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05080254 (3) CITY OF CUPERTINO BUILDING DIVISION PER C�NTRACTORINFOI2M ©.N -`. mom' wdF81 ? T^a�L?s�bP o_ ��= , BUILDING ADDRESS: ANTIQUE TERMITE & PEST PERMTr No.05080254 IRS NAME: PERMIT ISSUE DATE NE MONIRA NE: SANITARY NO. CONTROL NO. 408) 995-6300 ARCHITECT/EIJGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 sett LICENSED CONTRACTOR'S DECLARATION Job Description "+ 1lmreby affirm that 1 am licensed under provisions of Chapter 9(commencing i with Section lord)of Division Sof the Basin.and Note j�tns Codo,andmylicenseta :nom, in full force andeffec Z (2) BATH SUBFL. /REPLACE KIT. PLUMB . FIXTURE ��z u)ena etas_ re • m.« - KITCHEN REMODEL z ailDate Comis �� ARCHITECTSDECLARATION, I undarsmnd my plans shall he used a Public records �yaa ;0 Licensed Professional OWNER-BUILDER DECLARATION E I hereby.(Stam that I em exempt foo the Contncmis :License Law for the i c o which cmane..(Section IIll1.5.Baines and Improve, de tea Cod):Any city or county which mquinu issuance.Permit re carnet)alae impar.,demolish,teres sig ed tatement pdtheislenspalso uanttotesth)aiama,mfor eContrctor'sLicensegaednetement Valua¢t�10075 ssC (commecing wJPunuanl70the of Division thehamster'snd Proflsio(ChapterCode) Sq. F[. Floor Area F� (commencing exempthheeion romand of Diasiian3 or due alleged ess exemption. An item Codc)or .. Nat le is exempt therefrom end the basis for Ne alleged exemption,Any it Penalty of S<edon 7031.5 by any applicant for pertnll subjects the apPlicammaclvil penalty of ppN Number Occupancy Type not more than rise hundred doll...($500). 35906037 . 00 ❑1,as owner of the property,or my employee,with wages as their ale compensation, will do the work,and the strecwn is not intended or offered Sof Sale(Sam.70".Business Required Inspections and Profeaioa Cade:The Cantracam s License Law dam not apply m in owner of q P property Who builds orimproses thereon,and who doessuch work himaelforNmugh his own however. providedinOrimprovement I,improvements Year of dor mplctind roe owner. • hawwem Ne buildingofproving On, he did not yeaorLmproeion,the rposeo- builder will have the burden of proving Nat he did not Wild or improv)for purpose of Gale.), ❑1,as owner of the propony,am exclusively contracting with ties...d conhacura to connect the project(Sec.1044.Businw and Professrnm Professions Cade:)The Chur'a Li tens law docs not apply to an owner of property who builds or improves Centra,and . / / whoafor such projects with a conuectoKa)liapursuantedpursuantto N)CoContractorsContractorsor's License .W. cu ❑Lem Law. exempt under See .BhPCfor Nis recon Tar Date WORKER'S COMPENSATION DECLARATION v I hereby aifmn under penally of perjury one of the following declarations: 0 1 have and will maintain a Cenifice)of Consent to sell-iaur)for WorkeYa Comp)n- sadon,an provided for by Section 3100 of the Labor Code,for the perfarronou of the neo aro hieh this permit is issued. hove and will mainuin Workees Compensation Insurance,as required by Section 3100 of the Labor Code.for Ce perfarmmce of the work for which this p)rmia is issued. My Workers ComPcaaIti..Inaun a artier and Policy number art: Camier.S �G!'µ•`sYl Policy No.:eeio 4/S J9 u'� • CERTIFICATE OF EXEMP ION FROM WORKERS' ' COMPENSATION INSURANCE (This aection treed not he completed If the permit Is format hundred dollen($100) or lass.) ' 1 unify that In the performance,of the work for which this permit is issued,I shall net employ any person in any manner se,u to become subjecito the Workeri Compensation Law,of California.Date Applicant NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should 4acome subject m Ne Workers Compensation provisions of On tamsr Cskr,you mum .JO farthwi N comply with such provisions of this Permit shall W deemed moked. z CONSTRUCTION LENDING AGENCY [—t I hereby oRrm Nat there is a construction lending agency for the perfurmance of tyi> Ne work fur which this permit is issued(Sec.3091,CO.C.) W Q Undeb Name ' n• Lender's Address VQ 1 certify Cal 1 have read this application and sun Nat the shove Information is II. COMMF 1 agree to comply with all city and county ordinances and statelaws relating to C v building incarnation,and hereby sulurim npresentadvxs of this city to enter upon the W she.aro mond propcny for inspection purposes Ff+a (Wc)agree to ave,indemnify and keep humlea the City of Cupenina against Tq Iiabiiltin,judgments,costs and tape••.•which may in any way.can.egaial said City V'4 in consequent)of the granting of thisPermit. �-t APPLICANT UNDERSTANDS AND WILl.COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. -z_ Re-roofs Signature of AppiicanUConuoetnr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant rr(cure buildin6 eupanumrc or handle haysrdous material u defncd by the Cupertino Municlpa Chapter 9.12,and the Health and Safety Cod),Section 25531(01 - All roofs shall be inspected prior to any roofing material being installed. Elton Enu Will the applicant orfulun building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove emit h....door air contaminants as dcArped by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes grr I have read the havamnus materials requirements under Chapter 6.95 ofthe Califon ""/ / �� '�'7 •�ZH '^I{/C nia Health&Safetycock,Sections 25505,25533 and 25534.1 undersand that lithe building dace not curtcn0y have a tenant that it is my responsibility to notify the acupani of the requinmenu which..at he me�^orw issu son cerdrLate orlxerpaney. Signature of Applicant Date ; r" �� -�y z'� All roof coverings to be Class"B" or better Owner or authorized agent Don CITY OF CUPERTINO I 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35906037 . 00 DATE ISSUED. . . . . . . : 08/29/2005 RECEIPT # . . . . . . . . . : 30982 REFERENCE ID # • • • : 05080254 SITE ADDRESS . . . . . : 943 ROSE BLOSSOM DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MONIRA KAYANI ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : RECEIVED FROM . . . . : ANTIQUE TERMITE & PE CONTRACTOR . . . . . . . : RANDY MARTIN LIC # 24455 COMPANY . . . . . . . . . . : ANTIQUE TERMITE & PEST ADDRESS . . . . . . . . . . : 1913 STONE AVE CITY/STATE/ZIP SAN JOSE, CA 95125 TELEPHONE . . . . . . . . : (408) 995-6300 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPERMFEE VALUATION 10, 075 . 00 180 . 36 0 . 00 180 . 36 0 . 00 BPFIXTURE UNITS 6 . 00 54 . 00 0 . 00 54 . 00 0 . 00 BENERGY PERMIT FEE 180 . 36 86 . 57 0 . 00 86 . 57 0 . 00 BREMRECEPT NO. OUTLETS 2 . 00 2 . 40 0 . 00 2 . 40 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 BSEISMICRE VALUATION 10, 075 . 00 1 . 10 0 . 00 1 . 10 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 439 . 54 0 . 00 439 . 54 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ CHECK 439 . 54 7737 TOTAL RECEIPT 439 . 54 • CUPERTIN0 Assessor's Parcel Number: Name of owner. > g�� A�(� Project address.. 91 .3 / L/6S E126 Contact person. :2Tn & E Phone. Fax. 9 6S/Z Net square footage of lot. �l 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? 1 / Brief description of,.lwork. A/J/r x /DGl1� �� B KG rcl� �dG� Go4h e& 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 • Plan Review Process Work Book Page-8-Revised 4/28/04 t •CITY OF CUPERTIN# �-T, F v z.S'� '"®' • CUPERTINO PERMIT APPLICATION FORM APN 4 CJ / cs-37 Date: _Z 9 �� S Building Address: CS Mailing Address (if different from building address): S"L O,55 O,-7n Ir— Owner's Name: Phone#: O A /2 /4 Y/4H / 6 ba O b Contractor: License #: n 2/W e 1 eel( G SS-2 SZ Contact: Phone: GSS— 7S-7G Cupertino Business License#: _T CE Fax: 495' bSl Building Permit Info: / — / Bld fflX Elect, �/ Plumb Gd' Mech l� Job Descriptioon/ 4,17/7p!!x,/ rim �j�r/j� .. ee.0 /flee- �:x✓si�— Residential OR- 2 16,19 /1 Av._el S bf/CGJL Commercial ❑ k IvAe- 1~7eolel Sq.Ft. Floor Area: Sq.Ft.: Cost of Project- a6G Occupancy Group: Type of Construction: Please check this box if the project is a Alk second-story addition:IRV ❑ Project Size: Standard Large ❑ 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 IM Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING 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 <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELE 200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 3���? 1 of V7 C