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07060228 CITE'OF CUPERTINO BUILDINGflIV1SiON PERMIT 6WT �-T � ��I�N' BUILDING ADDRESS: PERMIT NO. 10691 JOHNSON AVE K DESIGNHRS 07060228 PERMIT ISSUE DATE OWNER'S NAME: PICKERING, DON & LINDA 2440 GOLD RIVER RD 06/26/2007 SANITARY NO. CONTROL NO. ONE: (510) 786-0455 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH i o p LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing tZ withScction7000)afDivision3ofdtcBusincssandProfcssio Cod-,-and INSTALL NIKE FOR LIKE WINDOWS (2) IN LIVING ROOM. t U y in full force and effect. / V b j v�z License Class Lic.S F o Date 7 O^U Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records )yU U.F Licensed Professional y OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the in O following reason.(Section 7031.5,Business and Professions Code:Any city or county �i which requires a permit to construct.alter,improve,demolish,or repair any structure r prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation z that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 St�.Ft.Floor Area (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $3450 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($500). 37531051 .q ❑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 forsale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of Q 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.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractors 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 Contractors License Law. ❑I am exempt under Sec B&P C for this reason OwnerDate 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 Workers 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 Workers Compens n Insurance carrier and Policy number are: „-� -/ Carrier;)//*/� �u^'�( Policy No.: �d CERTIFICATE OF EXEMPTION FROM WO COMPENSATION INSURANCE (This section need not be completed if the permit is forone hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,I 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 O forthwith comply with such provisions or this permit shall be deemed revoked. Z” CONSTRUCTION LENDING AGENCY (~—n►�+ 1 hereby affirm that there is a construction lending agency for the performance of _ (Y. the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name Z Lenders Address V 0 I certify that I have read this application and state that the above information is i correct.1 agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes. L1+ (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. ►- APP U Date ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: LAttONS. Z77 Re-roofs Sign—at ureo pplican UContra or Date Type Of HAZARDOUSRoof MATERIALS DISCLOSURE 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 st all be inspected prior to any roofing material being installed. ❑Yes 1° Will the applicant or future building occupant use equipment or devices which If a roof is nstalled 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? E]yes Nu I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia HcaWiA Safety Code Sections 25505,25533 and 25534.1 understand that if the building doc cu nil ve aunt that it is my responsibility to notify the occupant of the ich mus met prior to issuance of a Certificate Occupancy. Signature of Applicant Date ZG All roof coverings to be Class"B"or better wncr or authorixcd agent Date CITY OF C'JPERTINO 4 ITEMS OF 4 PERMIT ZECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37531051.00 DATE ISSUED. . . . . . . : 06/260/2007 RECEIPT # . . . . . . . . . BS000001794 REFERENCE ID # . . . : 07060228 SITE ADDRESS 10691 JOHNSON AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA OWNER PICKERING, DON & LINDA ADDRESS 10691 JOHNSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : KDESIGNERS CONTRACTOR LARRY JUDSON LIC # 23172 COMPANY K DESIGNERS ADDRESS 2440 GOLD RIVER RD CITY/STATE/ZIP . . . : GOLE RIVER, CA 95670 TELEPHONE (510) 786-0455 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- --- ------- ---------- BENERGY PERMIT FEE 104 .76 50 .28 0 .00 50 .28 0 . 00 BPERMFEE VALUATION 3,450 . 00 104 .76 0 . 00 104 . 76 0. 00 BPLANCHK PERMIT FEE 104 .76 139 . 80 0 . 00 139 . 80 0 . 00 BSEISMICRE VALUATION 3,450 . 00 0 .50 0 .00 0 . 50 0. 00 --- ------- ---------- ---------- ---------- TOTAL PERMIT 295 . 34 0 .00 295 .34 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------------------ CHECK 295 .34 3910274 --------------- TOTAL RECEIPT 295 .34 CITY OF CUPERTINO alPERMIT APPLII-ATION FORM CUPERTINO 0 ;7 � � APN# Date: , ,3 ) ,-5 3/ 0-5--/ q Building Address: 1� 1V[ailing Address (if different from building address): - /�(OiVSO^� �� ner's Name: Phone #' Contrac or. License ` tact: Phone: Cc '/3os Cupertino Business License#: gop/Z L �- Fax: ��3/ �� - Gci,-s G` J / �. r v; Building Permit Info: _,mss,4 L� /� ^ /-C j Bldg Elect ❑ Plumb ElMech El Job escription: Residential ❑ Commercial El Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: 9 (X� T olf,Const�ction: J Please check this box if the project is a Z .7`/J. �,iC GtJ `moi cXal-u second-storyaddition: El Project Size: Standard .❑ Large ❑ Major ❑ Quanti Fee ID I'ee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boi er<= 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 Bailer> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Inc/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH =3otel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 El ec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA [nvestigation fee BUILDING I of 3 aCITY OF CUPERTINO IWOF PERMIT APPLI(:ATION FORM CUPERTINO Fee ID Fee Description Fee Group Quanti BMISCELL Mi:cellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME Neve 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 Bld Permit Fees BUILDING BPFIXTURE ?b1g 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 Rei a Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawr. S rinkler/Backflo PLUMBING BPSTORM Sorm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT All of Drain &Vent PLUMBING BPWATER Instal I/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Mein Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C IJnits<= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY R,-model Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relc)cation of Furnace MECHANICAL BREMFURNOV Relc Furnace> l OK btu MECHANICAL BREMHEAT H eater Installation MECHANICAL BREMINHOOD In.;tallation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Po.e/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc ], Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY OF CIUPERTINO 11 aCOF PERMIT APPLICATION FORM CUPEkTINO Quanti Fee ID F,:e Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remo 3el Signs,Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ven tilation Systems MECHANICAL BSCBLVD Sc b Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Sr ecial Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM emUorary Bldg Permit BUILDING BTEMPSVCS 'Temp Dist Svcs ELECTRICAL BUSLIC B.isiness License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec: Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mec h Permit Issuance MECHANICAL PPERMITFEE Pluntbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Plannin J"R Comme/Multi-Fam PLANNING PLLONGRNGR Planning 1,ong Range Residential PLANNING 3 of 3