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06050008 (2) C CITY OF UPERTINO . BUILDING DIVISION PERMIT oil♦°L 1lL?,LTR,..'_.Itt Q,�y-�Tr.,,g1 jR BUILDING ADDRESS: PERM'N0.06050008 21831 HERMOSA AVE R'S NAME: PERMIT ISSUE DATE BULLOCK, JOAN PAIONE: SANITARY NO. CONTROL NO. ARCHTTELTIENGINEER: BUILDING PERMIT INFO BLDG ELECT IE!T NEON 1G z LICENSED CONTRACTOR'S DECLARATION lob Description ! 1 Wmby affirm Net I am under proof Chapter 9(mmmeDescrl tion withSeeuan70m)afOiNdon3afftBudnmWPmf=ionsCo , nmylkemis seg_ Ll aH a... it g s TERMITE REPAIR WOR Q,Ry 0 WALL IN THE BATHROO i,u: Llunsu Clue T'S DECLARATION .ED h,p De¢ Contractor, ARCH 7W arts"I M use D public and, )g 0 I undenUnJ my plans shall W used u public mmrtl& Licensed Professional MAY 2� ' sg OWNBan exempt FordDECLARATION 2006 0 1 Wrehy.(Sere on]Ban exempt from dm Conuamofa :Any C Law co the p o following moon.(Section 7fD t.5.B=in=s and Pmfcssio=Cade:Any sully or county 3$iva which requires a permit to cnnslruct.after,improve,demo@R or repair my suumum $800 i'y2 priarmiu iatuanm.atw rcquimathe epplicmtfarsuch permitto Oleasignodnamment 22 that heislicensedpurmanttolhaprovisia=oflhoCenMctoraLuuelmwlCMpmr9 Sq.Ft. Floor Area Valuation 2� (commencing with Section 1000)of Division 3 of the Business and Profession,Code)or 9 that he Is accept Ibmefm n and the basis(or the&Ulcd assumption.My violation of Section 70315 by any applicant far a perch subjects the applicant to a Civil penalty or er U u Occupancy Type mu mom than five handout dd1Ws ISS001. ❑1,u mw of Ne pmpeny,m my emPloyeu who ngu u theh Yk mmpenu0on, will dalhewons and the muctumhmesLia Law as an Budrof Required Inspections and PmrsuWON Codon The CanaumrS ndwho Law dead Out apply lf rt owner is q P properlywhohuIllsmimpmwach imn,endwho measuchwork Mmmlrer Iluough 4ts own employes,Provided ap such Improwmmts art ret intended ofc oralfamd roe tole If. hm.Wilder,the ove use or improvement ls ust within aro yeti of c prove ers.for the marax- Om Of W Ilder will Mase drc louden of proving thn W did rot Wild m Improve for pumosu of Yk.). ❑1.u awes of tha property.am exclusively can aning with licensed mnuactua to mnmuct the project(Sec.7044.Business aW Pro(esawm Cade:)The C.usctors U. aonY Law duo Out apply at an,miner a property who Wilds or haprova demon.md. who Contracts for such projects with a eonuactoKs)licensed pursuant to the Ceduamors Licease Law. ❑lamexemptadersec. ,B&PCfm Wsmamn Dau WORKERS COMPENSATION DECLARATION 1 hereby affirm under penalty of Perjury was,of do following deelsrWortc ❑I hwe aW wnl mainW n&Cenirimm of Convent mmlf-insum fm Wadmrs Cempm Ytim.an provided fm by Sation 3700 of tic Labor Code.fm the pallors me of IW work for which this permit is issued. ❑1 have and will maintain Waters Compensation Iuorsnce,as maivired by Section 3700 of NC Labor Code,for the performance of the work for which this permit is Wad. My WorkepI Compensation Insurance artier and Policy nu,mbeer�r w�: �p Cartkr.'••'��� CGa^n ' Policy No.:�� CERTI mEMpTGN FROM WORKERS' COMPENSATION INSURANCE must mine.od retbeeaspku:d EIW permit is for.huntheddoBan($100) orkma) I certify that in the Wimarm m of the work far which this permit is blued.I mail not employ anyperson in my mm.rm u to become subject to the Worker'Compensation Law,of Calirdroia.Dam Applicant NOTICE TO APPLICANT:IL after making this Cenificem of Exemption,you should Wants subject at the Warketa Cempcwdon provisions of the labor Code you mut .J zforthwith comply with mob provisions at this permit shall W deemed revoked. 0 ?Ey CONSIRUCfION LENDING AGENCY Ihereby affirm,dual them Laaeomucti.Lending agency for the pademosemof _ the work fm which this permit is issued(Sec.3(197.Cih,C) W� Le Wer Nese z Leaders Address U Q 1 cenify that I have mad this application and sum that the show information is IL P correct.1 agree to comply with all city and county ordinances and sum laws relating in O U Wilding convection,and hereby authodou repruenmiws of this city to enter upon the W above-mentioned property for inspection purposes. pw (We)agme to save.indemnify and keep harmloas the City of Cupertino against In liabilities.judgments,core aW eaperuu which may In my my same&III='old city IJ z Incomeammoeaf the rmtingefthumm prlt. { ^' APPLICANT U STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGU ONS. melte 975 Re-roofs SignaturriplimUCan tar Data H RDOUS MATERIALS DISCLOSURE Type of Roof Will de sppile orfutum Wilding a'cupmt,mrc or handle humid.rnmaied u dented by the Cupmorm Municipal Cade.Chapter 9.13.and the Health and Safety o .gains 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Y. ONO Will du applicant or future Wilding accupant tax equipment a devices which If a roof is installed without first obtaining an inspection,I agree to remove milt humNnu air conumi=nts as defitN by tire Bay Arta Air Quality Management all new materials for inspection. District? ❑Y= El No I haw mad the hazardous materials requirements under Chapmr&95 orthe Califor. nuH=Ith&Sal ty Code.Stttiom 25305,25533 and 25534.1 understand th alfthe Wilding des an,cumapily haw a enmt.that It Is my responsibility to notify the wupant of the mq4monhm.IW tynormiuum.ofacwBcamof mpmey. Signature of Applicant Date oed a nt \ Dam All roof coverings to be Class"B"or better 2/83/ NFRMoSH d4 Nd � v (lnc4� 12�dz�. �e C? O t.�o,v D ER gOQ� 1r1.uilH Arty TSE • HFPROVt�V rN ACCORDANCE WITH vE C-1 AHCE'. • CUPERTIHO 00,E MUS Van'. and sPecificationsit is ur a s set of I ib at all limes and oe kept on the i' changes or alteration, make a1 t Pero' from OR iantsome without verity P ertino. papt., City of CuP tions and Or tl be ar he building of this Plan ermit or t0 fhe stampin be he'd to P rovtsr0 COPY ;HALL NOt the violation of any P �� oProval o of)rata LaV6 tC1 1 C.iry Ordinance 06 EN1Ry • Met FLOUR /S lhmL /VD7d ; � WOO • fav:���� � _ - �-�. „�.�h �- `•� j�a�,-bond. �; ��_ w fw� O O 1.9o�uD�R Foltj FiN�dH A�/tH TLE • ASSESSOR COP `- Mqy 2p�6 Ew foe book � � f[.caR is hme /uB /s see. CITY OF CUPERTINO I� 1 of 1 PERMIT RECEIPT OPERATOR: bethe COPY # 3 Sec: Twp: Rng: Sub: Elk: Lot: APN . . . . . . . . : 35716107.00 DATE ISSUED. . . . . . . : 05/01/2006 RECEIPT #. . . . . . . . . : 34202 REFERENCE ID # . . . : 06050008 SITE ADDRESS . . . . . : 21831 HERMOSA AVE SUBDIVISION . . . ... . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BULLOCK, JOAN ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : S & H CONSTRUCTION CONTRACTOR . . . . . . . . LIC # _ COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . TELEPHONE . . . . . . . . : •• • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW, BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BENERGY PERMIT FEE 83 .16 39.92 0.00 39.92 0.00 BPERMFEE VALUATION 800.00 83.16 0.00 83.16 0.00 BUSLIC FLAT RATE 1.00 105.00 0,00 105.00 0.00 BSEISMICRE VALUATION 800.00 0.50 0.00 0.50 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 228.58 0.00 228.58 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ -___-------------- CHECK 228.58 08007 TOTAL RECEIPT 228.58 • a10CITY OF CUPERTINO PERMIT APPLICATION FORM CUPERTINO OW50008 N# 35 7 10 7 Building Address: Mailing Address (if different from building address): ,6 Owner's Name: hone# a vo ( II aC/L o� �--� 5, (o-3 Contractor: License#: S .4/ 7963 s S Contact: Phone: Cupertino Business License#: s-/o - S % - ST 2. Fax: Vo- Building o-Building Permit Info: Bldg Elect ❑ A , bAV4" Plumb ❑ Mech ❑ Job Description: Residential ❑ Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: dti v o Occupancy Grop: Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ I - Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL BBOILER3 Boiler>500K to IM Btu MECHANICAL BBOILER4 Boiler> IM 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> IOOOA ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING I of 3 CITY OF CUPERTINO cuPE 0 irvo . PERMIT APPLICATION FORM 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 BPBACKFLO.Ny Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool 'PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pbl ' Fixture PLUMBING ' BPGAS Gas Piping System Fee'. PLUMBING 13MITERCEP Ind Waste Interce for 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 cfrn MECHANICAL BREMAIRHAN 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> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platfonn 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 2of3 It CITY OF CUPERTINO CUPEf�TINO PERMIT APPLICATION FORM uantity 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 Inspection 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 Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Faro PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING • 3of3