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07020142 CITY OF CUPERTINO BUILDI.iG DIVISION PERMIT � � Ta IoMTI�N: PERMIT NO. Bul1fl�1t A/�DB513B RD A & A PLUMBING 07020142 l L� PERMIT ISSUE DATE OWNER'S NAME: WASSON ROGER E AND LILLIAN H 924 E FI:EMONT AVE 02/27/2007 SANITARY NO. CONTROL NO. INE: (408) 738-8878 BUILDING PERMIT INFO ARCHITECI7ENGINEER: BLDG ELECT PLUMB MECH 0 Id p C LICENSED CONTRACTOR'S DECLARATION Job Description vF` 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of the Business and Professionsand myliccnsc is GAS LINE TO FIREPLACE r H in full force sod t n Z Licen �,o Datc Conlreelor ARCHITECTS DECLARA N i a< 1 understand my plans shall be used as public records iyu W F• Licensed Professional y c OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the 0 o following reason.(Section 7031.5.Business and Professions Code:Any city or county <m 01 which requires a permit to construct,alter,improve,demolish,or repair any structure z y prior to its issuance,also requires the applicant for such permit to rile a signed statement Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $700 y l= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i 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 Number Occupancy Type not more than five hundred dollars(5500). 3 6 2 110 61 •-l7V ❑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 for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of 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 reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑1 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. Q 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 Worker' Compeasation 1 rance carrier and Polity n , O Carrier.� Policy No.: �`J M TIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) 1 certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date 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 ,J Z forthwith comply with such provisions or this permit shall be deemed revoked. z OCONSTRUCTION LENDING AGENCY F~•t►fir 1 hereby affirm that there is a construction lending agency for the performance of (x > the work for which this permit is issued(Sec.3097,Civ.C.) aQ Lender's Name r0 z Lender's Address U C—) I certify that I have read this application and state that the above information is fL"' correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorise representatives of this city to enter upon the W above-mentioned property for inspection purposes. f7, (We)agree to save,indemnify and keep harmless the City of Cupertino against Nto liabilities,judgments,costs and expenses which may in any way accrue against said City �7 V z in conxquVG� the ranting of this permit. Date Z— ` APPLI ARSTANDS AND WILL COMPLY WITH ALL ON-P INT Issued b) SOJd#CETIONS. � v z Re-roofs ra-s Applicant/Comractor ° Type of hoof HAZARDOUS MATERIALS DISCLOSURE Will the applicantor future building occupant store or handle hazardous material ed by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety ection 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes f7]No (- If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection. District? 1 ❑Yes No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building docs not currently have a tenant,that it is my responsibility w notify the occupant f the requiremen �t be met prior w issuance of a Certificate of Occu cr. • Signature:of Applicant Date v� All roof coverings to be Class"B' or better uauthorized agent D CITY OF CUPERTINO 4 ITEMS OF 11 PERMIT RECEIPT OPERATOR: amyw COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot: APN 36211061. 00 DATE ISSUED. . . . . . . : 02/27/2007 RECEIPT #. . . . . . . . . : BSC00000550 REFERENCE ID # . . . : 07C20142 SITE ADDRESS . . . . . : 11E4 BUBB RD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER WAESON ROGER E AND LILLIAN H ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4966 RECEIVED FROM . . . . : REC'EIPT INTERFACE CONTRACTOR . . . . . . . : MIYE FOX LIC # 25401 COMPANY . . . . . . . . . . : A S. A PLUMBING ADDRESS . . . . . . . . . . : 924 E FREMONT AVE CITY/STATE/ZIP . . . : SUr`NYVAL•E, CA 94087 TELEPHONE . . . . . . . . : (4(,8) 738-8878 FEE ID UNIT QUANTITY 1,MOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- BENERGY PERMIT FEE 1. 00 34 .86 0. 00 34 .86 0. 00 BPGAS OULETS 1. 00 5 .40 0. 00 5.40 0. 00 BSEISMICRE VALUATION 700. 00 0.50 0. 00 0 . 50 0. 00 PPERMITFEE FLAT RATE 1. 00 38.370. 00 38 .37 0. 00 ----------- ---------- ---------- ---------- TOTAL PERMIT 79 .13 0. 00 79 .13 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 350 .91 5287 --------------- TOTAL RECEIPT 350. 91 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING s CITY OF CUPERTINO -7 .: 0 0 26 ` .. CUP��pr o PERMIT APPLICATION FORM CPN# Date: r Q 1.- /n Building Address:, dress: _- Mailing Address (i different from building address): 6 ) cc O n is Name-- P one#;1 o� - 6 6 6 l.k ) , 5(a Co r to : '� Li et�se#: 3�1 Ctact: � � Phone: � ;'� " Cupertino Business icense#: Kc, [-C; Fax: :Z�'J A Building Permit Info: Bldg ❑ Elect ❑ 'lumb Mech ❑ Job Description: Residential 6�e2VAAc ) R 0 commercial ❑ Sq.Ft. Floor, a• i Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this box if the project is.a second-story addition: ❑ Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Dther Ap liances MECHANICAL BBOILER1 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 F oiler> 1.75M Btu MECHANICAL BCONSTAX -onstruction Tax BUILDING BCONSTAX In J/Off/Comm/Quasi BUILDING BCONSTAXBQ Ccn. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Flee 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Imergy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING I of 3 CITY OF CUPERTINO CITY of PERMIT APPL][CATION FORM CUPEkTINO Quantity Fee ID - ee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME Now Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME In3pection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE 1'.ld2 Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Ga:;Piping System Fee PLUMBING BPINTERCEP Incl 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 Lavin Sprinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Inst?tll/Alter 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 BRE A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY 1Zemodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Re]o Furnace> I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Reri Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER PoiN er Device/Apparatus ELECTRICAL BREMRECEPT Rc itl, Switch & Outlets ELECTRICAL BREMRELOCA I:elocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL '.of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rm3l Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Thoatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS V mtilation Systems MECHANICAL BSCBLVD 36 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 Tewporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC 13usiness License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE El,!c 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 Plannin LR Comme/Multi-Fam PLANNING PLLONGRNGR Plannin Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3