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07030027CITY OF CUPEK1INv $UILDINCrDIVISION PERMIT _--- PERMIT NO. ADDRESS: 503 STEVENS CREEK BLVD #215 PALISADE BUILDERS INC 07030027 PERMIT ISSUE DATE OWNER'S NAME: CUPERTINO HOUSING PARTNERS ME: ARCHrrECT/ENGINEER: i p O LICENSED CONTRACTOR'S DECLARATION tit I hereby affirm that I am licensed under provisions of Chapter 9 (commencing Z W with Section 70()U) of Division 3 of the Business and Professions , and my license is t y in full force and effect. CQ7 !`i/ a(O : n ? License Class Llc• N Conuac F- W !)are ARCHITECTS DECLARATION ,,-J I understand my plans shall be used as public records JyU c u. Licensed fessional a a OWNER -BUILDER DECLARATION j< 1 hereby a1T,- that 1 am exempt from the Contractor's License Law for the p o following reason. (Section 7031.5, Business and Professions Cafe: Any city or county < which requires a permit to construct, alter, improve, demolish, or repair any structure u �+ prior to its issuance, also requires the applicant for such permit to file a signed statement ? < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 4 t= (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 not more than five hundred dollars ($500). ❑ 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 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. ❑ [ am exempt under Sea 4.&; P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of tha fo0owing-declarations; : _ 909 ALM. % STREET SANITARY NO (650)47)-4700 BLDG Job Description WATER DkMAGE REPAIR IN BEDROOM #2 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. 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 Compensation lmmnce carrier and Poliny�nOher O• Q f J Carrier: s-rik y4 cy g polity Nc CCJJ Ll CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (this 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, 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 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address 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 building construction. and hereby authorize rcpresentativcs of this city to enter upon the ahovc -mentioned property for inspecuon purposes. (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 in consequence of the granting of this permit. AP ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SO REGULATIONS. 3 v o7 SigJd1hL.CtHrtino plicant/C for Date AZARDOUS MATERIALS DISCLOSURE appliant or future building occupant store or handle hazardous material as Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? �-tU-/ ❑ Yes ll 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 District? ❑ Yes G01 -- I 01 -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 not currently have a tenant, that it is my responsibility to notify the occupant of the rcuuirBtttents which must be met prior to issuance of a Ccrtificaje of Occupancy. Date 3q. Ft. Floor Area 31649051. Number Issued b: Re -roofs Type of'Zoof $3500 Required Inspections CONTROL NO. BUILDING PERMIT INFO ELECT PLUMB vatuatlon uccupancy All roof! shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signatur-. of Applicant All roof coverings to be Class "B" or better Date CITY OF CUPERTINO 2 ITEMS OF 4 PERMIT RECEIPT OPERATOR: kiersaw COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 31E49051.00 DATE ISSUED.......: 03/06/2007 RECEIPT #......... BSC'00000616 REFERENCE ID # 07030027 SITE ADDRESS .....: 19503 STEVENS CREEK BLVD #215 SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER ............: CU:?ERTINO HOUSING PARTNERS ADDRESS CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM R=IPT INTERFACE CONTRACTOR J DOUGLAS ROSS LIC # 25638 COMPANY PALISADE BUILDERS INC ADDRESS . 909 ALMA STREET CITY/STATE/ZIP PALO ALTO, CA 94301 TELEPHONE (650)470-4700 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT- - THIS -REC- -- W-BAL BPERMFEE VALUATION 3,500.00 104.76 0.00 104.76 0.0 BSEISMICRE VALUATION 3,500.00 0.50 0.00 0.50 - ------------------------------ ------- - TOTAL PERMIT : 105.26 0.00 105.26 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER CHECK 221.32 32004 --------------- TOTAL RECEIPT 221.32 1 CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM C/)- �WJOOa //7 _ iPN#— Date: 3 1-5-10 7/ Building Address: Mailing Address (if different from building address): 19 S v '> SiN S C Z-euc 2 s - Owner's Name: Phone #: %A o o �>I a1(r Pa (mo c; r s Boiler <= 100,000 Btu Contractor: License #: F-SLAiLOLA-�, Yj MECHANICAL Contact: Phone: 6So - 7 Cupertino Business License#: :I:gAn6s KAL-1" ► NZ.C: Fax: o173-18zt 25 6,3 u Building Permit Info: I ' `aP C, ,r Bldg Elect ❑ Plumb ❑ Mech ❑ Job escription: Residential D4 Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Construction Tax BUILDING Cost of Project: Occupancy Group: BUILDING BCONSTAXBQ Type of Construction: Please check this box if the project is a \jJ A C n \JA AAA LC: 1 N' second -story addition on: ❑ BUILDING BCONSTAXR project Size: Standard ❑ Large ❑ major ❑ BUILDING Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI 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 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ ("on. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 El ec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 - CITY OF CUPERTINO a PLICATION FORM CITY OF PERMIT AP CUPEkINO Fee Group Fee ID Ff a Description BUILDING Quantity Miscellaneous Fee BMISCELL BUILDING BMITIGATC Comrr. . Housing Mit. Fee ELECTRICAL BNUCOMME Ne -,j Comm Electric MECHANICAL BNUCOMMM New Comm Mechanical PLUMBING BN[7COMMP New Comm Plumb BUILDING BOVERTIME Ins �eetion Overtime pLUMBING BPBACKFLOW Atrr ospheric Vacuum PLUMBING BPCESSPOOL Cesspool BUILDING BPERMFEE B Id Permit Fees pL,UMBING BPFIXTURE Pblg Fixture PLUMBING BP GAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor BUILDING BPLANCHK flan Check Fee BUILDING BPLANCKADD Plai Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee PLUMBING BPREPIPE R 'Dipe Of Fixtures PLUMBING BPSEWAGE Sewa a Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn SprinklerBackflo PLUMBING BPSTORM .,torm/Rain Water PLUMBING BPTRAP Kitchen Trap pl,ViBING BPVENT p1t of Drain & Vent PLUMBING Inst all/Alter Water Pipe -- BPWATER PLUMBING BpWHEATER Nater Heater/Vent PLUMBING BPWSVCS I/lain Water Service BUILDING BREINSPECT Reinspection Fee MECHANICAL BREMACOVER A C Unit > 1000 cfm MECHANICAL A/C Units <= 10,000 cfni BREMAIRHAN MECHANICAL BREMAPPLI Appliance Install ELECTRICAL BREMBUSWAY Remodel Busways. ELECTRICAL BREMFT Lighting Fixtures MECHANICAL BREMFURN F:elocation of Furnace MECHANICAL BREMFURNOV R. -lo Furnace > IOK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD [nstallation of Hood ELECTRICAL Misc Apparatus BREMMISC Appliance ELECTRICAL BRENINRAPP R�m Non -Res App ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT R c tl, Switch & Outlets MECHANICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating ELECTRICAL BREMRESApP Remodel Res Appliance 2of3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEI,TINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS R, -model Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN `Dent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb 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 Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE :�;.'lec 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 Planning LR Comme/ Multi -Faro PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3 s :.xRESIDENTI��L PROJECT COYER.SKEET C17Y'OF CUPEkTINO Assessor's Parcel Number: Name of owner. CaPC IA) iaC I Project address. IGl �O 3 Contact person. �TA.MtS W`''IC-I i y a E - Phone. ) %;_0 L/ L/ L/ - c� Fax. i/u8 8 73 -��— Net square footage of lot. Existing Square footage: First floor: Second floor: Garage: TOTAL: i�) `v' 7 Sl? Iff Proposed Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N Is privacy protection planting required for the project? Y N On what floor(s) is work being done? Brief de sc ption of work. 1 j,4 S 7A i w c-" 5 r4 eL 7 ill, t Q, L u u i ASL j t�-Y7L) Code editions: 2001 CBC (Y - N)2001 CFC (Y - N)2001 CMC (Y- N) 2001 CPC (Y - N)2001 NEC (Y - N) Effective ll/l/02 Plan Review Process Work Book Page-8-F.evised 4/28/04