07080182 77777777777777777.-
-7777
CITY OF CUPERTINONV
� TI(�N
l3UILD[NG DIVISION PERMIT
PERMIT NO.
BUILDIN ADDRESS:
y�5 FERNGROVE DR TBD - TO BE DETERMINED 07080182
PERMIT ISSUE DATE
OWNER'S NAME:
BOB & MARY KIRBY 08/20/2007
SANITARY NO. CONTROL NO.
JE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0
cd Z LICENSED CONTRACTOR'S DECLARATION Job Description
W p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U with Section 70(X))of Division 3 of the Business and Professions Code,and my license is INSTALL BACKFLOW VALVE AND TRANSFORMER HOOK AS
a a in full force and effect.
z License Class G-Z-77? Lic.a PART OF A LANDSCAPE PROJECT
p Date �"7�"�� Contractor
u ARCHITECTS DECLA TIO
a< 1 understand my plans shall be used as public records
�U
,a
U.ti Licensed Professional
o a OWNER-BUILDER DECLARATION
m� a the
1 hereby alTirm that 1 am exempt from the Contractors License Law for
:00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
m� which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement gq•Ft. Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $350
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of qpN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of (TO
not more than five hundred dollars(5500). 3 7 5 3 9 0 5
0 I,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 docs 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.IL
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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractees 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.
0 I 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:
LJ 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.
0 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's Compensation Insurance carrier and Policy number arc: �t
Cartier.
P�'+ol.��`�4.�. Policy Na.:-O clo s �7x '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis 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.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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z rr CONSTRUCTION LENDING AGENCY
[~t r--� I hereby affirm that there is a constroctinn lending agency for the performance of
(x r7 the work for which this permit is issued(Sec.3097,Civ.C.)
4r]QLender's Name
Lender's Address
U 0 1 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
rJ U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
2
►� APPLICAUNDE ANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
NT
SOUR EGUL O
o Re-roofs
S ignadircofApplicanUContractor Dam T of Roof
MATERIALS DISCLOSURE Type
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 Safely
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes L7No
Will a roof is installed without first obtaining an inspection,I agree to remove
ll 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 materials for inspection.
District?
0 Yes Nu
I 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
does no urrcntiy It a tenant,that it is my responsibility to notify the occupant of the
requi Ls whit u be mel prior ance of a Certificate of Occupancy. S ignatun;of Applicant Date
q NQ�w q-?�-0'7 All roof coverings to be Class"B"or better
Owner or authori-rcd agent Date
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Bl{: Lot:
APN . . . . . . . . : 37539055. 00
DATE ISSUED. . . . . . . : 08/20/2007
RECEIPT #. . . . . . . . . : BSDO0002430
REFERENCE ID # . . . : 07D80182
SITE ADDRESS . . . . . : 915) FERNGROVE DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : BOB & MARY KIRBY
ADDRESS . . . . . . . . . . : 913) FERNGROVE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : BRIAN BAIRD
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BSEISMICRE VALUATION 350 . 00 0. 50 0 . 00 0. 50 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
PPERMITFEE FLAT RATE 1. 00 38 .37 0 . 00 38 .37 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 184 .24 0.00 184 .24 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 184 .24 AMEX
---------------
TOTAL RECEIPT 184 .24
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
CITY OF CUPERTINO
CITY OF PERMIT APPLI[CATION FORM
cuPE�TINO
o7ogo/ga
PN# �7Jr ' .3 q 055 Date: W-2 6.-d'7
Building Address: Mailing Address (if different from building address):
F-e.^ f 0 '
Owner's Name: Phone#:
gab K.tlr-6
Contractor: License #:
5e-c t as I,+- �>. G-27 $71 SS
Contact: Phone: (pyo^ 916�4te>' Cupertino Business License#:
F2i(o- 134-L4 Fax: fo5z 01-033
Building Permit Info:
Bldg 0 Elect ®-' Plumb ❑ Mech ❑
Job Descripti,,o_n/ -},.�,.,,�5 Pp-� ��:--�-'A
Residential Lid' 1.c.,r..�S /V ommercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group: 0--3
� 350
Type of Construction: Please check this box if the project is a
El
second-story addition:
-o'Ject Size: Standard Large ElMajor El
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Bo:-ler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boil-,r> 500K to 1M 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 Co z. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax-Resi/Mobile BUILDING
BELEC 1000 El-c 600V <= 1000A ELECTRICAL
BELEC1001 E lec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA [nvestigation fee BUILDING
1 of 3
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
7UPEkTINO
Buildi.n De artment
JOB ADDRESS: PERMIT #
S 07018010-�2
OWNER'S NAME: 13,yb PHONE #
GENERAL CONTRACTOR: �,�,« FAX # --70t—o3 3 t'
I am not using any subcontractors:
S ggnature Date
Please check applicable subcontractors and com lete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
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