08110022 CITY OF CUPERTINO kgn7
7
BUILDING DIVISION PGU1T�T igyQR; QyYyA
l
BUILDING ADDRESS: PERMIT NO.
23667• BLACK OAK WAY STERLING GENERAL
OWNER'S NAME: CONSTRUCTION PERMIT ISSUE DATE
*T Dna T-nVT
vNE: s4'v A CONTROL NO.
(408) 871-1372
ARCHDEC(ENGINEER: BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
X00 LICENSED CONTRACTOR'S DECLARATION .
V I bemby affirm tat 1 Am licensed under Provi.4ona of Chapter 9(commencing Job Description
wit Section 7(X10)ofDivisian 3 of to Business and Pmicasians Code,and my license is
� N infll(MonandAffect �, � DRYWLL 3000SQ, FIX SHWR(NEWHOTMOP&TILE) , FIX ANY
j
Lt.naPiTa,+ Lic g
h,qqq Date fVAV a(.' Conlrutr n. DMGD PLMBNG& GREENBOARD, PAPR, LATH FOR SHOWER
'-�g ARCHTfEurS DECLA ATION ,
-'a I understood my plans Nall he used As Public recorN
JA.
gG Licensed Pmf.mianal
OWNER-BUILDER DECLARATION
I hereby Affirm tat I am exempt from the Cone.s License Law for to
OO following mason.(Sab7(91.5.Business and Professions Code:Any city or county
$� which.,.i.A permitan m ennvmeL Auer.improve.dem lash.or repair any structure
prior ut its issuance.also Acquires tW applicant for such permit to file a signed statement
Es G that heis licensed puraanttatcprovisions ofthe Con=oriU==Law(chapter 9 Sq.Ft.Floor Area Valuation
YF (commencing wit Section 7000)of Division 3ofteBusiness and Put
fessionsCade)ur 41000
y $ tat he u exempt Oemfrom and to basis for to Alleged exempdoo.Any violation of
Section 7031.5 by any applicant for A permit subjects to aPPlkmL to a civil Penalty of APN Number Occupancy Type
nut mom tan Ove hundred dollars(SStlO). 34256021 . 00
I,v owner of time Property,ar mY emPloym wit wages u dteir sek compensation,
will do Oe work,and tbe snerum is not intended or offered for aide(Set.70N.Business
and Porosities Cade:The Con=Wes License Law does WE apply t an Owner of Required Inspections
property who builds or im proves th.mn,and who does such work himself or Omagh his
awn employees,provided tat such improvements are not inumded.offered for vie If.
however.to Wilding.improvement usold within one yew of completion.to owner.
builder will have th burden of proving that he did WE Wild or improve for Dur,.of
uLe.).
1.As owner of to Property,am exclusively contracting wit licensed rontranors As
construct to project(Sec.7016,Business and Profmiamn,Code:)The Contracizes Li.
cense law does not apply tan own.of propene who Wild..,improver terean.and
who contracts for such pmjecu with a conuxtor(s)Hemand pursuant O die Contractures
Lk'.Law.
❑1 om exempt send.Sec .B BE P C for this reason
Owns, Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of to following dcclaotions: -
hamand"I maintain a CeNOote ofCWAmt t self-insure far W.keesComPen-
on,v provided f.by Section 3700 of die labor Cade,for the performance of Me
work for which tis permit is issued.
❑1 have and will maintain Wormes Compensation Insurance,an mequimd by Section
3700 of to LaWACade,for to perfomsvce of to wort for which this permit is Issued. '
My Workees Compematlan W.m carrier and Poliry Writerare: -
Camer Fro(. Policy No.:AIA ILL 02q 1
CERTIFICATE OF EXEwnON FROM WORKERS'
COMPENSATION INSURANCE
(ITU Auction need not be completed if the Permit is for one hundred dollars($10a)
.Less)
I Emory tat in the performance of the work for which tin permit is issued,1 Nail not
employ any person in any manner so as in become subject to Ore Workers'Comperoation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,ager making this Certificate of Exemption,you should
become subject m to W.tees ComP.uadon provisions of the Lab.Cede,you mut
OfoMwit comply wit such pro,ism.or tis permit Nall be deemed revoked.
,zy 0 CONSTRUCTION LENDING AGENCY
1 bereby.M.than fere lsacmoa OW Imilingagee,for to perfarmance of
to work for which this permit is issued(S..3097,Civ.C.)
Iat Q landees Nauru
z Lettuce:Add.
C)Q 1 certify that 1 hate lead dos application and stat OW dte shove information u
conect.I agree in comply with all city and county ordinances and auto laws relating in
.QU Wilding construction,and hereby autoriae representatives of this city in enter upon to
W ahove-mentioned property for impaction purposes
6. (We)agt.t were,indemnify and k.P harmless site City of Cupenin0 against
rA Iimilities,judgmeno,eoso and expernsses which may in any way accrue Mainstvid City
(,)z^ Ior Elie swung of tis Permit.APPLICANT UN STANDS I
AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREG ONS.
Re-roofs l%
Signarum ofA IicaHAZARDOUS
Dan,
HAZARDOUDOU S MATERIALS DISCLOSURE Type of Roof
Will sire applicant.forum building Code.Chapter
orand O hevNom material
az deBncd by the Cupertino Municipal Codc.Chapser 9.13,and to Health arW Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes ff..
Will to applicant or fumm Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It bacmdous air contaminants as deOncd by the Bay Area Air Quality Management all new materials for inspection.
a ell
❑ens .0-N.
1 have read the Imandons materials requireme as under Chapter 6.95 ofte Calif.-
meHcultJ,SAf lYCede,Sections 25505.25533 Aid 25534.1 understand WE ifte Wilding
drca not c tly have 'tenant Out it IS my maponsiMlity to notify Elbe occupant Of to
require c which m t be=Loor b issuamm o(a Ccmfrcate of Occupvry.
�._ /I�D✓6 Signature of Applicant Date
oWn�tbomed agent Dam'
All roof coverings to be Class'W'or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34256021 . 00
DATE ISSUED. . . . . . . : 11/06/2008
RECEIPT # . . . . . . . . . : BS000006558
REFERENCE ID # . . . : 08110022
SITE ADDRESS . . . . . : 23667 BLACK OAK WAY
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : AL POWELL
ADDRESS . . . . . . . . . . : 23667 BLACK OAK WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SHAWN MOSSING
CONTRACTOR . . . . . . . : PATRICK WEHNER LIC # 22979
COMPANY . . . . . . . . . . : STERLING GENERAL CONSTRUCTION
ADDRESS . . . . . . . . . . : 1727 DELL AVE
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 871-1372
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ------- ------
1BPFIXTURE NO OF FIXTURE 1 . 00 8 . 16 0 . 00 8 . 16 0 . 00
1BSEISMICR VALUATION 41, 000 . 00 4 .10 0 . 00 4 . 10 0 . 00
IPPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
---- -------- -----
TOTAL PERMIT 93 . 84 0 . 00 93 . 84 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------------
CREDIT CARD 93 . 84 VISA
---------------
TOTAL RECEIPT 93 . 84
a
RESIDENTIAL PROJECT COVER SHEET
Assessor's Parcel Number:
Name of owner. Q �
Project address. 2366:�- C c,(< (�(ak l �J( �a. y / 1Mo CA �SU( q
Contactperson. if 6nf Phone. /QS-C{83-2C(E(S
Fax. /C9 S- Ks7/ - 8t(ZO
Net square footage of lot. Z
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the gar, e? Y/�-N,
privacy protection planting required for the project? Y NAppROVEO
IN ACCORDANCE
WITH THEClTy
On what floor(s) is work be' done? 7, 2 �UPERTINO CODES AND ORD NARCM
Brief description of work. �urvt1�,
i i
be kept u r, ' o c.4ca„��
Code editions: 2008 CBC 2008 CFC Pon 6 � i_'m s
-1� �-N)2008 ®l�I�to rr,(Y-N) nd'd is on
2008 CPC N)2008 NEC (Y -N) `m Same waoor alteradon,
'he building Liep„ ° mission fron
rho Stamping of.h. , C':Pertino. ��
'HALL NOT ba hard t. nd'Pepficadons
Effective 1/1/08 ,awl of tha vio� Pr.mit or to.be ar
Inv (:'. , radon of any P►WOS�r,
'�l T'L�:7R?nip Rf VW taw
v U
BMP SHEET
v C/
JUL 1,12DB9
a �
j
Plan Review Process Work Book Page-8-Revised 1/1/08 $.
Community Development
�p 10300 Torre Avenue
Cupertino CA 95014
y Telephone(408)777-3228
CITY OF Fax(408)777-3333
46UPEkTINO
Building De artment
2 B ADDRESS: PERMIT #
OWNER'S NAME:NAME: AI oWe-(1 PHONE #Llog-�f71-Ij7Z
GENERAL CONTRACTOR:-9er11 FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
ileOwner/Contractor Signature Date
00,2,�
I...— CITY OF CUPERTINO
4 CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # �_3 qa 5 �/ Date: ,/o✓ 2Q6�
Building Address:
Mailing Address (if different from building address):
Owner's Name: Phone #: z�
Dawe l '-�bFS-30-92
Contractor: Phone: [/off 6�1-/37Z
-"er�'in (�,enerc, CCASiru6�W, Fax: yGS- �7/-6LPZ0
Contractor icense#: 781-Z£SI
Cupertino Business License#:
Contact: Phone: ((Cy- &3 2gg5
P't cick Ae/-
• Residential Commercial Fax:
Job Description: (uwi�
FiK CAI
_a�wc& 3,T4, 4,x -1 He shower (r ewhoF,�cyan� f l� J
(green 190J/ P(Lel (' SGtowrr
Building Permit Info:
Bldg l / Elect ❑ Plumb 0—_ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/IIIN-A ❑ I1/III B, IV-HT, V-B
Valuation:Cf if vo 0 Square Footage:
Project Size: Ex ress Standard ❑ Lar e ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
• For help, contact Build it Green at www.builditgreen.org
Revised 10/20/08
F CITY OF CUPERTINO
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h 29.3kw
1 BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
IBBOILER3 Installation/relocation ofea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1BBOILER4 Installation/relocation of ea M •
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1 BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1 ELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
IPLMBINSP Other Plumbing & Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B e