03010063 (2) r
CITY OF CUPERTINOrs >�
BUILDING DIVISION PERMI S, x CONTR'ACTORIfINFORMAT,BUILDING ADDRESS LAMIA CONSTRUCTION PERMITNO.
21541 REGNART RD 0 063
'OWNER'S NAME: 4749 CAMDEN AVE - APPLICATION SUB DATE
EVANS WILLIAM D AND GERTRUDE K 01/10/2003
PHONE: (408) 594-1401 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
OCZ 0 0 t�
js00 LICENSED CONTRACTORS DECLARATION
I hereby )of that I am licensed under pmvisionsofChapter 9(commencing Ig Job Description
�Z with Senion]o01Bof Division 3of the eusinnsendprofeuiom Cakes and myliccnx is P,g)�a,1�,,)�
I-= Imm�ram an flea x KITCHEN REMOzonDEL"` �- D"
r4l— Licen TE=D O
OZ–Q Da cut.
gga I unleowad my plans 0.111 he,used. htc mcEC mds / (7 /003
W.
3 � Licensed Prufeasional ��
t L OWNER-BUILDER DECLARATION j D j jVG
u<i 1 hereby affirm Nat I am exempt from da Contractor'sLiccnx Law for the
i–p0 following motion,(Seeton7031.3,Business and Prafessinm Code:Any city at county
a $ which requires a permit m construct,alter,improve,demolish,or repair any Someone
Fly prior to its issuance,also mquirea the applicant for such Perm it to file a Signed tactical
QQ Nat he is licensed pursuant to the Provisions of the Comocmr'sLicense Law(Chapter 9 Sq.Ft.Floor Area $2SYfilQatlon
8 � (Com mencing with Section 7000)of Division 3 of the Busi was and Professions Code)or
ta, Net on is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant fon Permit Subjects the applicant to a civil pausby of EYP
not more than five hundred dollar(5300). be Occupancye
O I....,of the Property,or my employe.with wag..their sole mmpewuan,
will do the work,and me wuctum is not i.Mn or offered for We(Sm.7040,Business –
and Pmfersions Code:The Commerce,Limnx law dots nos apply to m owner of equlred Inspections
property who buil&or improves marcor,and whodoessuch work himselforthrough his 102 - PIERS
awn employees,provi&d that such improvements are not intended proffered torture.If, 103 – UFER
however,the building or improvement Is told within one year of completion,the owner,
builder will haw me burden of proving that he did not build or Improve for purpose of 104 - REBAR
S°I`, 105 - ANCHOR BOLTS
❑I,u owner of the property,am exclusively conuacung with li¢nsed cwon"W's m 106 - SEWER Se WATER
conswcr dm pmj.t(Sec.7044,Business and Professions Code:)The Contractor's an
terse law does not apP,;to an owner of poepeny who buil&or imposm thereon,and 202 - UNDERFLOOR PLUMBING
wk ContraWts1011 nPmectswith.eanvumrtt)licensedpursuanttnmeContaaatora' 203 - UNDERFLOOR MECHANICAL
lam exempt 'Sac
Sec.�---,B&PC for thisrt an 204 - UNDERFLOOR FRAME
exec I 205 - UNDERFLOOR INSULATION
WOR 'S COMP NSAnON DECLARA N
I hereby aOlw under Penalty of perjary one of me following dechundons: 301 - ROUGH PLUMBING
❑ In.ve.newinmaintsm.cenifit,.marelasenrmxu.i.aremrwakericampn. 302 - TUB 5a OR SHOWER
cation,u provided for by Section 3700 of the labor Code,for me performance of the 303 - ROUGH MECHANICAL
work for whim this Pewit it hemod. 304 - ROUGH ELECTRICAL
❑I haw and will maintain Workefs Compensation I.urance,u required by Section 3 0 5 - FRAME
3]00wnm
of the labor Cade,for the perfoaClmw
e weak for which this leit is i,w L \
My Workeri Compensation Insurance canner and Policy number art: 306 – HOLDOWNS
c.niar:
CERTIFICATE OF EXEMP ION FROM WORKERS'
Policy No.: 307 - INSULATION
COMPENSATION INSURANCE 308 – SHEETROCK
(Ibis section need not he completed if the Permit is for one hundred dollars 309 - EXTERIOR LATH
Iron'.) 310 - INTERIOR LATH
et'loymosi the pyponanneoftheooh(uwhich NisPewitisissued.'snailnot 311 - SCRATCH COAT
employ any persmrlda/y mannerro/u�b��oasa Subjxt m the Workeri COmpenuauon
I(�awB,�iorC.rr 1 S3 313 - ROOF NAIL
PyyP CE PPL A .I, rmakinghisCenif—¢nJofExemption,youshould 501 - FINAL ELECTRICAL ENERGY
0zlkcome subject o the Worker's Compensation previsions of the favor Code,you must 502 - FINAL PLUMBING ENERGY
forthwith comply with such provisions or this Pcwiuhall M deemed revoked.
K0 CONSTRUCTION LENDING ADENCY 503 - FINAL MECHANICAL ENERGY
F4 Thereby,Birmthat there isaconsmucuonlending agency for the Performance or 504 - FINAL BUILDING ENERGY
CG vim. the work for which this Pewit is issued(Sec.3097,Civ.C.)
p LendersName 505 - FINAL ELECTRICAL
Z Lenrea 506 - GAS TEST
Up 1 cenify that I have mad this application and tame W t the above infOMwLbm is 507 - FINAL PLUMBING
gS torten.CLIagree
agree In comply with all city and county ordinances and sole laws relating in
�U building Construction.and hereby aumonse representatives Of this city to enter upon me 5 FINAL MECHANICAL
W
show pmpcny for inspection purposes. O 9 F I N
(We)agree m sew,indemnify and keep harmless the City of Cupertino against
rte lol liabilities,judgments.costs and expenses which may in any way accent,agalnstmid City 5 N Gs
U 7 in consequence of the granting of this Pewit. �71(/�)
•7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by91 WORKS Date C
S U ONS,
e o Re-roofs
rgnamrt ofApplic HAZA DOUS MATERIALS DISCLOSURE Da 'Type of Roof
Will the applicant or future building Occupant aarc or handle Nurdous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25533(x)7
❑Yes �No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cm it hasallous air coneminants as defined by the Bay Area Air Quali ty Management all new materials for ins ection.
,.I District? P
❑Yci No
I hale mad the ha.Nous materials mluirementsunder Clupler 6.95 of me Califon
its Health&Safety Code.Secuem 25505,25533 and 25534.1 mWcrwnd then III&Wilding
docs not current) have a tenant.that it is my nespo.iNlity to our the Occupant of the
reqs+ a NOT,¢ r eI' eY. Signature of Applicant Date
�!0 03
ncr Or eulhorixeJ a t D„ All roof coverings to be Class "B"or better
C D% CITY OF CUPERTINO b3
CUPEkTINO PERMIT APPLICATION FORM
APN# S — 2 2 DO 4 Date:
Building Address: 4 I n 1
o� � •� /CC /(Q r Kpl
Owner's Name: fPhone#:
Evawt. S 2s6 7
Contractor: `A 1�{ License#: — ..7g ' /
o'Yl [o �Q
Contact: Phone#:
fern l�af� �s;s 468 - S794 - 140
Applicant/Contractor: Fax #:
e_ � w— 408 —ti3"8 7909
uil g Permit Info:
Bldg Elect Plumb Mech
-Jo escription:
Residential: ITC4 4fp0F,� L Commercia .
Sq.Ft. Floor Area: /0 SF $/Sq.Ft.:
Architect/Engineer: k �r� n�I� Valuation:
Type of Construction:p �CV w � �D zN Occupancy GrduMy
O; r
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BO 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
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
91EWMULTI New Multi-family Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
lof3 `' � /
i 1251 g =nk CIUJ�
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ROTS 15-4 _ DSL
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��pRpyE CITY OH 12L
IN ACCORDANC
WITH T� INANCES
S41 TINO CD . �tjND 47
483
CUPFR 1(l �_„�
135
GATE MUST 8 JD-�
8 , ecn orations
cD-UA— tins okw and it is nn
49Bet P' at all times alterations
2, kept the lob changes from
to make anY ermission DISH D-W
e without wririe of�uPertino' 24" 2142
0n s m Dept., City s ecifications -R
oildrng of tbis Plan enmit or to be an
2TQ3Q stamping held to P r D-W 52
• D SHI LL N0T be r O
of royal of the violation c 8 a
rri Ordinance or D-B
Aviv C' FHDR
D-UC
138 2498 I
D-W D
SV
2 421 II
I UNDERSTAND AND APPROVE
4 OF THE ABOVE SP IFICATIONS
Design: 08f27A2 Dw8 no,
0 ct slae rukeedesignations TMs b an edgtnel copied and must Scale:3l8"=1' Date : 10108/02
MOM subject to uedfiCaOon an - real be released or copied unless eveu2
site adjustment to fdjob applicatelefes,has been paid orJob Deaer
ondiNions. "der Placed• d
kA
rose
• SUBMITTAL
u #1 SUBMITTAL
y. br
138lip
D
�— 3224 60
42
65 D 8
a 000
9838
•
54 I
26
m m
f— 303 AT 24 —7 27 24 --'
S-
I UNDERSTAND AND APPROVE
OFTHEA60V P IFICATIONS
SIGNED
d6nensWm 8 alae dealgnatlons TMs b an oroid deslpn aM must eeene4 Scale:1Q•-r 0"no.
gh en am suNed to vaticmbi on not be tdeeaed or copied unless ev�s2Lvovw
job aft end atouebnent to fit job appikOle to bas been paid or job
eomipians.
Wa9/CLbrev
arderplaced. 1
UBM
#1 s
1253 vD
�— 19 36 4 10 2003
I JJAN
21
61121 R VE
9636
54 o m
o �
343 e
hp
f— 18i 36 15 36 --�
n el-o
QI UNDERSTAND AND APPROVE
OF THE ABOV SP IFICATIONS
SIGNED
&etas designations This Is an cdghud design wid must ° a4 Soale:l2"m T , Dwg na
Om are subject to vein on not be reba d or aapM unless ft
jab aand adjushnent to 0job appNcebls lee has been paid or job evana2
fan
CaMitlan. oMer placed. WSW Line# 4
}
SUBMITTAL
4 AL
#1 sem$
135 —�
�- 24 9 i 54 21 's018T
6
8 JAN 1 0 200003
B
35
813
o �� UA,�,a
p uU UUU
9838
oI p e a o❑
54
DD
341
' y
�— 38 47 52
38 1 24 24 -�
I UNDERSTAND AND APPROVE
OF THE ABOVE S�' C IF�ATIONS
SIGNED !� __
iam&aim designations This Is an odgvii design and must 3oe6:112 =1' D'B no..
Jeb she angivienared to, a not be rebased a copied radess evmn2 .
lob applicable fee has been paid or job
ardmom. mW placed. WaWCLir�S 5
SUBMITTAL " , ..:
#1
D �
0 2003
0 By
oo�<I
I UNDERSTAND AND APPROVE
OFTHEABOVE ATIONS
SIGNED-� � y —
• NoW This dmwhip to an erttetic ems4 Dwo no.
d the penerm e�mro2
eppeam=of the floor plan.It Is
W mem,to he en exact rendition.
•
SUBMITTAL
JAN 10 2003
Y III
I UNDERSTAND AND APPROVE
SI THE IgIZICATIONS
SIGNED
• Note:This drawbrg Is an mdstb exaneb Dwg no.
kwp.ewbm of the general
appeararxce of the fbw plan.R b exrars2
rat meant to be an exact mndAbn.
CITY OF CUPERTINO
BUILDING DIVISION PERMIT rCONTRACTORINFORMATIQN •,
T.zr_ . r„ -o,
BUILDINGADDRESS: LAMIA CONSTRUCTION PERMIT NO,
21541 REGNART RD 03010063
INHR'S NAME: 4749 CAMDEN AVE APPLICATION SUB DATE
EVANS WILLIAM D AND GERTRUDE K 01/10/2003
PHONE: (408) 594-1401 SANITARY NO. CONTROL NO,
ARCIIITECT/ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MPH
0 0 0 0
P 02ff LICENSED
CONTRACTORS DECLARATION
ZUl- hereby a affirm Lha 1 am Awide,provandoofChaffer 9(commencing Job Description
��� with Section71k1(17 of Divieion)nf the Buaineee and mm,xdns Code,andmyliaenuis
in roti n,m an Tact. Q KITCHEN REMODEL
Liccnm la. Lic.A .y y Js p D
G0n� Da Comma 4i'xC �
F—� ARCHITECTS UO
aSy z< 1 understand my plans shall be used assp public records _ pp �s
u�3>;p a Fill 6 2��3
ta LiccnxJ Pmlessiawl
OWNER-BUILDER DECLARATION
7 1 hereby abirm that I am exempt from the Contractor's License law for the
fulluwing reason.(Section 7031.5.Business and Professions Code:Any city or county BUILDING
x m which requires a permit to consumer,alter,improve,demolish,or repair any structure
to-''^ prior un its issuance,also requires the applicant lot such permit to file a signed statement
SZOthalheislicensed pusuanuothdpmvisionsofthe Conoacmr's Licen. lUw(Chapmr9 Sq. Ft. Floor Area $25Ytt Gatlon
'Il (commencing with Section 7000)of Division 3 of the Business and Prommions Carl
that he is exempt themfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). bC Occupancy Type
❑ I.as owner Office property,or my employees with wages as their sole compensation,
will do the work,and the smmure is not intended or offered for sale(Sm.7044,Business FOUN
—
and Professions Code:The Convectors License Law does not apply to an owner of 102 - PIERS equ)red Inspections
progeny who builds or improve thereon,and who does such work himulfor through his
man employees,provided that such improvements are not intended or offered fors ale.If, 103 — UFER
however.be building or improvement is sold within one year of completion,Ne ow rs,
builder will have she burden of proving Nal he did not build or improve for purpose of 104 - REBAR
sole'). 105 - ANCHOR BOLTS
❑1.as Owner of the propcny,am exclusively contracting with licensed contractors to 106 - SEWER & WATER
consumes the project(Sec.7(k4,Business and Professions Code:)The Contractor's Li.
cense Law does nor apply to an owner of property who builds or improves thereon,and. 202 — UNDERFLOOR PLUMBING
wno conof such Projects to the Cnnvacmrs
Law. 203 - UNDERFLOOR MECHANICAL
Law.
Ia�!m/exempt code,Sec. ,B S P C forthis rd eon 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION Reath I vg 205 - UNDERFLOOR INSULATION
301 - ROUGH PLUMBING
I hereby affirm under penally of perjury one of be following declarations: 3OZ — TUB & OR SHOWER
❑Ihavc end will maintain Cenificete of ConunuoulGinsure forwoher's Com Pon- 3O3 — ROUGH MECHANICAL
cation,ae provided for by Section 3710 of she Lahr CMe,for Ne perlormantt of the
walk for which this promo is issued. 304 - ROUGH ELECTRICAL
I have and will maintain Worker's Compensation Insurance,u squired by Section 305
- FRAME
3710 of the Lahr Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc: 306 — HOLDOWNS
Carrier: Policy No: 307 - INSULATION
CERTIPIWORKERS'
COMPENSATIONE
INSURANCE
308 — SHEETROCK
(Thcambon dammit lacnmpletedinhepermhisfornne hnndreddolhos S10) 309 - EXTERIOR LATH
orleSt) 310 - INTERIOR LATH
1«nify thm in then comm t I the work for which this permit is issued.I shall oat 311 — SCRATCH COAT
employ any rcr a ymenncr m a suhjea unhe Workers'Compboodion
Laws ofC.rmmu ,c ��%A7`u� 313 - ROOF NAIL
CE PPL A :l, er making thii`f�ExemPlion,you should 501 - FINAL ELECTRICAL ENERGY
&come subject to the Workers Compensation provisions of the Labor Code,you must 502 - FINAL PLUMBING ENERGY
O O forthwith comply with such provisions or this permit shall be deemed revoked.
ti CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
[-. .N. I hereby affirm that there is a construction lending agency for the perlarmance of 504 - FINAL BUILDING ENERGY
t1e >
the work for which this petmitisissued(Sm.3097.Cw.C.)
Len505 - FINAL ELECTRICAL
W q der'sNamc
� z Leader'
AJdmss 506 - GAS TEST
U O 1 minify that I have read this application and state that the shove information is 507 - FINAL PLUMBING
W Fconcet.I agree to comply with all city and county ordinances and stale laws relating to
U building conswninn,and hereby authnrirz representatives of this city mentor upon the 5 FINAL MECHANICAL
>, W above mentioned proPeny lin inspection purposes. O9 FIN E
(We)agree m save.indemnify and keep harmless the City of Cupcnino against
Ir V) liabilities,judgments,costs and expenses which may in any way accord against said City 5 N G
U z in consequence Of the granting of this permit.
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by51 WORKS Date
Cl "7.
S U IONS.
7�
e o Re-roofs
ngnatom of Applicant/ nvactor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupam store nr handle havardom mammal
s defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
(
de,Section 25532D)7❑Yes iTNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or boom building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit hazardous air emosdomnts as derided by the Bay Area Air Quality Managcmem all new materials for inspection.
Diatricl7
Cl Y", V t
�I��IN�
I have mad the haardoVVVusmaterials requirements under Chapter 6.95 orthe Cr lifor-
nix I I.IN a Stdcty CtAc,Sccuons25505,255))and 25534.1 underswnd that if dm building
Jres dol curmna tensor,that itis my resrysrmihility to Duly the oecupanl of the
mgai ew m tl have6 m0date Tea,�pea Signature of Applicant Date
IID 03
Ane,or wthotiveda I Da All roof coverings to be Class"B" or better