05060055 (2) CITY OF CUPERTINO
BmLDINc DIVISION PENT CONTRACTOR INFOR TION.
arta. .., ..<�.� > >_, a.
BUILDING ADDRESS: PERMIT'%5060055
OW HER'S NAME: PERMIT ISSUE DATE
ELIZABETH SABAD_0__
ONE:
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG EIPCT PLUMB MECH
0 0 0 0
uo0 LICENSED CONTRACTOR'S DECLARATION
iF❑ I hereby affirm that I am Located under provisions or Chapter 9(commencing Job Description
W with Section 70(10)efoivision 3 Orlin Basirces and Profession Cade,and my license
^ e in full force and Often.
Sqz Lieensclna Lie.g REMODEL MS . & HALL BAHTRMS
Z—' Dat Contractor NO STRUCTURAL CHANGE
^��4ry ARCHITECTS DECLARATION
a< 1 undcratand my plans shall W used as public records
JyU
;4. Liconsed Pmfcoinnal /
S OWNER-BUILDER DECLARATION _
1 Wrthy alarm Nat 1 am oc arm from We Camtrmum'S Liccns law for Lou /
00 following moon.(Section 7031.5,Business and Profession Code:Any city of county
m which mquitet a permit to enntrum,alter,improve,demolish,at repair any swcture
FZi
prior it)its issuance,alm requires the applicant forsuch permitiu file asignedsmmeent
Nat W alicened ..arm We provision of thc Cimrazrars License U.(Chapter9 Sq.Ft. Floor Area Valuation
-$ (commencing with Section?01107 of Division 3 arrive Businessand Professions Code)or
that he a exempt therefrom and the bois for the alleged exemption.Any violation of 814000
section 7031.5 by any applicant for a Permit subjects the applicant as a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
Pli'o owner of the property,or my employee with wages as their sole compensation,
II do the wart,and to awcmm is not intended or offend for sale(Sec.7044,Business
and Profession Code:The Conme,or's License Law does not apply to in owner at
Required Inspections
propenywha Wildsmrimprovs Woman.and whodoCasuch work himself ormanough his
own employees,provided Nm such improvements are not inmrded oroRered for We.If,
however,We building or improvement is sold within one year of completion,We owncr-
builder will have We burden of proving Nat he did not build or improve for purpose of
axle.).
❑1.as owner of We property,am exclusively contracting with lianed Contractors to
construct We project(Sec.7044.Business and Professions Code:)The Contractor,Lt.
cense law dos not apply to an owner of property who Wilds or improves thereon,and
ivW contracts for such pmjacm with acontroton(s)licensed immortal octal m We Conuxlols
Liocme law.
❑lam axe to der$cf .B&PC for this moon
Owned an / 1 Ls
jo-S
WORKEIVS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I ham and will maintain aCenifieate of Consent to self-inure far Wmkee.Compere
s ition,as Provided for by Section 3700 Cr the labor Code.rat the Performance of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as m4uired by Section
37W of NC labor Code,rar the performance of We week for which the permit is ismad.
My Worker's Compensation Insurance Cartier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
flTe section need not he completed if Ik permit is for one hundred dollars(SIM)
(ir Less.)
1 unify that in to perf lmomen of the work for which this Permit is;issued.I shall not
employ any person in any,immirm.so u19 beryn�nbject to We WorkersCompensation
La ws of Celifo pate f • Yr CY /y
Applicant�y, J
NOTICE TO APPLICANT:IL after making this QNEnm W Exemption,you should
.J Obecome h comp y the Woher,Compcnation provision of tide Laed Code,you mux
forthwith comply with such provisions or this permit shall W deemed remked.
ZN CONSTRUCTION LENDING AGENCY
(—t Ihembyaffrm Out there iso Construction Itodingagenry for the perfmmanceuf
C> the work for which this Permit is i.7(Sec.3097,Civ.C.)
W� Q Lender's Name / 1 /
DLender's Addots
U Q 1 certify that 1 have mad Uri,application and ser¢that the above infmrmatan is
f' coned I agree m comply with all city and county ordinances and that laws relating to
0 building convection.and hereby atomfire rtprtsnutivca of this city to enter upon the
shove-mcnrioncd property forinspcetion purposes.
f+0. (we)agree to on,indemnify and keep harmless We City of Cupertino against
to liabilities,judgments,Onto and experts which may in any way as.against said City
U Z in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL CO PLY WI H ALL NON-POINT Issued by: Date
SOURC REGU TIO S44_0�(a
Date S.
it 4 ac
m l-gCn
Srgnarur pplteanVContrador Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof .
Will the applism or forum Wilding occupant stare orh urdle hasudoo material
o defined by We Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code,Section 532(a)?
❑yt, qa All roofs shall be inspected prior to any roofing material being installed.
40 Will the applicant or rutum Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants o defined by the Bay Arca Air Quality Management all new materials for inspection.
District `�
❑YeIJs Na
1 havemad the hanrdousmaterialsmquimm nmunderChapter695oftheCalifor-
nia Hstth&Safety Code,SOCUons 155)5,25533 and 25534.1 undcrswd Nos irthe building
does not currently have a Arent,that it is my m,Ponnibiloy as nodl'y on Occupant rarue
rcgmr w hy5} t erptinr ::a Ceara rtificareau-7-n<
Oca la Signature of Applicant Date
—"�"'� "'� � l Pg te All roof coverings to be Class"B"or better
Owneru rhari'reJ egcm Gate
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CITY OF CUPERTINO
I 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . : 36917003 . 00
DATE ISSUED. . . . . . . : 06/08/2005
RECEIPT # . . . . . . . . . : 29906
REFERENCE ID # . . . : 05060055
SITE ADDRESS . . . . . : 6375 MYRTLEWOOD DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER ELIZABETH SABADO
ADDRESS
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014
RECEIVED FROM . . . . : ELIZABETH SABADO
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS RECNEW BAL
-- - - ------ ------------- ---------- ---------- - --------- ------- --- -- - -------
BPERMFEE VALUATION 14 , 000 . 00 212 . 76 0 . 00 212 . 76 0 . 00
BPLANCHK PERMIT FEE 212 . 76 283 . 93 0 . 00 283 . 93 0 . 00
BSEISMICRE VALUATION 14 , 000 . 00 1 .40 0 . 00 1 . 40 0 . 00
BENERGY PERMIT FEE 212 . 76 102 . 12 0 . 00 102 . 12 0 . 00
ELECTRIC SQUARE FEET 67 . 50 5 . 40 0 . 00 5 . 40 0 . 00
PPLBG SQUARE FEET 67 . 50 5 . 40 0 . 00 5 . 40 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMFEE SQUARE FEET 67 . 50 5 . 40 0 . 00 5 . 40 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ------- --- --- ------ -
TOTAL PERMIT 731 . 52 0 . 00 731 . 52 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 731 . 52 2588
TOTAL RECEIPT 731 . 52
•
r
Mid
i� f'a �wi}9 a' . l3-u��+i �'` rry�i,
RE - I�DENf4W PRO��CT"C r VER SHEET .
ITYO h _5u „�.r K< 1f� '{ h'j1n ti3vey}��453'
• CUPEIz,TINO _ 4��Rs- -A =
Assessor's Parcel Number:��(D 9�ZGO 3
Name ofowner.
Project address.
Contact person. > �hF 7/J � /�/J �_Phone.
Fax.
Net square footage of lot. coo
Existin 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 P�/�
• Is privacy protection planting required for the project? Y Nv/"¢
On what floor(s) is work being done?
Brjef descripti f work.
i
Code editions: 2001 CBC (Y -N)2001 CFC , (Y -N)2001 CMC (Y- N)
.- — — 2001 CPC (Y - N)200 NE
Effective
Effective 11/1/02
Plan Review Process Work Book Page-8-Revised 4/28/04
•
CITY OF CUPERTIA vSb
CITY OF PERMIT APPLICATION FORM
• CUPEkTINO
APN # Date:
'3 —
05
Building Address: Mailing Add ess (if different from building address):
Q
O ne 's Name:
*il-
Contractor: License #:
C / .t.0z 213
Contact: Phone: 395-&V71 Cupertino Business License#:
S Fax:
Building Permit Info: /i' Mo(j(E 1 NG ,45 + /V O5hVuc1VV1f1 e7 Av
Bldg V' El ct ®--' Plum (j�/ Mech 1�-
Job Description: EMO 8 Ws
Residential Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Costo Project: Occupancy Group:
JZ0: 0A4)
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard.�Q Lar e ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI 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 BUILDNG
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
BNVESTIGA Investigation fee BUIILDNG
'2 �
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CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
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
BOVERTfME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg 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 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 InstalUAlter 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 > IOK 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
BREMRELCCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2of3
IRTY OF CUPERTINO
CITY°r PERMIT APPLICATION FORM
CUPEkTINO
Quantity 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
67- 9— 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
?. S PPLBG Plumbing Fee s foot PLUMBING
PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
•
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CITY OF CUPERTINO s °, OR '
BUILDING DIVISION CONTAACTNE0
MATION �-LN
DINGADDRESS: PERMIT NO0 5 0 6 0 0 5 5
W NER'S NAME: PERMIT ISSUE DATE
ELIZABETH SARAnQ
ONE: SANITARY NO. CONTROL NO.
ARCHTIEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� (�
3
00 LICENSED CONTRACTOR'S DECLARATION
uC1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
�Wwith s
wuction7070)af Division Sof the Business aM Profession Code.and my he..is
in full force and effect.
Licence Class Lica REMODEL MS . & HALL BAHTRMS
pro Date Contractor NO STRUCTURAL CHANGE
tJs ARCHITECTS DECLARATION
6
U 1 understand my plan shall be used As public rectums
;Qin Leonard Prefcssianal
5 OWNER-BUILDER DECLARATION p' r\ I�
.� y 1 thereby arm Nat 1 em exempt rum the nlnu
Cotoh License Law for the
❑O rollowins reason.(Secdm]031.5,Business and Profcssiun Code:Any city or County J\ r >I : I'_ ITz�
$ which rcyuno a permit to construct.alter,improv,demolish.lir repair any Armenian -
Fie prior us its issuance.also requires the applicant forsuch permit to file a signed statement
Zs0 that he is licensed pursuant to thc provisions of the Contractors Ucense Law(chapter 9 Sq.Ft. Floor Area _ 7 1n1[ Valuation
Us 1- (commencing With Section 2000)of Division 3 of the Business and Professions Gale)or 3 GOU;1
that he u exempt therefrom and the huts for the alleged exemption.Any violation of a 4 Q Q Q
Section 2031.5 by any applicant for a permit subjects the applicant in a civil penalty of ppN Number Occupancy Type
not moo Nan five hundred dollars(5500). 0,II I ��II (`�l p II/(P„ Y YP
�u owner of sex Property.or my cmployas with"go u their sole compar udon, D ll i Il 1� .. ,
will do the work,and the structure is not intended or offered for sale(Sec.20th,Busiow
And Professions Code:The Contractors License taw door nor apply LEE in owner lir Required Inspections y
property who buildsor improves thereon,andwhd doessuch work himufforrhrough his
Own employcn,provided that such improvements are notinteMed m offered for sale.If.
however,the building or improvement is sold within one or of completion.the owan-
builder will have the burden of proving that he did not build or improve for purpose of
Age.).
❑h as owner of she property,am exclusively convecting wish licensed contractors to
consumer the project(Sec.7W,Business and Professions Code:)The Coneraewrs Li-
cerue raw dos not apply ro an owner of progeny who Wilds or improves Norton,and
o contracts for such projects with a con omor(s)licensed pursuant a the Contractors
se Law.
am excm t under B&PC for this reason
nor Dae
KE 'S COMP ATION DECLARATION
I hereby affirm under penalty of perjury arse of the following declaration:
1 have and will maintain A CcniOate or Consent a self-insure for WorkefsCompen-
salion.As provided for by Section 3200 of the Labor Code,for Ne performance of Ne
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,As required by Section
3700 or the tabor Cosh,for Oc performance of she work for which this permit is issued.
My Werkcrs Compensation Insurance urrio and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu Auction need not beeompleted if the permit is frame hundred dollars($11m,
car less.)
1 certify that in the peffmonoce of the work for which this pored,is issued.I shall not
employ anyy'person marry marine sou hcgRtnbj^ec�l'ro the Worker
Lawaof Caliersonmate 4' //
Applicam G
NOTICE TO APPUCANr:If.after making Nu Ccnificate of Exemption,you should
become subject to the Workers Compensation provisions of the tabor Code,YOU must
.J Z forthwith comply with such provision or Its permit shall be deemed revoked
ZO CONSTRUCTION LENDING AGENCY
I-+ I hcuhy af0fm that them is a convection lending agency for LOU Performance or
C' the ,it for which this permit is tssuog(Sec.3092,Civ.C.)
r51 A Lundcrs Name
Lk, Lundin',Adduce -
oz
U 0 1 sonify 0-11 have read this application roti All Nm rW AWw information is
IL F Correct-I agree b Comply with all City and County omIM11Rs and sure laws relating in
OU Wilding construction.and hereby authane,representatives of Ois city to enter upon the
shove-mentioned Property for inspection purposes.
F�•,y (We)agree 10 rave,indemnify and kap harmless the City of Cupertino Ageinr
Z inconsesirro,O Louis.costs gaming eapemeswhich may in any way attroc against acid Ctey
U z in eonuguenec ofNc gaining of this permit.
^ APPLICANT UNDERSTANDS AND WILL CO PLY WVH ALL NON-POINT Issued
a•➢.(R
by
:SOC Date s.
SignorefApplicarEVC(snnclr tv/'g' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Date
Type of Roof
Will the applieam ser future W ilding occupant norc or W tWlo hvemous material
iurv,0
Mcd by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
.pts.us3z(a)2 ftu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hacardnuA air contaminants As tle0ned by the Bay Aux Air Quality Management all new materials for inspection.
�//
El Yes t9No
1 have um the hxasmous materials usluircmcnts under Chapter&93 of0te Califor.
nia Health&Saf<tycodc,Secumv 25515.25533 and 25534.1 undcrsmntl Out if the Wilding
Jas nm cmrcnd,hast A tenank Nat it is my o,Umibd,,,w nobly(be Occupant lir Oc
rcym wht� metpnor a er. oxificrucoycrrufxancy. Signature of Applicant Date
Ow Date All roof coverings to be Class "B"or better
Owneru thorn da int