03120085 (3) •'` try
CITY OF CUPERTINO -0N40RBUILDING DIVISION PTT� 1 "-
BUILDING ADDRESS: ANDREW STACK PERMIT NO.O 3 12 0 0 8 5
PERMIT 15EUe DATE
OWNER'S NAME:
% E: ONTR
ANDREW STACK SANITARY NO. COL NO.
BUILDING PERMIT INFO
ARCHTIEC(ENGINEER: BLDG ELECT PLUMB MECH
pp LICENSED CONTRACTOR'S DECLARATION lob DBSCrIpIlOn
�+C 1 hereby affirm Nat 1 am 3.f Me
Basin.,
under provisions n,Copter 9(commencing
UU with ScIIiana meb,ti of Masion n Is.
Nri Buaincm apMvisionsinna Code.inad 9(mylicenei is
;mmllmmeandeffem. BATHROOM REMODEL--HOT
License Clam Lt..as RNMED
p Dam Contmclar
C
ARCHITECTS DECLARATION
y 6 1 underhand my plana Mail he used ss public memds 2004
yU FEBF
off' Licensed Professional
OWNER-BUILDER DECLARATION
<E I hereby Orion,that 1 am exempt from Ne Commctor's License Law for the
p o following mason.(Section 103 1.5,Business and Professions Code:Any city or county
$ which monou a paten to mosuuet,site,.improve,demolish.Or repair any structure Ri In r)1Nac;nnn
He In its issuance.also minims the applicant for such permitto file a signed statement S Ft.Floor Area Valuation
SGdust Wislimmaculpursuanttnthe pralilionsarthe Commelm".Limit. aw(chaptm9 q•
t� (commencing wilt Section 70(a)of Division 3 of the Business and Professions Cede)or
3 Net he is attempt therefrom and the btu for the alleged exemption.My violation of
+ Suit.7031.5 bya"sippliunt far a pattern subjects theapplicanuoaeivilpenaityof 3"15202*e0To0 Occupancy Type
not mom Nan fwe hundred delta.(550(y.
Luowner work. rad property,or my employees withwagesutheirtelec0mpenu0cer
will Pr len.end the he Coo is tots tended offend fLaw does notcppy to an Business Required Inspections
and Profusions Code:The Cantncton, rad who Law dais not apply tom owner of
property who builds orimpratu(hereon,arad who doe sou ch work himself or NrougM1 If,
own ,,Mecup lodori prowhimis vements sold witamnetintendedaraRered forMe owner.
bowewq Ne buildingvMan o improvementg t sold within one year of completion,Ne owner
builder will have Ne burden of proving Nn he did not build or Improve for purpam of
.it.).
❑1,as owner of the property,am uelusively contacting with licensed connotes to
convect the ptoj9Ft(San.7044,Business and Profusion Code:)The Contractors Li-
cense Lew does n'l pply m an owner of property who builds or improves Menton.and
wM10 tomato fon ch pmkcR,21bri mltncmgq licensed pursuant in Me Contractor's
Li as w.
la met unS .B&PCforthisommen
D
I '
a I
Owner
lORK'R'. COk PENSATIONDECVa N
1 hereby affirm madder penally of perjury one of Ne fallowing decisandome
I"wind will maintain a CcAfcow of Continua setpWum for Workers Cr mpen-
ation,a provided for by Section 37M of Ne Labor Code.for Ne performance of the
wsk for which Nin pam0 is issued.
-1I haw and will maintain Workers Compensation Insurance.an required by Section
37M of M labor Code,for the performance of the work for which Nis permit is issued.
My Workers Compenaden insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(r ds section need net he completed if the permit is for one hundred dolhor(5100)
or In$ )
1 unify that in the performance of the work for which this permit is issued.1 shall not .
employ any person in any mmwrse as to become subject to Ne WorkersCompertsadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis Cenifmaw of Eacmpdon,you should
become subject On the Worker's Compensation provisions of the labor Code,you must
3 O foodwilh comply with such provision or this permit shall be decreed revoked. -
i ti t CONSTRUCTION LENDING AGENCY
I hereby affirm that MO.isaconMonsoon lendingagency for the MIT smarun of -
i 7 Na werk for which this permit is issued(Sec.3097,CO.C.)
QLenders Name
Z
Lenders Address
0 1 certify that I haw read this application and slow Nat Me above information is
mutant.I agree to comply with all city and county ordinances and stew laws misting In
V building eantd
swction.and hereby auorine repressnlotiws of this city to enter upon the
L5l thaw-mentioned propertyms cost for iexpnicines purposes.
y a (We)agree to ave,indemnify and keep harmless the City of Cupertino against /
h Ifab0111 hjudgmcm costs add expenses which may in any way settee against aid City \l
z in eo uena o e granting of this permit.
+-+ APP 1 ANT U R AND ND WILL COMPLY WITH ALL NO
Issued by: Date
SO GI A 09!
Qnstm_ Z2 , Cj Re-roofs
igKeture ufA is HAZARDOUS MATERIALS DISCLOSU Dew Type of Roof
Will the applicant or future building occupant ture or moldlic havardous material
as defined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
Cade,Section 25531(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu No
If a roof is installed without first obtaining an inspection,I agree to remove
Will Ne applicant or Toms,as derimng occupant use ea All Quit
s device which
emit District? us oir conlominanu n dcfncd by the Bay Area Air Quality Managcmant all new materials for inspection.
Disuim7
❑Yes �No
I haw medB an. of wsme trials mquimmenuunder Chapwr6.95of&clifao-
nuHcalN&5aAl
diffotenant.d a it ismyespunaihilitymnotify the eccupant of NcmemeTp - tainaananracmrdrrmmye4QCcap. .D Signature of Applicant Date
onive ascot ( GG Dam All roof coverings to be Class"B" or better
O ER-BUILDER VERIFICATIW
1. (Check one) I or /my immediate family (parent,spouse or child)will perform
• A. All the work authorized by this permit
A portion of the work
C _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work DEC 2003
B. A portion of the work (complete section belo )
Contractor Address/City Phone # St to ' erase # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of hnsurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.......................................................................................................................................:.............................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information r erre idd
Property Signatus l�� DateV
Job Address: Permit#
An anges to the information provided on this form shall be submitted to the City of Cupertino Build
De�arfinent.
•
City of Cupertino Building Department
10300 Torre Av
CITY OF Phone: (408)777-3
CUPEkTINO
Dear Property Owner.
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record r
on such a permit;Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
if you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection .
If you employ or otherwise engage any persons other than your immediate family,and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensatioe
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor,only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit erroneously implying that the Property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your community or at 1020 N Street,Sacramento,Califorbia 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these mattes. The bvilding,pern-dt will not be issuednurntil the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
Q.
*ITY OF CUPERTINO* o 3 � 2
•CUPEYOF PERMIT APPLICATION FORM
APN# Date:
Building Address:
3 (4-0 d a
Owner's Name: Phone#:
t1A 2 W lL 6l6 —
Contractor: / License#:
Contact: Cupertino Business License#:
Buildin Pennit Info: p/1
B g Elec Plumb a Mech
J b e c 'ption:
Resp ential — mrJ� 7 L,#J�,Commercial ❑
Sq.Ft. Floor Area: I $/Sq.Ft.:
,57-cj S
Cost of Proje Occupancy Gro-':
S0-vi . W
Type of Co truction:
VIlleI+1
low
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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 lnd/Off/COmm/ nasi 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. Housin Mit. Fee BUILDING
1 of 3
OITY OF CUPERTINO ++
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
ISQuantity Fee ID Fee Description Fee Group
BMPTIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g 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 Repipe 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 WaterHeater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cf n MECHANICAL
BREMAIRIIAN 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
LdEk BREMPOLE Pole/Platform Fixture ELECTRICAL
2of3
I , ' WITY OF CUPERTINO*
1TYOF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL -
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heatmi MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, 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 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
EPERNUTFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
1
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witt+q, � fino•
TeD i eAi�l C ptinns
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he mP�`�held to pemit or to +
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s oo gNAtl�i of the\solation of any p*off+
app UAW* OT
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got 10
4 00
OFFICE COPY
' THRESHOLD FOR THE SHOWER PAN
® PLUMBING ELEVATION
/0Jvo
35.2 0 0.7
LEGEND
6 1200 (, IM❑SIRRAH 30A C,MARFIL POLISHED 12X12
7, IMOMK,SIRRAH 12X12
2100 C,MARFIL MESH 1X1
8
8, 01013 1X1 ON 12X12 MULTICOL❑RED SLATE
8100 G'Ro()r CoL-op, - T1p t4m4 CL19110MOk
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