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08100142 CITY OF CUPERTINO BUTAIS DIVISION PE ;z VTRACT, R°I,NFORMA BUILDING ADDRESS: PERMIT NO. 21044 HAZELBROOK DR TL. Q0NSTRUQTI0U_PNTF OWNER'S NAME: PERMIT L%UEDAIE A 0. 0 CONTROL NO. 408) 318-1531 ARCHIfECTfENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 up0 LICENSED CONTRACTOR'S DECLARATION Job Description I hreby affirm Nal 1 am liecncd under provisions of Chapter 9(commcning p wit Secdon 70111))of Division 3 of the Business andProfessionCode,and my license is y 11 fora andeffm. D �7 RMODEL KITCHN, NON-STRUCTRL, 160SQ j Z License I Lk.g F Dam !/ Conmemr ARCHITECTS DEKILMFLATION I undusund my plans Nall h used as;public records s G In Licensed Professional i5 OWNER-BUILDER DECLARATION 1 hrohy oRrm t1m 1 am aeropt from tiro COnBLctor's License law for the Let O following reason.(Section 703 1.5,Business and Pmfzsiun Cade:Any city or county m which requires a permll to conwuct.stet,M(bu ,demolish.or repair any reroute _Z< Prier be its ouwam.also reuires to appliant for such permit to Elea signed summcnt Nath u Jimmied pursuant to the provision of the Cmtracmr's Liccme Law(Chapter 9 Sq.Ft.Floor Area Valuation Em4e (commencing wit Section 7000)Of ONision Sof the Bear.and profauon Cade)w W$ dont h u oaempl merafrwm and to basis for me alkfed evmpdan.Any violation of920000 Sccmm 70313 by any applicant fors permit ubjecs to spplkant he a tivil Penley of APN Number Occupancy am roam tan five hundred dellasi 01500). 32655034 . 01 Type ElI.uowna a[te pmpmy,ormy employees wit wags uuanxk cmmpewtion, will do the work and the strveum Is nos amended or offered for sale(Sec.7W 4.Business Nd Profession Code:The Contractor's Limme Law does an apply m an OWnr of Required Inspections property who buildswidprows Lemon.andwho doessuch work himeelfor Waugh his awn employee.provided than such imprommens art not immuded aroffued forsale If. ' howem,to building or improvwment is sold within an yen of completion.W awrcr- Wilder wit lave to burden of proving that h did nm Wild or imprme for puryo¢of - ule.) 0 1.u wrar M da property-am exchu vely contracting wit licensed contracsom an Wastrml W pmjee(Sec.7044,Business and Profession Code:)The Contractor's U. cane law does ma apply m an owns of property who Wilds or impdm temen,and, who contracts for such projects wit a chousctor(s)Reamed pursuant m me Contractor's License Law. 0 l am aempt under See ,B h PC for mu won Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby stand under penally of perjury ane of the foikwing declarations: I lure and will maintain•Cm4fiaeaf Comeatto self-inud forwoAms'scompen. Man..provided for by Section 3700 of the Labor Code.far ala pedorma a of use work for which Nie permh is Wood. 701 have and will murnam Worker'.Compensation Ins ..u required by Section 0 of to Labor Code,for tc pcdormanee of to wart for which tis permit is issued. My Worker's Com mad Wsurtnm anis and Policy number art: Carrier. Policy No.: I9J CEI[fIFlCATE OFXEMPTION FROM WORKERS' COMPENSATION INSURANCE !Otis xeim need sot W completed ifthe permit is format hundred donars(SI00) or W.) I certify mot in to perionco nm of to work for which tis permit is issued.1 shall not employ any person in any munnrse as m become subject m to Wofkesf Compormumn Laws Of California.Data APPlicard NOTICE TO APPLICANT.If.ahr making tis Certificate of Eremptiod,you should bama subject to to Worker's Cwnpemades pronisiom of d o Labor Code-you mesa .JO forthwith comply wit such provisions or tis permit Nall doomed!e doomrewkcd. E� CONSTRUCnONLENDINGAGENCY EI hemby anben that thre u a comtrucdnn lending agency for de pedormana of CL to work for which tW Permit is issued(See.3097,Civ.C.) OWi Q lender's Name z Lemer'a Add. U Q 1 certify that I haw read tie application and sue tun to aWn information u ut P contet l agora to comply wait all city and county ordinances and stale laws relating to 0U Wildingcrosuuction,aM hereby audtorim mpacsenudm of this city m enmrupon tie yshove-crommood Property for inspection puryues (we)agree to an,indemnify and keep hamdess to City of Cupertino against fry liabiliues.judgmens.cons andcaNnseswhich may leanyway accrmafalntsid City („),z in consequence of tc framing of tis pcmit. ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �2 t >•E� BOU§C'JItEGU TIONJ./, S, to/2��a� VT'EG L Re-roofs Sifnmurt of ApplinDaa HAZARDOUS US MATERIALS DISCLOSURE Type of Roof Will to a Cu a t or!Muni Wilding eampantumrc or Tanto Healthmuctaft.material H dcOmd by me Cuperdco Municipal Cade.Chapter 9.11,sW to Health and Safely Cada.Section 15531(.)+ All roofs shall be inspected prior to any roofing material being installed. ❑rte Will to applicant or fumy Wilding oecupam six equipment Of devices which If a roof is installed without first obtaining an inspection,I agree to remove Olt herardnus air cmu nimims as defined by the Bay Arca Air Quality Management all new materials for inspection. 5imictT �� Y. aw- I have read the mamrialshoWmemmu under Chapmr6.95oftm Califon, hisF aIth&SafeLy Code Seen=15505.35533+nd355}4.l undwswd tunJune building does no,curdntly hese a.4 that it 4 my rap rnibilky he edify to acc:upam of de dg�ztawhiahmwthe met Print toiuwnecofacad .m pkQB Signature of Applicant Date ''ay All roof coverings to be Class'W'or better Owner or authodsd agent Dow CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: pdtg COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . . 32655034. 01 DATE ISSUED. . . . . . . : 10/23/2008 RECEIPT # . . . . . . . . . : BS000006439 REFERENCE ID # . . . : 08100142 SITE ADDRESS . . . . . : 21044 HAZELBROOK DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . .. CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . .. REGNER CUNANAN ADDRESS . . . . . . . . . . : 21044 HAZELBROOK DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : REGNER ANDERSON CUN CONTRACTOR . . . . . . . : MOO POK LEE LIC # 27642 COMPANY . . . . . . . . . . : JL CONSTRUCTION ENTERPRISES ADDRESS . . . . . . . . . . : 1070 TERRA BELLA AVE CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94043 TELEPHONE . . . . . . . . : (408) 318-1531 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL -------- ------- --- ---- -------- 1BSEISMICR VALUATION 20, 000 . 00 2 . 00 0 . 00 2 . 00 0 . 00 1REMRESKIT SQ FEET 160 . 00 429 . 00 0 . 00 429 . 00 0 . 00 1STPLNCK HOURS, 1 . 00 122 . 00 0 . 00 122 . 00 0 . 00 - --- ----- ---------- TOTAL PERMIT 553 . 00 0 . 00 553 . 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER -------- ----------- CHECK 553 . 00 #123 --------------- TOTAL RECEIPT 553 . 00 • " r �\ 4 O � � � N sw © o 0o f } w = v Z _�_ DL o t]. o o, m o d Zm F 0 � � � 0 I1 � z z 7 - - N C, 0 0 0 0 0 � O z 73 � � o �Y c7Z 1 7Z rn O 0 0 0 0 0 06 C /75 7Q 76 76 7C$ _r Z y � ~ � zz c 7K5 w N N o N N N OO A rn h v ,o �O OO p 7 z . O � I o i I� 7K !f n O O I S N C1 Q Q 6 Q Q --tet 77Z � CCCRRR� � Z Q 7� C1 lZt CR D CR � � 7Z y z yy r 7cO� 7a z v Z N S � O , N 71 Cl =4 CITY OF CUPERTINO ADDITION/REMODEL CITY OF • CUPEkTINO PERMIT APPLICATION FORM APN #1'_� / V. / Date: /0 Z3 �DD Building Address: `� Mailing Address (if different from building address): Owner's Name: Phone# : G✓ yr LD ,y W Contract6i: Phone#: (�S OS -f68 _$w3 IA 12* Fax #: 5D lbg 21ri Contractor License#: fty Cupertino Business License#: Contact: Phone #: (4D s� nR.✓ //, Cu vta r�tv Fax #: Building Permit Info: Bldg. Elect. Plumb. [ Mech. [g-- Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? k��l cGca-✓� rew�oe�,�. ron �-Yr-�:�w-o-�, Remodel Includes Re-Roof: Yes ❑ No Eg If yes list number of squares Remodel Includes Structural: Yes ❑ No Do you have the pre-application planning approval? Yes ❑ No ❑ If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: _ Porch: Deck: Garage: Detached Attached Remodel: Kitchen /6v Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B 0 II/III/V-A ❑ II/III B, IV-HT, V-B ❑- - Valuatio 6) pv- Please check this box if the project is a G second-story addition ❑ Project Size: Ex ress [5-StzrIdard ❑ Large ❑ Ma-or ❑ Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, Green Building Points Achieved: include in plan set & the sheet index. ***For Office Use Only*** Over-the-Counter 0 Revised 10/01/08 CITY OF CUPERTINO D ADDITION/REMODEL arr o CUPEkTINO FEE SCHEDULE • Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft ADDITIONS 1R3SFDADD PLLONGRNGR Long Range PL Planning/Residential lR31NSP Dwellings Inspections B I R3PLNCK Dwellings plan check B IR3REPINSP Dwellings Repeat B Inspection 1R3REPPLNC Dwellings Repeat Plan B Check 1R3HINSP Dwellings Hillside B inspection 1R3HPLNCK Dwellings Hillside plan B check 1R3HREINSP Dwellings Hillside B Repeat Inspection • 1R3HREPLNC Dwellings Hillside B Repeat Plan Check 1R3ALTINSP Dwellings Alternate B Materials Inspection 1R3ALTPLNC Dwellings Alternate B Materials Plan Check 1PCESS Cesspool P 1PPRSEWG Ea. Private Sewage P Disposal System 1PRSEWER Sewers P 1BPSPRINK Lawn Sprinkler/Backflow P 1BPWSVCS Main Water Service P 1BSEISMICRE SeismicResidential B 1REROOFRES Residential Re-roof Each B 100 SF DECKS IR3SFDADD OR 1R3SFDREM • 1DECKWOOD Deck(Wood)-Each B (Each) 1DECKRAIL Deck Railing-Each B (Each)