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07010174 CITY OF CUPERTINO BUILDING DIVISION PERMIT CON7C7 GTOR,INFORMATION PERMIT NO. BL �G�P/ OWNE 'S NAME: PERMIT ISSUE DATE JNE: SANITARY NO. (!CNTROL NO. 11'_�114 6/z/z ARCHITECT/ENGINEER: I ��j\ B&PER Prr IN O p LICENSED CONTRACTOR'S DECLARATION J U t= I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description :Z,d with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. p / Q z License Cl C'-'� Lie-I �S !- Date l 0-l' Conuanor A rlrlZ�-g C a 04?S rt -ARCHITECTS DECLARATION i z< t understand my plans shall be used as public records )yU 'n y Licensed Professional y OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the n O following reason.(Section 7031.5,Business and Professions Code:Any city or county e m fu� which requires a permit to construct,alter,improve,demolish,or repair any structure Z} prior to its issuance,also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area ///���� Valuation (commencing with Section 7000)of Division 3 of the Business and Professions Code)or ��1-�j/ u that he is exempt therefrom 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 N Number Occupancy Type not more than five hundred dollars($500). ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered forsak(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of 9 P property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale,if, however,the building or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec. ,B&P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: '❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worke.r��s..C�o11mpe��nsation Insurance carrier and Policy number are: Carries: FrJaJ�� PolicyyNo.:dO0Tl4 O CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) i certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.DO- Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of fYi 7 the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender:s Nam^ ]z Lender's Address U C) I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to Ubuilding construction,and hereby authorise representatives of this city to enter upon the W ahove-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino agamst rA liabilities,judgments,costs and expenses which may in any way accrue against said City �/ V z in consequence of the granting of this permit. Date 4_ ►- APPLIC NDERSTANDS AND,WiCL C PLY WITH ALL NON-POINT Issued by: SOU REGU ATION . Re-roofs Signatur£of Applican HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes f No 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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes 1[71 No 1 have read the hazardouss materials requircmcros under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building does n ntly have a tenan that it is ponstbility to notify the occupant of the icy' men hied` Prt tan acerirrAwofoc Signature of Applicant Date —�%77 7, �"7 All roof coverings to be Class"B"or better Owner or authorized agent Date CITY OF CUPERTINO 12 ITEMS OF 12 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34244018. 00 DATE ISSUED. . . . . . . : 01/29/2007 RECEIPT #. . . . . . . . . : BS000000339 REFERENCE ID # . . . : 07010174 SITE ADDRESS . . . . . : 22690 ALCALDE RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER ANDERSON THOMAS P AND DORIS V ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3977 RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR . . . . . . . : CORBETT, GARY LIC # 21736 COMPANY . . . . . . . . . . : GARY CORBETT CONSTRUCTION ADDRESS . . . . . . . . . . : 413 ESMERALDA DR CITY/STATE/ZIP . . . : SANTA CRUZ, CA 95060 TELEPHONE . . . . . . . . : (831) 420-1148 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BENERGY PERMIT FEE 137.16 65. 84 0 .00 65 .84 0.00 BPERMFEE VALUATION 7, 000 .00 137. 16 0 .00 137.16 0. 00 BPFIXTURE UNITS 3 .00 27. 00 0 . 00 27. 00 0 . 00 BPLANCHK PERMIT FEE 137 .16 183 . 04 0 . 00 183 . 04 0 . 00 BREMFIXT NO. FIXTURES 2 .00 2 .40 0.00 2 .40 0 . 00 BREMRECEPT NO. OUTLETS 3 .00 3 . 60 0 .00 3 . 60 0 . 00 BREMVENFAN NO UNITS 1.00 45 .39 0 .00 45 .39 0 . 00 BSEISMICRE VALUATION 7, 000 .00 0 .70 0 .00 0 . 70 0. 00 BUSLIC FLAT RATE 1 .00 107. 00 0 .00 107 . 00 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 PPERMITFEE FLAT RATE 1 .00 38 .37 0 .00 38 .37 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 687.24 0 . 00 687.24 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 687.24 VISA --------------- TOTAL RECEIPT 687.24 c) 1' r O _}m ti -. i iN r RESb1t3N� -Y Ot a0ATE�z•�n4 ThiS SO 0 p'a'f'� uii;t SPC�ItiCaJORS MUS � r oe kept on tl*ie 0 at i,Il times and it is ui lakmful to make s-ly Chingos or aiterabor on same >vith.:.,,t wri.-ten permission frai, tme buildim„ Dept. p City of Gu ertino. Fhe stamping of this pan and specification SHALL NOT be he d to peg mit or to be , ���; t�"•' approval of the violation of any provisro, -- �'�� ��'' Lt'r , , %� if any City Qrdinarrca or 5mra i a- 06, r Pc= 200 w Community Development 10300 Torre Avenue Cupertino CA 95014 "p Telephone(408) 777-3228 CITY OF Fax(408)777-3333 rUPERTINO Building Department JOB ADDRESS: I PERMIT #� ;�/6/ 7� OWNER'S NAME: P--,c;c�—t ! PHONE # Z z S .3(/A GENERAL CONTRACTOR: G,4,-,c Gc �, I FAX # I am not using any subcontractors: l Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork I 1 Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO 'OF PERMIT APPLICATION FORM , TINO COPE APN # Date: i U'1 `1 0 7 1 Building Address: Mailing Address (if different from building address): *?-Z6 �1C AL_ <AL_0 E c�iA Owner's Name: Phone #: 'AC-)`v ZZS 3� Contractor: License#: 6 A.S_--e c&;�Z, iB-4 `(4 3A 3 Contact: Phone:20 At Z& t\ (� I Cupertino Business License#: G'k Ry C c,c-fltz r-r Fax: x/73 J Building Permit Info: Bldg ❑ Elect M Plumb © Mech Job Description: v _\\0 Residential [,9 t� JT" 1_"­o c, R� r-c L Commercial ❑ Sq.Ft. Floor Area: I Sq.Ft.: Cost of Project: i Occupancy Group: " `1oe_ E. . �a_� 1 Type of Construction: i Please check this box if the project is a second-story addition: ❑ i Project Size: Standard ❑ Large ❑ Major ❑ Quantity I Fee ID Fee Description Fee Group t BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 ( Boiler> 100K to 500K Btu I MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 , Boiler> 1.75M Btu MECHANICAL J 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 BELEC 1000 Elec 600V<= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A j ELECTRICAL BELEC200 Elec Svcs 600V<= 200A i ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 aRrl CITY OF CUPERTINO CITYOF 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 BOVERTIME { Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING / BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING 3 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 ( Repipe Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn SprinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pipe PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER ( A/C Unit> 10,000 cfin 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> 1 OK 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 3 BREMRECEPT Rcptl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 aoz- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity I 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 I ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL j BUSLIC Business License BUILDING 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 PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3