04020146 (4) CITY OF CUPER-1'INO +� 'g` '� `"
BUIf.DING DIVISION PI:RN aCONTRACTtIRf jNT'ORM*
,r --,c.�«as a.,. %x . .> a
.DING ADDRESS: PERMIT NDO 4 0 2 014 6
OWNER'S NAME: PERIvIrT ISSUE DATE
on
NEJACK & SANITARY Q. nCONTROL NO.
ARCHITE-CIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
erioo LICENSED CONTRACTOR'S DECLARATION lob Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
n with Sution7SMg0rfDivision3 of lhcpusii msand Nofcuimu Cad,andmylicenwis
. tu� m I.Bmrteagd aTsar. X/ SO6 (Y ( BATHROOM REMODEL
Sq? LlccnttG s Lic.M c
Zip Do w Coact y c ..:lcecyaa. CONTRACTOR: KOBETSHKY CONSTRUCTION
•y ARCHITECTS D ARATION
a lis ersmnJ ypl ss all la used es publicacmds
�aU
o Licensed Professional
3 OW NE AUILDEROECLARATfcN
I 1 herebyrstOm rRrm Ihm 11. comp.from Jur Contractor's e:Any c Lew for IM
a o which mo mann.(RCNon IIDL0.Dusiten and improve,
de inu Code:Any city or county
which rtgnires a permit nn construct,alter.improve,demolish,or repair any struclum
prior m its issam.....Is.untlim eam.,nieam for such P..it o file a signml sta@menl
�<
that he is(entrancefloc mud Pursuant m the pmvlsions of the Contractor's Liomw Law(Chapter 9 Sq.Ft. Floor Area Vallltllin�OOO
ea $ (entrance acing with Section 7")of Division 3 of the Business and Professions Code)or Y
_ that he is exempt therefrom and the basis for Ne alleged uen tion.Any violation of
Section 7031.5 by any applicant for a permit subjecu the applicant to a civil PemRy,of APN Number Occupancy Type
not more than Rve hundred callus(1500).
01,as owner of the prophany.or my employees with.,an as Nair sole ceularmikin, 34245005 . 00
will do Ne work,and Ne someone Is not intended of offered for We(See.71144,Business
and Professions Code:The Convene.License law does not apply to an owner of Required Inspections
propertywhon,.orimpmvu Ncuogandwho.net
intended
nhimuUedlfrugh Me
own employe.,Ping or i this such imps sold
wit art not ear of
complemciffetion,
for If,
however,thebuildingorimprovementgsoldwithin one year of completion,Ne owner,.of
builder will have Ne buurcn of proving Nat he tlitl nm Wild or improve for puryou of
sale.). I�tl I�
❑I,as owner of the property,am eaclusivefy contracting with]learned contrselmrsm tJ�;J +, L F.M
consumer the project(See.7(4,1,Business and Professions Code:)The Contracmrs Li-
cueIsom does not apply m an owner of prpeny who wilds or improve Ihemon,and.
a nv.ofmsuchpmjeauwithacanuacmr(s)licensedpursuanttoNeContractors JUN 2 12004
ase L w.
lam ea cm in under See ,B&P C for this reason
Gwoe, Date 40
WORKER'S COMPENSATION DECLARATION
1 hemhy affirm under Penalty or perjury one of the following deela(llloms:
1 have and will mountain a Certificate of Consent to sel6insum for Workcrs Compcn-
ulion,as provided for by Section 3700 of the labor Code,for the performance of the
work for which thin Permit is issued.
❑I have and will maintain Workers Compensation Insurance,n required by Section
37W or the labor Code,for the performance of Ne work for which this Permit is issued.
My Workers Com penution insurance carrier and Policy number arc:
Cartier. Policy Nr.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section freed not wcompleted if the Permit is for one hundred dollars(SIM)
mless.)
I unify Nat in the rfn ace of the work far which this icrmit is Ismsd,1 shall nn
cmployanypersonm n ; roses rose subjcermlhe Wgrkcri Compcniatlon
Lawanf Calif rola. c _l.`/
AppRcam
Np�CE TO APPLICANT.if,of/ making Nis Cenificatc mf Exemption,you should
wc�de E.hies m Nc Workeri C mpenamion provisions of me Latnr Code,you..in
0Z roMwith enmply with such irnvidmas or Nis permit Mull he leered evrked.
Z O
CONSTRUCTION LENDING AGENCY
Ihereby affirm Nat there is a construction lending agency for the Performance of '
the work for which this Permit is issued(Sea.3097,Civ.C.)
1x7 Lender's Name
11 Lendcri Addseu
U Q I certify that 1 have lead Of,application and sum Nat the above inroonsflm is
W p cored l agree to comply with all city and county ordinances and some laws miming to
0 U building conmfunion,and hereby suthorim rcprucnmtives of this city to enter upon the
W an.-rufmorund proPefmy for'msPcction purposes.
(We)agree to save,indemnify and keep harmless the Cil of Cupertino against
�j
liabilities,judgments,am.end as pcnsca which may in any way acerae against said City ��/
U z APPLICANT UNDERSTANDSranting of Ihis AND Ton it.
WILL COMPLY WITH ALL NON-POINT Issued by: Da 5
SOU EG_ULATIO S�_
d Re-roofs
ignaluin of APP]icaHCo OUS MATERIALS DISCLOSURE Data' Type of Roof .
Will the applican car future wilding occupant store.,handle harmdous material
or
u defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Code.Section 15532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑re �(
Will the applicant or fumes building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil haeardous air conmminan,as carried by the Bay Arca Air Quality Management all new materials for inspection.
ofu h i
❑Yes No
I have read Ne Maturing maa:rims requirements under Chapter 6.95 of the Califon
ria Health&Safety Code,Sections 25505,15533 and 25534.1 underslmd Nm if the wilding
Joos not curcndy have a tenant.Jurat it is my responsibil ily to notify the accomam or the
requirement,which must efPrrro ingance ora eemreate or C<aaPanc. Signature of Applicant Date
2,6-
ncrOrautbmisdago Date All roof coverings to be Class "B" or better
® REC EKED
FEB 20 2004
CITY OF CUPERTINO37
BUILDING DEP4TMENT-�
5110
� 0
O
- ---__._Hall Bathroom
12'5
Jack and Trish Taylor
10388 Krista Ct.
Cupertino, CA 95014
Hall Bath
ca fares and it is VI
G: ja,Zt on Gla rr$ or, uDWe 005
io
is°n PeYorrssion fzo+n
on same ..0�of CuPertmo.
® the badinz 0�l Ian and specifications
The at7mPjnN of this P s er d' or to be ar.
SHALL 1407 be held to P roarat000
®' approval of the violation of any P
It any 6ity 0rdmanca 01 °
`( ITY OF CUPERTINO�0a a
CITY OF PERMIT APPLICATION FORM
CUPEkTINO /
N# � z Sf D D�/ Date: 1 O /0 L(
Building Address: Mailing Address (if different from building address):
10386 r s Jo. Cl-.
Owner's Name: Phone #:
crc f 7r,-,.r4 lot- 969 - 77,22
Contractor:KobLicense #: 60611-11 e� Jk C6nSC
><�v '�lOn
Contact: Phone: " 73Z 9522 Cupertino Business License#:
rit /
key �C p 6 c,/,r k Fax: +06 737 1787
Building Permit Info: /
Bldg F-1Elect ET" Plumb Er, Mech 3
Job Description: /�
Residential Z Oct A1oo,1, ke ^ odc Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: fJ/S Occupancy Group: �j e
e of Cons ruction: Please check thi box if th oject is a
a.fAroom 1z0N.adt'1 second-story adds
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permit sq. foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 1 OOK 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/OfVComm/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
BMITIGATC Comm. Housing Mit. Fee BUILDING
14r—�170 • 3
/lof3
TY OF CUPERTINO 10
® NCITY F PERMIT APPLICATION FORM
CUPERTINO
Wuantitv Fee ID Fee Description Fee Group
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 BldgPermit Fees BUILDING
BPFIXTURE Pbl 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 Re eat 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
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> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNItAI>P 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
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
2 of 3
& 'ITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
uanti Fee ID FeMDescription Fee GrouBREMTHEATR TheatFix ELECTRICAL
BREMVENFAN Vent uct MECHANICAL
BREMVENSYS Venms MECHANICAL
BSCBLVD ScBUILDING
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
WEP;ERMITFEE
Tem Dist Svcs ELECTRICAL
C Business License BUILDING
IC Electricals foot ELECTRICAL
Elec Permit Issuance ELECTRICAL
EE Mechanical s . foot MECHANICAL
FEE Mech Permit Issuance MECHANICAL
FEE Plumbin Permit Issue PLUMBING
PPLBG Plumbin Fee s foot PLUMBING
ZADDCHG Address Chane BUILDING
3of3