05080229 (4) CITY OF CUPER'fINO CClNTg2ACTQ-R INS'ORM�ON ',.
BUILDING DIVISION PERM 7t>'a
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BUILDING ADDRESS: BATHROOMS BY REMODELING PERMIT NO.05080229 5080229
R TTT T)R
tER'S NAME: PERMIT ISSUE DATE
PHONE:H r- QTTV 1422 SARATOGA AV SANITARY NO. CONTROL NO.
408 378-6700
AR CHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
'tax LICENSED CONTRACTOR'S DECLARATION Job Description
WU C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U with Section7B0o)uf Division Sof on,Business and Profession Code.end my license is
ca
mm�mrceand er REMODEL (2) BATHROOMS
j�2 Licenses Clns Lle.k
4�,� Date Contmc
ARCIIITELTS DECLCLARATBa
o; I understand my plats shall he used As public records
0 U
Licensed Pmfcssiowl
S OWNER BUILDER DECLARATION
a1 herehy Off.that 1 Am exempt film Ne Conuactors License law for the
-00 following reason.(Section 7031.5,Business and Podcsxions Code:Any city for county
suis m e which oaquirrs a permit un consumer,alter,improve,Jcmdkch,or repair any structure $33697
°-'^ Poulin its issionce,alsu requires the applicant forsuch permit to rile asignd statement
_i< that he is licensed pusuanun the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
�1-O (commencing with Section7000)of Division 3 of to Business and Professions Code)Or
i that he is exempt therefrom and the bus for the alleged exemption.Any violation of
.Section 7031.5 by any applicant for a permit objects Bic applicant to a civil penalty of _SXFff er 0 0 Occupancy Type
nut more than firs hundred dollars($50(d).
L As owner of the pmpcny,or my employees with wagesas their sole compensation,
will do the,work.and the structure is not intended toruffeel forsalc(See.?BM,Business ns Required Inspections
and Professions Cade:The Contractors License Law does not apply to An owner Of q P
Own enywho
s,buildsorid datuthercon,andwha does omendech oroffcself or Balogh his
ownemployees,provided to such est isc cold
wit arenot intendedmpeered for sales If.
boldvxr ,the building or improvementisoldedidnone year of completion.Nepose of
builder will have the burden of proving that he did not build or improve for purpose of
❑1,as owner of the property,am Business
Ad contracting with:)TheeJ mn0azers to
consents the es cot apply
tooan Business and Fewho bui Chile:)The Cs thencor's nd ))
come man with
ofprmpeny.liccow ldsorimpro the lemon,and,
who contracts for such prefects wit a conuazmr(s)licensed pursuant a the Contrumrs /
Law.
C]lam
❑lam exempt under Sec. .B&P C for this reason116 v�
Date V
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Ceniricate of Corsunt to self-insure fur Wmrtrrs Cmmpcn-
cation,As provided for by Section 37W of the Labor Code.for the performance of the
work for which this permit is issued.
Tare and will maintain Worker's Compensation Insurance,az required by section
of Ne labor,Code,for Ne peRatmance of Ne work On Which this permnit is issued.
My Worker's COtrkcr's pc"sx rx op Noy n`� b a��C// b Wo
Ca er.
CERTIFICAT11OF INFROM WORKERS'
COOMPENSATIONSATIONINSURANCE
(Thb section n¢d not be compleled if the permit is formic handed dollars(5100)
or less.)
I certify Nat in the performance of the work for which this permit is issued,1 shall not
employ any person in any mortician as to become subject lO theWOrkeri Compcwtion
Laws of California,Data
_Applicant
NOTICE TO APPLICANT:If.after making this Cri ificate of Exemption, no shmW
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O foMwith comply wit such provisions or this Permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-+.2. I hereby allior tat tors is a construction lending agency l'tn to performance of
!Yi > to work for which this permit is issued(Sec.3090.Civ.C.)
[V 0 lender's Name
z LenartAddress
's Addr
U 0 1 certify tat I have read this apirk.0m,end Afore that to about information is
I,L f" correct.L agree to comply with all city and county ordinances and Able laws relating to
CU building consuunion,and hereby autharion representatives of this city to enter upon the
res abovementioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless to City of Cupertino against
F.i rq liabilities.judgments.costs and capcnus which may in any way action,against said City
cZ to consequence of to grand ng of this permit.
.^ APPLICANT UNDERSTANDS NO WILL COMPLY WITH ALL NON-POINT Issued by: Date %)
SOURCE REGULATIONS.
/ Re-roofs �k
Signature of AppluefAgContranim Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tc applicant ser furore building oceupam same m handle hazardous material
U defined by the Cupcnino Municipal Code.Chapter 9.13,and the Health and safety
,dftJc.seed ma ns3xan All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
Will the applicant or future building mccupam use equipment for devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air emonconmts as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 0N
I have read the hanNnus mamrials rcyuircmcns under Chaptcr6.95 ofthe Califor-
nia Halt i SA1c1y COdc,SccJmn 35585,35533 and 3553a.I understmJ to dere building
dre,not cumen I h tenant,that it is my responsibility m nntify the nncupant of the
rcquicmcnts wh' At to met poor to issues of a Cc�w m ,panry. Signature of Applicant Date
Owncr'r,ethmri,ed agent SD,re All roof coverings to be Class "B" or better
MEN m
N JIM 0,
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• +r . RE IDENkTI � yx
EC� ` OVER� E16
CUPERTINO
Assessor's Parcel Number:
Name of owner.
Project address..
Contact person. �'r” ^ v � Z Phone.
Fax.
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
• Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y N
On what floor(s) is work being done?
Brief escri tion of work.
Code editions: 2001 CBC (Y -N)2001 CFC. . (Y - N)2001 CMC (Y- N) /
2001 CPC (Y - N)2001 NEC (Y- N)
Effective 11/1/02 ��'`�'t� 6 �jel
Gds -Z�
•
Plan Review Process Work Book Page-8-Revised 4/28/04
IE o CITY OF CUPERTA
o Z 2
• CUPERTINO PERMIT APPLICATION FORM
APN# o d3� Date:
Buildin 'Addiess:''` 4
Owner's Name: Phone#:
Ho wsiR,P -4 Su E T12d DElI41 X 5 7- 6 7 03
Contractor:
,gA%*Pp D�15 �i/ QE,* License#:
/ JoD6 Lin/G Sic 6 7�0�3
Contact/.� �o✓�� Phone • 11
lGo�/ 240,7Applicant/Contractor:
Bui 'ng Permit Info:
ld Elect lumb
ech
escription: (p / / •_
Residential: �/�` �`� Commercial:
Sq.Ft. Floor AL
$/Sq.Ft.:
Architect/EngiValuation:
s� 33, 6/. 7• ov
ype o.2 onstrL �/ Oc22Y Group:
ti odd
uanti Fee ID Fee Descri tion
BAPPLOTHERFee Grou
Other A liances MECHANICAL
BBLDGFEE Bld Permit --. foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M 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
BCONSTAXB 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 Ener BUILDING
BENERGYADD PneEgy Add Multi BUILDING
BINVESTIGA investigation fee BUILDING
BMITIGATC Comm. Housin Mit. Fee
BUILDING
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0 CI T Y')OF CUPERTIA
c'TM�F PERMIT APPLICATION FORM
• CUPE TINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housin 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 PLUMBING
BOVERTIME Ins ection Overtime BUILDING
BPBACKFLOW . Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg Fixture PLUMBING
BPGAS Gas fiping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
13PLANCKADD Plan Check Add Multi BUILDING
O BPLANCKREP Plan Check Re eat Fee BUILDING
BPREPIPE R i eOfFixtures 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 Rein -tion Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <— 10,000 cfm MECHANICAL
BREMAPPLI A liance Install MECHANICAL
BREMBUSWAY Remodel Buswa s ELECTRICAL
BREMFIXT Li htin Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREnEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
• BREMMISC Misc App azatus ELECTRICAL
BREMNRAPP Rem Non-Res A liance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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CITY OF CUPERTINO
clTMo 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 Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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
BSF&2FAM Single &2 Family BUILDING
BSFNA Single Family New Add 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
ZADDCHG Address Change BUILDING
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