04120080 (3) CITY OF CUPERTINO
BUILDING DIVISION p�R CONTRACTORINFORM�ON
BUILDING ADDRESS: PERMIT N004 12 0 0 8 0
10305 EL PRADO WAY A
OWNER'S NAME: PERMITLSSUEDATE
ERNA JACKMAN 4
ONE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uo0
LICENSED CONTRACTOR'S DECLARATION Job Description
s GI by affirm that I am littnred under p iov al Chapter 9(commencing
_mawish Sccupvn��"x))If Division7nf the Boarmasafitl Pss fcssinnn Codc,and my license is
y ia1.Bralvvoaerjeel� ✓ — 3� KITCHEN REMODEL
DZ�, Lan lam Cerra CONTRACTOR: HOME PROS
i-K Da¢ Lic.# lar
pp� ARCHITEFf s DECLARAT^ON
�i C.v 1 undcrsunJ la shall k used u pu ds
W�
u.t, Licensed Professional
oma /O
WNER BU71:D IND RATION
sE 1 hereby affirm thaw-i�am eiicmp gine Cnnuacmr'a License Law for the
p o following reason.(Schon](131.5.Business and Pvfeseduv Calc:Any city Or county
as
m whicknequira a permit set construct,alter,improve,demolish,or repair any swcture
prior to its issuance,also mquims the applicant far Such permit to file a signed statement
that he is licensed Perxuant Indic Provisions ofdo,Cimraewrsuceaaelaw(Cbapmr9 'Sq. Ft. Floor Area Valu$ti_Q0714
�'a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the busu for the alleged exemption.Any violation of
Section 9031.5 by any applicant for a permit subjecu the applicant to a civil penally of APN Number Occupancy Type
not more man five hundred dollars(ssoo). 34230015 . 00
-
I,ss owner of the pmpcny,a my cmployccs wim wags as Breit mlc compensation,
will do me work,and me swcture is Our Intended or ifered for aalc(Sec.7044,Business _
and Professions Codc:The mstmoned.oodwho Law does our apply m an owner of
Poois LED equired Inspections
Own employ ,provieimpmvesch inon.andwbo am not ihomAr andedor offered gh
m�
owtyebuildivi or Impat rovement
is std ualS within one
ear Ofdao@red for onwof, ryYygl—�
Witterhowever,me have
dr g e ded of proving
is sold within one year of c prove on.for Be ase,of
Wilder will have the burden of proving met k did not Wild or improve for purpose of
sale.).
I,as owner of the propcny,am exclusively convecting with licensed contractors to JUN 2 0 2005
construct the project(Sec.9W4.Business and Pmfesxions Cade:)The Convector's Li
cove law docs not apply v an owner of pmpeny who Wilds or improves Braman,and.
who contracts for such Projects with a eoncaaos(s)licensed purauam to the Conuactoes
m
law.
Ion exempt under Sec. .B&POfor mix m,=on
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decli ations:
❑ I hart and will maintain aCcrifiate of Convent to sel6inxure for Workcts Compcm
sarion,as provided fur by Section 3700 of me Labor Code,for me performance of the
work for which mix panni,is issued.
1 have and will maintain Worker's Compensation Incurrence,as required by Secuon
3000 of me tabor c.forme performance of the work for which this Permit is issued.
y W rker' _tp auto �f:�[d�IPolicy numkr are:
C a,: ! -Paltry No.:
GE Inc 67 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rlbuecction decd not W completed if the Permit is[arctic hundred dollars(5100) ...
nr Icix)
1 early 0. a,,, up of the work for which Ibis permit ix issued,1 shall nut
employ4ny minany manna seastokmme subject 1.Bit
rkcri Compensation
laws of damia.Deu
N ream ...
N01;'J7 TO APPLE :f;Wlpf makin6 Nis Ccnifica¢of Exemption,you should
kco uhire rdiF Waks"a pcncmion provisions of the labor Code.you must
�zfoMwW
ith comply wtuch ismisaoes or mix pamBr
nit.hill k dcccl rewind.
z O CONSTRUCTION LENDING AGENCY
[-+ � ,I hereby affirm that dere is a construction lending agency fifer the Performance of
IY> the work fur which this Permit is issued(Sec.3091,Civ.C.)
{t1 m Lender's Name
z Lendeis Address
V 0 1 cenify mal 1 haw mad this application and some that the above information is
Ia. career I agree to comply with all city and county ordinances and sure laws relating to
QU building construction,and hereby authdrivc rnpresenedives of this city m enter upon me
W above-mcnuuned property far inspection purposes.
(We)agree to save,indemnify and keep found v the City of Cupertino agaivt
f' N liabilities,judgments.costs and expenses which may in any way accrue against mid City
(,)(Z in consequence of the granting of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RCE�kG;L-ATI[ /
C i%/t Re-roofs
Signa or pp ocq odor '-- Data
l �AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcupantatore or handle fooanchour material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.section 255320n All roofs shall be inspected prior to any roofing material being installed.
❑Ya l o
Wm mea licantor future building occupant use equipment or devices which
If a roof is installed without firs[obtaining an inspection,I agree to remove
PP 6o pan Area
mit herardnus air contaminants u defined by me Bay Arca Air Quality Management all new materials for inspection.
Diwia?
Cl Yes WN.
I have real meds.haSandous
rms 255 5, requirements under Chapter 6.95 of the Calling
nuHwlm&Sntly Calc.Sccucv2ad iti my ra momil4.l unkrsuM thuifute Wilding
J or currently he�a unanv9au n is my mspovibililY to notify the aeupanl of me
rcy a which ram,k mete oris uancc oI C ❑ u Pf OP.eupancy.
"'��- Signature of Applicant Date
em� All roof coverings to be Class "B"or better
Oauthb Sid.agcm Date
•
CITY OF CUPERTINO
m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 4
Sec : Twp: Rng : Sub : Blk: Lot :
APN . . . . . . . . : 34230015 . 00
DATE ISSUED. . . . . . . : 12/13/2004
RECEIPT # . . . . . . . . . : 28018
REFERENCE ID # . . . : 04120080
SITE ADDRESS . . . . . : 10305 EL PRADO WAY # A
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER ERNA JACKMAN
ADDRESS . . . . . . . . . . : 10305 EL PRADO WAY # A
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JEFFERY WEED
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
CITY/STATE/ZIP . . . . t7
® TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- -- --- -- - -- ---------- ----- - ---- --- ------- ---------- --- - ------ -
BPERMFEE VALUATION 10, 714 . 00 180 . 36 0 . 00 180 . 36 0 . 00
BPFIXTURE UNITS 3 . 00 27 . 00 0 . 00 27 . 00 0 . 00
BPLANCHK PERMIT FEE 180 . 36 240 . 69 0 . 00 240 . 69 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
BPSTORM PER DRAIN 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BPTRAP NO OF TRAPS 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BPVENT UNITS 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00
BPWATER UNIT 1 . 00 9 . 00 0 . 00 9 . 00 0 . 00
BREMFIXT NO. FIXTURES 6 . 00 7 . 20 0 . 00 7 . 20 0 . 00
BENERGY PERMIT FEE 180 . 36 86 . 57 0 . 00 86 . 57 0 . 00
BREMINHOOD NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BREMPOLE NO. FIXTURES 2 . 00 2 . 40 0 . 00 2 .40 0 . 00
BREMPOWER POWER UNITS 2 . 00 65 . 95 0 . 00 65 . 95 0 . 00
BREMRECEPT NO. OUTLETS 6 . 00 7 . 20 0 . 00 7 . 20 0 . 00
BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 . 0 . 00
BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
BSEISMICRE VALUATION 10 , 714 . 00 1 . 10 0 . 00 1 . 10 0 . 00
BUSLIC FLAT RATE 1 . 00 102 . 00 0 . 00 102 . 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 960 . 86 0 . 00 960 . 86 0 . 00
HOD OF PAYMENT AMOUNT -- NUMBER
-------------- - ----- -------
OTHER 960 . 86 VISA
SMA- • CITY OF CUPERTINO•
CITY OF
PERMIT APPLICATION FORM
CUPEkTINO
APN # 372- ° O Date: /
Building Address: Mailing Address (if dif rent fr m building address):
OS 270
Owner's Name: Phone#:
,vl C� T 6 133 07
Contractor: License #;
U
Contact: Phone: 51c) '8a5 007 Cupertino Business License :
S-eF� Fax: -/b
Building Permit Info:
Bldg [k Elect ❑ Plumb ❑ Mec
Job Descri do
Residential ��mG cial LJ'
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: ) 15 Occupancy Grou
Type of Construction: t Please check t 's box Tf-tjLepfoject is a
f
second-story addi
Project Size: Standard Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
lof3
,(Cam* CITY OF CUPERTIN#
CITY OF PERMIT APPLICATION FORM
CUPERTINO
uantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Conon Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
_ BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbJg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPL CHK Plan Check FeeBUILDING
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
T) 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
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFLXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace > 1 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
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
(CCj 7 *ITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmd] 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 Inspection BUILDING
BS WIM 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 Mechanical sq. foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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SIGNEU — vr393a s+R
This set of pla,s and peci',caffons P4US
oa kept on th at all times and it is ur ,s- �=— ss- — 33' 3,:
lowtul to make any changes or alters *c ,
on sam3 without written permission fresxa- � 33v k sr
the building oft'
City of .
`� rn
The stamping of tF.iCupertiro.c CLZ::er .0 spe_fmdon, 3V sow
SHALL NOT be held to Gerr..."c: to to ar 12rIPProt21 of the Viol-"bor. ct a-p p_,,.nsla,•
,f anv City Ordinance or Srate Law
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as;anat m8ry aau m�as bo
•` .5ahjectm Veejfit57GanwJoh�e arW id�ased OC espied nnlma apPareFFa fsa Laa ]D/2Z/fke
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