03100091 (2) CITY OF CUPERTINO
s BUILDING DIVISION PERMIT ?CONTRACrOR INFORMATION •':
BwLDINGADDRESS: PACIFIC PLUMBING PERMIT No.03100091
"n T"TAIJ AUR
OWNER'S NAME: 1667 ROGER.S' AVE PERMITISSUEDATE
CARL RTTrK TRUST
RY NO.
E: (408) 452-8633 SANITACONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
IGp LICENSEDmthat CONTRd under
SDECons of CON
as 1 Mreby affirm shed I em licensed under provisions of Chapter 9(commencing Job Description
with Section? MEof Division 3 ofthe Business and Professions Code,and my license is c w.
s mfall
ense and cfrcct— _ WATER SERVICE r�.v�i �
License Clara Lk.N
Dal G con chi
II
ta astoWill
RCHE DECAAIO
esruhlicnrsoLNOV as
2
06
: . Licensed PfcsmvlQ3 m
OWNER-BUILDER DECLARATION
0 1 Wupy.(firm Nat 1 t. exempt from the Contractor's ro :An,I law fou the BUILDING
❑O following reason.(Scorn)1)31.5.Business and va.Protrusions;demolish,oe:Any city n,county
$an which royuircs a permit set construe,alter,t t forsu hpermittor term,any ssument
•y< prithtnoiucense pursouyuircs the
ovisio so ft he Contuarmil micensle e Law
statement
that heircing wit pursuant provisions of theeBuacmr i (Chapter 9 odc)us Sq.F[.Floor Area Valuation
2 $
that
examwithshco,inn and of Division r of the al aged ass and Proon.Any
Cale)to
1 shat io u exempt sang applicant
p li and U¢ruse for the alleged assumption.to Any violation of 37508036 . 00
Semion983Lsby any dollronpermitsubjects the epplicanuo,civil penalty of ppN Number Occupancy Type
not more than five hundred dollars(SSBB). P Y YP
❑1.ass owner of the property,or my employees with wages u their sole compensation,
will do thework,and the structures is not intender or offered for mR(Sec.704PI,Business 116 — ER 'd' eC[IODS
and Professions Code:The Contractors License Law does not apply to an owner of
property who build,or improves mereon,and who doessuch work himself.,through his 202 — UNDERFLOOR PL GING _
own employees,provided that such improvements me not intended o,offered for talc.IL 301 — ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,the owner.
builder will have On burden of proving Nat he did not Wild or improve for purpose of 3 02 - TUB & OR SHOWER
❑1,u owner of she property,.B tints and contractingfsss with licensed contractors to
502 - FINAL PLUMBING ENERGY
construethe project(See.to o344.Business andProfessionswho Widsoe:)Thoves Ocrtr's Li 506 — GAS TEST
censeontrdoes r such apply tamoith aofproper(swho sedpurrimprovice Contra,oand
's 507 — FINAL PLUMBING
who
mar Laces for such pmjccu with a contractor(s)licensed pursuant m see Contractor's
License law.
❑1 am exempt under Sec. .B A P C for this mason
Owner Dao
WORKER'S COMPENSATION DECLARATION
I hereby afrimt under penalty of perjury one of the following decimations:
and will maintain a Certificates of se
of Consent lf-imte
um for Worker's Comfort
n.m as provided for by Section 37W of Ne Labor Clues.for Ne performance of the
work for which this Permit is issued.
1 have and will maintain Wmkerb Compensation Insurance,az required by Section
W of Ne Imus,Code,for the performance of ten work for which this permit is issued,
ywo ere oattenuation Insurance carrier and Policyn roper Q
Carrier: _�1sfLLs�yNi.:XR.Policy N /
CERTIFICATE Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sealed need not W complemU if the perosis is for one hundred dollan(gIIX))
or fete)
1 certify that in the performance of she work for which this Permit is mesad.I shall not
employ any person in any mannCCr��sn ee55lY MCVV9Csubjecno the Worker.Compensation -o•
Laws orcmacro it.non. /Y'10^O S -
Applicant far- •
NOTICE TO APPLICANT:If,after making this Cmuflcam of Esemption,you should
become subject to the Wmker',Compenamom provisions of the Lahnr Cnde,you most '
z forthwith comply with such provisions or this Permit shall W deemed revoked.
z 5; CONSTRUCTION LENDING AGENCY
I hereby arms Net them is a cmmmction lending agency I'n,she Performance of
X F5:-t
she work for which this permit is issued(Sec.3007.Civ.C.)
A Lender's Name
2.
=I z Lender's Address
O 1 certify Nat I have mad this application and sum that the above inrmmuion is
y F correct.I ague to comply with all city and county on inanees and sues laws relating m
�O building construction,and hereby authorise representatives of this city to enter drum the
NC ahovetms,judgtpupertyst forinspection purposeswhichm.
y (We)agree to eve,indemnify and keep harmless the City of Cupertino against
N inconseejedgmenRcosumd eapeuc,mit. may in any way accede gains reit City
:�Z, in
consequenceof DEhe grarning of TANDS AN WILL WILL COMPLY WITH ALL NONPOINT Issued by: Date
L NS,
"I Re-roofs
PPlxan Comract Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
e applicant ser future building occupant stare or handle havacdous material
the Cupeninn Municipal,Code,Chapter 9.12.and the Health and Safety
zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
1�Nd
e applicant.r fm rc building occupant use equipment or dcviccf which If a roof is installed without first obtaining an inspection,I agree to remove
air common U dcfncd by the Bay Axa Air Quality Management all new materials for inspection.
❑Yes Nu
Ihave s,Sdo the hxslNnusmaxrials. 5533andenuundcrCharles
istand.95 ofsheWilding
nicer mlthfk Safc Cotler SC Nom tat iti3my responsibility
us arms the
accup Wilding L/
dens not cu ant.Nm itis my responaiM1ility m nosily the occupant of the _
require m u metprio Inatome.of.cenlpcateofOra Signature of Applicant Date
o r ,ambornedagem boa�b G5 All roof coverings to be Class "B"or better
CITY OF CUPERTINOOD l
REPIPE/SEWERS/MAIN SERVICE
S CUPERTINO PERMIT APPLICATION FORM
APN# 0 ! �� Date:
Building Address:
Owner's Name: Phone#:
i
Contractor L ggel: v JLicense#:
Contact:IPhone: Cupertino usiness License #:
�p .
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description: v O
i
Residential Commercial ❑
Cost of Project: o�
Qty. if
A lic e Fee ID Fee Description Fee Group
PPERMTI'FEE —Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
*1--2
From: 04/12/2004 11: 13 #035 P.003
CITY 09 C PERTINO III I Vj,.
BUILDING DIVISION PERMIT " I" gmni'
BUILDINOffD Eyb TANTAU AVE. PACIFIC PLUMBING lil PERMITN'03100091
jillih
gMkL BUCK TRUST 1667 OGERS AVE FzRMrrh`1T/?0/2003
PHONE: SAN J SE r CA 95112 SANITARY N0. CONTROL NO,
AACHITECIENGINEER; PHONE e: WATER SERVICE BUILDING PERMIT INFO
B� ELECT PLUMB ME�CHJ
'' I� TO ARRANGE INSPECTION JOB DESCRIPTION
,�,ve" Ifl yA `; CALL 7.3228 MONDAY.FRIDAY 24 HOURS RESIDENTIAL:
�a BEFORE EQUIRED INSPECTION. 0SFDWL 0KITCHENREMODEL
d' Q FOUNDATION/PIERS/H.D.S. AND PB MTrA ARENEEDED WHEN PHONING, OADDITION ❑ PLUMBING RE-PIPE
UFBR GROUND ❑ MULTI-UNIT STRUCTURAL
CCC MODIFICATION
6� PADISETBACK•CERT RE.SIDENTIA _COMMERCIAL__OTHER— 0INTERIOR ❑ CHIMNEY REPAIR
!I GARAGE SLABS/PREGUNITE IMPROVEMENT Q SWIMMING POOLS
\7� P LOIRSEIRE AREA C BATH REMODEUMEPAIR 0 DEMOLITION
UNDERGROUND/SLAB AYES Iryu n•Cim A roof\s¢mbly b RQuired, COTHER
UNDERGROUND PLUMBING
UNDERGROUND ELECTRICAL ONO InitialI.C.B.O.e
rOMM�Ar.,
NEN BLDG/ADDITION 0 DEMOLITION
UNDERFLOOR PLUMBING 0 TENANT 0 FOOD SERVICE
UNDERFLOOR MECHANICAL Numberoreei ng cP••dnP IMPROVEMENT,
UNDERFLOOR ELECTRICAL To be removed To be reulned O OTHER
UNDERFLOOR FRAMING VENTS
UNDERFLOOR INSULATION
TYPE OF ROOF COVERING
PROPOSED:
ROOF SHEATH/DIAPHRAGM
PLUMBING (] Built- Roof Q Buill•Up Raaf
PLUM
TUBS B SHOWER PAN ❑ Aephs Shingles 0 Asphalt Shingle*
HANI 'AL ❑ Woe4 hawWeed Snekes
;RIC AVPOOL BOND ❑ woad nlAgles wood Shingles
/STAIRS/E.EGRESS C) Other pecify) ❑ Other(Spgeify)
ON/VENTILATION Provide I,C,B.O.Report No,
Provide Mrgr.Installation Spam
R SHEARJHOLD DOWN
SHEAR/HOLD DOWN INSPECTION SPECIAL INSPECTION REQUIRED DATE INar
SHEETROCKtSHEETROCK SHEAR Q ❑
EXTERIOR LATH/W SCREED
SHOWER LATH
SCRATCH COAT
SEWER/WATER
TEMPORARY APPROVALS
OCCUPANCY
PLANNING 777-3308
X> GAS TEST IMPORTANT
y0 GRADE(PW.777.3354)
D z FIRE-CALL 408 378-4010 When i permit has expired, a charge totaling one-half
HANDICAP
the fee to obtain a new permit must be paid to
} U]
ELECTRICALreactii ite the permit.
PL
UMBING _ Ll
J x MECHANICAL
ENERGY If a p it has been expired for more than one year, a
VISUAL FINAL ONLY - charge totaling the full fees to obtain a new permit
BUILDING must I a paid to reactivate the permit.
. �'.' � ❑ lrlltlal5
CERTIFIC E OF OCCUPANCY
PRE-INSPECTION; PLYWOOD: IN-PROGRESS;
INSP, DATE INSP, DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS; FINAL:
INSP. DATE INSP. DATE DJSI, DATE
•r��n AAI\ • • AA\ITA l /•.1r I'•P.T 111"\I•r A.. � • • w••��...w�� �� ��••.�•�..
From: 04/12/2004 11: 12 #035 P.001
� AEHR
TEST 1191Y®TEM9
400 Kato Terraoo
Fremont,CA.94539
MAIN: 670973.9400
FAR: 610.0239450
Facsimile Cover Sheet
Date:
To: �� C From:
Company: Lu�sru'�r� I,w'I Id. JRP>` Phone: 5/(7'-6- 3 - I9W) Ic 3b'/
Phone:
Fax: No. Pages: (Includlnpthis one)
Comments:
4,e
tvddk T he gr tcs a
�8 ale_ �A �( r,,,,o- �� h la,v r✓ a,r. i,.�.,,�17.rn.s ,
From: 04/12/2004 11: 13 #035 P.002
• 10300 7brre Avenue
CITO rAX408) 777.3333cupertlno, collfornfo 95014
CUPE �TINO hone
08) 777-3228
CC qMUNITY DEVELOPMENT/BUILDING DIVISION
April 06, 2004
Facility Manager
CARL BUCK TRUST
10320 Tantau Avenue
Cupertino, CA 95014
SUBJECT: Permit: #03100091, water ervice
Dear Facility Manager:
Our records indicate that the above listed lermit is due to expire on May 04, 2004.
If due to circumstances beyond your con of you have been unable to schedule an
inspection, you may submit a letter to the I Nty of Cupertino Building Official
irequesting a one-time extension for his re iew. Please state in the letter the reasons for
your request If no extension is granted anno inspection is called before the expiration
date, this permit will be voided and the pei mit application discarded. After this point, you
will need to submit new plans for plan rev ew and pay permit and plan check fees to be
issued a new permit.
If your records show that the permit cardi las signed and released by an inspector as
being complete and final, please notify this office at your earliest convenience. We will
update our computer files and close your ermit, and we apologize for any inconvenience
this matter may have caused.
Thank you for your attention to this matte i.
Sincerely,
� GJ ,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk