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09010095 CITY OF CUPERTINO BUILDING DIVISION PERMIT � `.. � ' :.. ..:: PERMIT NO. BUILDING ADDRESS: 2 RT PERMIT ISSUE DATE OWNER'S NAME: A CONTROL NO. 'y0 408) 449-3344 BUILDING PERMIT INFO ARCHITECf/ENGiNEER: BLDG ELECT PLUMB MECH u p p LICENSED CONTRACTOR'S DECLARATION Job Description U I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. KTCHEN RMDL - 2 2 8 SQ 1 NO, STRUCTRUL&NO RE-:ROOF irn a Date Z License Class Contractor [— ARCHITECTS DECLARATION 1 understand my plans shall be used as public retards �,U Oy Licensed Professional 3 OWNER-BUILDER DECLARATION H 1 hereby affirm that 1 am exempt from the Contractor's License Law for the a O following reason.(Section 7031.5,Business and Professions Code:Any city or county K which requires a permit to convect.alter,improve,demolish,or repair any structure y'ti prior to its issuance.also requires the applicant for such permit to file a signed statement $q.Ft.Floor Area Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Y t-- (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or $25000 i 9 that he is exempt themfrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars IS500)• 35704032 . 00 0 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 for sale(Sec.7044,Business Required Inspections and Professions Code:The Conuactoes 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). W,ss 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 contractors)licensed pursuant to the Contractors License Law. ❑I am exempt under fEc r B&_P C f this rean Owner Date ER'S COM ENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 1 have and will maintain a certificate of Consent to self-insure forWorker's Compen- Ion,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 Workees Compensation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foroac 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 sp to me>1rbleC4la the Workers'Compensation Laws of California D��7 L Applicant NOTICE TO APPLICA :If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J z forthwith comply with such provisions or this permit shall be deemed revoked. Z Q CONSTRUCTION LENDING AGENCY (~r.C4.. 1 hereby affirm that there is a construction lending agency for the performance of Q!> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lendces Name az Lender's Address 1 certify that I have read this application and state that the above information is corer.l agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hemby authorim representatives of this city to enter upon the above-mentioned property for inspection purposes a (We)agree to save,indemnify and keep harmless the City of Cupertino against to liabilities,judgments,costs and expenses which may in any way accrue against said City J V Z in consequence of the granting of this it. Date / ��—CXs r'" APPLICANT U ERS NDS AN WILL COMPLY WITH ALL NON-POINT Issued by: — SOURCERE ( Zl Re-roofs �y Signature of App cant/Contrsc r D81C T of Roof HAZARD 5 MATERIALS DISCLOSURE Type 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 shall be inspected prior to any roofing material being installed. 0 Yes o If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which all new materials for inspect-ion. tit hazardous air contaminants as defined by the Bay Area Air QualityManagement strict? 0Yes �Nu 1 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 docs not currently ha a tett t drat it' my responsibility to notify the occupant of due Date requircritc w' ust be et prior issuance of a Ceniticate of Occu Signature of Applicant 1 All roof coverings to be Class" "or better Owner or authorize agent Date CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 35704032 . 00 DATE ISSUED. . . . . . . : 01/21/2009 RECEIPT #. . . . . . . . . BS000007014 REFERENCE ID # 09010095 SITE ADDRESS 22284 PALM AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER RYOJI WATANABE ADDRESS 22284 PALM AVE CITY/STATE/ZIP CUPERTINO CA, 95014-2709 RECEIVED FROM LILY C LI CONTRACTOR DON MCDONALD LIC # 30634 COMPANY LIBERTY CONSTRUCTION ADDRESS 1009 S 3RD ST CITY/STATE/ZIP SAN JOSE, CA 95112 TELEPHONE (408) 449-3344 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---- 1BCBSC VALUATION 10, 000 . 00 1 . 00 0 . 00 1 . 00 0 .00 1BSEISMICR VALUATION 10, 000 .00 1 . 00 0 . 00 1 . 00 0 . 00 1REMRESKIT SQ FEET 228 . 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 #151 --------------- TOTAL RECEIPT 553 . 00 0 C CITY OF CUPERTINO �m ADDITION/REMODEL .CUPEt�TINO PERMIT APPLICATION FORM APN # 3:5Date: Building Address: , = ��' `GIr►� Mailing Address (if different from building address): Owner's Name: Phone# : t. �, > ZS` , p 677J Contractor: Phone#: (-C-Q�l `� Y j q Fax#: Contractor License#: (S C 7 J Cupertino Business License#: Contact: 11 Phone#: Fax#: 7 Building Permit Info: Bldg. ER-- Elect. [ Plumb. ��- Mech. ❑--- Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? Remodel Includes Re-Roof. Yes ❑ No [ If yes list number of squares Remodel Includes Structural: Yes ❑ No [v� Do you have the pre-application planning approval? Yes ❑ No Ej� If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Valuation: Please check this box if the project is a t15i 0 0 0 second-story addition ❑ Project Size: Express ML&wdard ❑ Large ❑ Major❑ 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. J_�_. ***For Office Use Only*** ElRevised 01/07/09 Over-the-Counter CITY OF CUPERTINO ADDITION/REMODEL CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft ADDITIONS 1R3SFDADD PLLONGRNGR Long Range PL Planning/Residential 1R3INSP Dwellings Inspections B 1 R3PLNCK Dwellings plan check B 1 R3REPINSP Dwellings Repeat B Inspection 1 R3REPPLNC Dwellings Repeat Plan B Check 1R3HINSP Dwellings Hillside B inspection 1R3HPLNCK Dwellings Hillside plan B check 1 R3HREINSP Dwellings Hillside B Repeat Inspection 1 R3HREPLNC Dwellings Hillside B Repeat Plan Check 1R3ALTINSP Dwellings Alternate B Materials Inspection I R3ALTPLNC Dwellings Alternate B Materials Plan Check 1 PCESS Cesspool P 1PPRSEWG Ea. Private Sewage P Disposal System 1 PRSEWER Sewers P 1BPSPRINK Lawn Sprinkler/Backflow P 1BPWSVCS Main Water Service P 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES / Commission Fee 1 BSEISMICRE SeismicResidential B 1RER00FRES Residential Re-roof Each B 100 SF CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft DECKS 1R3SFDADD OR 1R3SFDREM 1DECKWOOD Deck (Wood)-Each B (Each) 1 DECKRAIL Deck Railing-Each B (Each) 1R3SFDADD OR GARAGES DETACHED 1R3SFDREM 1GARDTW<=1K Wood Frame up to B 1,000 SF (each) 1GARDTM<=1K Masonry up to 1,000 SF B (each) BCONSTAXR Construction Tax Res (new detached garage) PATIO'S OPEN 1R3SFDADD OR 1R3SFDREM 1PATIOWOOD Wood Frame up to 300 B SF 1PATIOMETAL Metal Frame up to 300 B SF 1PATIOOTHER Other Frame up to 300 SF B PATIO'S CLOSED IR3SFDADD OR & SUN ROOMS IR3SFDREM 1PATIOENCLW Enclosed Wood up to 300 B SF 1 PATIOENCLM Enclosed Metal up to 300 B SF IpATIOENCLO Other Enclosed Patio up B to 300 SF 1 COVPORCH Porch Covered Each B (Each) REMODELS 1R3SFDREM — 1REMRESKIT Kitchen Remodel up to B (Deduct "$"for ea plan 300 SF check 2 2 1REMRESBAT Bath Remodel up to 300 B " SF 1REMREOTH Other Remodel up to 300 B �� SF SAM �£ f m Dish- al ish- " w °--to Washer E `D 24" w — CA .� O w \ o O c� 0 N O 1 ® N O LAMM co, C LAMOM 0- - N C:) N .g m c c to O O • N t n to G Ol ��f Z O Ln W3 loo su1S1110ad11.4w < `D 'OUlI 3W 1s(. uoai uv,;; t� U; 6G ) jdeA C G,n 0�, / �n� N ��3H1 H11M 3�Nb42lp��H � IF «Z£ U _ a D , � y a � D �m � a -1 � � -� � � cc m �. (� _ rt _ fG O a N s ; SOD O. O 7 C Q OO„ Z O CY N �• CD C d N to 0 rt _L p1 O G O .a C7 0. fl: N 'p C.CD CD M CL °' O C r mM z � �+ d cD O Q � O ^, CD f• m /� C7 CD TI n C " 7 0 'r N C) r► cm EL Co �lp� W� > O O "* N N O O 7 x CL n a cr Oar � ' * CD CLS. ? `° Q. N CD n Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 "UPEkTINO Building Department JOB ADDRESS: ?: PERMIT# .. tj OWNER'S NAME: PHONE GENERAL CONTRACTOR: 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 I/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date