm OWNER-BUILDER DECLARATION'
1 hereby from Nat 1 am exemn>from Ne Cornelius Liecnse Law for the
E O O fallowing reason.(Section 7031.5,Business and Profesdons Cole:Any city or county
which requires.peamit to contract;site,,improve,demolish,m repair any structure
a$ prior so its issbut...itd regmru the applicant fartash permit in rile a signed statement' -
-FZs< NatWisikcnaJpunuanLLONcpmnror
saofNeConmcar'sUccnaUw(Chepmr9 Sq.Ft.'FloorArea Valualon '� _ .
irFm Icomouincing with Section 7W0)of Division 3 of the Business and Professions Cob)or
that he is amount therefrom and da hasu for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of �3 i nWd�T6i@.PI0 0 _ ,, t Occupancy Type' +•
not roam than fixe hundred dollars(S500).
- OrA4PJ+V YI CY .
'. O 1,as owner of Ne property,or my employees with wages as their sole wmpenwtion,
will do the.,k,and the aavcma is hatimaunedarolfared petiole(See,7W,Business - (1 Re hired Ins ections -- -
and Pmfeseimu Code:The Comeacmr's Liana Law it=not apply m an owner of - ,p -
propenywhe builds or impmvef theaomandwho doessuchwork himselforthrough his "." '-' '
hown owever.thecs,provi or improvement weltiis mimentsaa not our oftlaraBtad for ale If
howeve.111 houil the ons. is unMilhinoroyear arimin.esion,die
orpose f 00 ��
builder will have the burden of proving Nas he tlitl oat Wild ar Improve for puryoa of
sok,). �// W� _
❑1,ru owner of ct properly,.B exclusivelyinesand connecting with:)The
mnwhirs t.
construct dpmjen(See.7an Businessandnywhobui Cotle:)The Conhermra U.
cove law dam nos epp1Y so en owner of propenY who Wilds or impmws Neeson,and
gho mm common;for such pmjecu with acontracr(s)licensed pursuant Ne Committal's
...Law.
❑I am exempt under See. .B&PC fw this recon ,
Owner Data
WORKER'S COMPENSATION DECLARATION
,fi hereby affirm under penalty of perjury one of the following declarations:
l have and will maintain a Certificate of Consent o self-Insure for Workers Compen.
sation,as provided for by Section 3700 of da Latour Code,for the performance of she
work for which this promo is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code.for the performance of Ne work for which this permit is issued,
My Workers Caoupensadion irmusanm cmricrand Policy number aa: _
Cartier: Policy No.: -
CERTIFICATE OFEXEMPTION MOM WORKERS'
COMPENSATION INSURANCE -
(This section need nos M completed tribe permit is furore hundreddollart($1011)
leas.)
1 certify that in the once of she work for which his peris issuctla Nall net
employ anypeno ipermit I.
n`to r u cct1 c Workers Compensation
Laws of California, att
tJpTICIt TO AQPt ANT:If,after mg Inns CEra mate of Exemption,you should
'- "' - ^'-'> -•^- 1—" ---�- -
c e mbjom m the Worker's Compemnion provisions of the Lahor Cmin,you most
0 fo wish comply with such pmvisimu or this permit shall W decreed invoked.
Z� CONSTRUCTION LENDING AGENCY
[-r I Wroby aRfm Out them is a connection imoingagem-y,Car the permanence of
LLer s7
the work for which this permit Is istaed(Sm:.3097,Civ.C.) '
QLender's Name '
z Lender's Add.
U Q I certify that 1 have mad Ws application and state that the shove information is :I
{I. F cmrecL I agree to comply with all city and county ordinances and sate laws missing to
0r building construction.and hereby authada reprasmmaws or this chyle cater upon one
r u] ahove-mentioned property far inspection purposes.
04 (We)(We)agree to save,indemnify and keep harmless the City of Cupertino agaims
H in liabilities.judgments,coats and expenses which may in my way acerae agalaataltl Clly
U Z in consequence of the gaming of this permit
F-r APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU E E LATI
�_7 Re-roofs
rte reofApplican o mmr Type of Roof
De
HAZARDOUS MATERIALS DISCL6
Will the applicant at future building uccupmtsmre or handle hasardous material
as defined by the Cupertino Municipal Code.Chapter 9.17.and the Health and Safety
Code.OYes 75537(x)? Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant tuna Wilding occupant um equipment or Jevicsa which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as deriocd by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yea
I have read the W7ardo s maarisls requirements under Chapter 6.95 of the Califer.
.is HeskN&Safety Code Sections 25N)5,25533 and 25534.1 undersmrd thin irb,Wilding
Jens not currently have t anent,Nat his my responsibility to modify the occupant of the
re airman which u Winetpd ai oma on enirie orae may. Signature of Applicant Date
1W!f
en thoriae a can ,m All roof coverings to be Class"B"or better