07050215 CITY OF CUPERTINO
BUILD1114G DIVISION PERMIT +�OI�T�iG�O�IN�URMArTT0�1:
BUILD NG DRESS:7 PERMIT NO.
�1� SHATTUCK DR TBD TD BE DETERMINED 07050215
OWNER'S NAME: PERMIT ISSUE DATE
MARK RUDEN 05/22/2007
)NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION Job Description
V F I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
ZU with Section 7000)of Division 3 of the Business and Professions Code,and my license is
SERVICE UPGRADE 200 AMP & ADD LIGHTING IN HALL &
'Q a in full force and effect.
j z License Class Lic.# LIVING ROOM.
F,W Date Contractor
ARCHITECTS DECLARATION
i a< I understand my plans shall be used as public records
)yU
'u.l- Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
C C O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
`e which requires a permit to construct,alter,improve,demolish,or repair any structure
u Z} 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 Sq.Ft.Floor Area $3500 Valuation
Y i-G (commencing with Section 7000)of Division 3 of Ote Business and Professions Code)or
y 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 ofNumber Occupancy Type
not more than five hundred dollars($500). 3 5614008:l7
❑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 9 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.).
as owner of the property,am exclusively contracting with licensed contractors to
ons.ruct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does no apply to an owner of property who builds or improves thereon.and.
who contracts Cor s h projects with a contractor(s)licensed pursuant to the Contractors
License law.
❑I am exempt r Sea B tit P C or tPis reason
Owner Date
KER'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 Workers 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 Insurance carrier and Policy number are:
Carrier. Policy No.:
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 a the workforF permit is issued,I shall not
employ any person in any man a Y ore ib iche t the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this c7r m emption,you should
become subject to the Workers Compensation ps visions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z t-" CONSTRUCTION LENDING AGENCY
(~i 1A I 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.)
aQ Lender's Name
r7 z Lender's Address
U 0 I certify that 1 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
Vbuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmen costs and expenses which may in anyway accrue against said City
U Z in consequence or c of this permit.
�. APPLICANT U S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU ON .
Re-roofs '
Signature of Appli6AVConLriRor Date Type of Roof
HAZARDOUS 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 ;hall be inspected prior to any roofing material being installed.
❑Yes `o
If a roof i:;installed without first obtaining an inspection,I agree to remove
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 all new materials for inspection.
District?
C]YesIo
I have read hva us materials requirements under Chapter 6.95 of the Califor-
nia Health&Safe cu 25505.25533 and 75534.1 understand at if the building
does not current) ave a an that it is my responsibility to notify th ant of the
requirements wit must t riortoissuance ofaCertificate Signature of Applicant Date
All roof coverings to be Class"B" or better
Owner or authorize agent a
CITY OF CUPERTINO
5 ITEMS OF 5 PERMI" RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Bll:: Lot:
APN . . . . . . . . : 35614008 . 00
DATE ISSUED. . . . . . . : 05,'22/2007
RECEIPT #. . . . . . . . . : BS000001417
REFERENCE ID # . . . : 07050215
SITE ADDRESS . . . . . : 21927 SHATTUCK DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : MARK RUDEN
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4761
RECEIVED FROM . . . . : MARK RUDEN
CONTRACTOR . . . . . . . : TBI) - TO BE DETERMINED LIC # 00096
COMPANY TBI) - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY INOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----------- ---------- ---------- ----------
BELEC200 METERS 1. 00 29.43 0 .00 29.43 0 . 00
BENERGY PERMIT FEE 1. 00 34 . 86 0 .00 34 .86 0 . 00
BREMRECEPT NO. OUTLETS 1. 00 1.20 0 .00 1 .20 0 . 00
BSEISMICRE VALUATION 3, 500 . 00 0.50 0. 00 0 .50 0. 00
EPERMITFEE FLAT RATE 1.00 38 .37 0 . 00 38 .37 0. 00
----------- ---------- ---------- ----------
TOTAL PERMIT 104 .36 0 .00 104 .36 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 104 .36 5898
---------------
TOTAL RECEIPT 104 .36
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CITY OF C'UPERTINO - � �/S
OF PERMIT APPL]_CATION FORM 7
CUPEkTINO
�.C� iJ i aft �' ' c5� T a Ib�
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LPN# L)�✓r Date: 'r 1. �
Building Address: �. Wailing Address (if different from building address):
�l. Jc
Own10'r-kc-
Contr Phone#:
�or:c ^ � x , � License #: 4 � 7�
Contact: Phone:( .5 $-- Cupertino Business License#:
4��JS Fax:
Building Permit Info: �/� r ,i „
Se<v
Bldg ❑ Elect Plumb ❑ Mech ❑ n '�
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group:
—t ?, Q-—r-�
Type of Construction: u Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Large ❑ Maj)r ❑
Quantity Fee ID lee 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 Boilei > 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Cor.. Tax for BQ Zone BUILDING
BCONSTAXH hotel and Motel BUILDING
BCONSTAXR Con stax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 El�c 600V> 1000A ELECTRICAL
BELEC200 Elee Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD E-iergy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF C UPERTINO
OW OF PERMIT APPLI=CATION FORM
CUPEkTINO
Quantity Fee ID lee Description Fee Group
BMISCELL 1V=iscellaneous Fee BUILDING
BMITIGATC Com;n. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP N,-.w Comm Plumb PLUMBING
BOVERTIME In,pection Overtime BUILDING
BPBACKFLOW Atriospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK flan Check Fee BUILDING
BPLANCKADD Plaii Check Add Multi BUILDING
BPLANCKREP Plar. Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Law:i Sprinkler/Backflo PLUMBING
BPSTORM S1 orm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT AI. of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit > 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Romodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> I OK btu MECHANICAL
BREMHEAT H tater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC T✓Iisc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pol-.-/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rcpt , Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 c f 3
av
CITY OF C+UPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rindl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Veit Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
_ BSEISMICOM Se smic 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 Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
MPERMITFEE Meeh Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
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