09070133 CITY OF CUPERTINO
BUILDING_DIVISION PERMIT � � w *�` �
. :::..
BUILDING ADDRESS: PERMIT NO.
22065 MC CLELLAN RD TBD - TO BE nFTFRMTNFn- nqn:Z01 "
PERMIT ISSUE DATE
OWNER'S NAME:
A94V CONTROL NO.
.J
BUILDING PERMIT INFO
ARCHITEC(ENGINEER:
BLDG ELECT PLUMB MECH
u0p LICENSED CONTRACTOR'S DECLARATION lob Description
U C I herebyarfum 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 Licu or eandeffect.�r+ Lie M Qt.L�'2b7 RMV & R:�PLC LIKE 4 LIKE RETRO-FIT WINDOWS & DOORS
EF,'o pate Contractor CAI-1 22A;KlS1Md-/e�►'►' SjW, 3D; 110 EGRESS- CALIFORNIA CUSTOM CREATIONS PD
ARCHITECTS DECLARATION
I understand my plans shall be used as public records FOR BUS L I C
X96
4 H Licensed Professional
y OWNER-BUILDER DECLARATION
a� I hereby alTitm that I am exempt from the Contractor's License law for the
i p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
y which requires a permit to construct,alter,improve,dcmolith,or repair any structure
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 Sq.Ft.Floor Area
YH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 2 4
y that he is exempt therefrom and the basis for the alleged exemption.Any violation or S38
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 3571302_D . 00
❑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 Contractor's License Law does not apply to an owner of q P
property who builds or improves themon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.lf.
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.
❑1 am exempt under See. B&P C for this reason
Owner Date
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 Worker's Compen-
sation,at 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 Worker's Com e sagon Insurance carrier and Polity other am: {W=U
Cartier. Policy No.: ( Q
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
I cenify 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
'on CONSTRUCTION LENDING AGENCY
F~.r►�-� I hereby affirm that there is a construction lending agency for the performance of
fY the work for which this permit is issued(Sec.3097,Civ.C.)
W Q
Len
dces Name
ader s Address
Z Len
V O I certify that I have read this application and state that the above information is
w 0"r correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes
f7n (We)agree to save,indemnify and keep harmless the City of Cupertino against
HCA) liabit ' menus,costs and expenses which may in any way accrue against said City
U Z in co terse of the granting of this permit. Date
r"t AP LICANT UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT Issued by f
S RC GULATI S.
Re-roofs
Si ° o pylic Lot/C°"'rxt°r �ALSDISCLOSLn T Of Roof
HAZARDOUS MAREType
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,Stenon 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
[:]Yes
No
Will the applicant o future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
District?
❑Yes °
ve mad the harardtws ma rials requirements under Chapter 6.95 of the Califor-
nia Health& cty Codc,Sections 25505,25533 and 25534.I understand that if the building
docs of cure ly have a tenant,that it is m 'it to notify the occupant of the
rcyo me hick mu1st x m no issuance of a Ccrtr tc or a panty. Signature of Applicant Date
All roof coverings to be Class"{"or better
Owne r authorized agent Dale
1
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot :
APN 35713025 . 00
DATE ISSUED. . . . . . . : 07/17/2009
RECEIPT # . . . . . . . . . BS000008212
REFERENCE ID # . . . : 09070133
SITE ADDRESS . . . . . : 22C65 MC CLELLAN RD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER EIKO WEBER
ADDRESS 22C65 MCCLELLAN RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4005
RECEIVED FROM . . . . : PAUL WAGNER
CONTRACTOR . . . . . . . : TBI, - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY 7,MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -------- ---------- ---------- ----------
1BCBSC VALUATION 3 , 824 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 3, 824 . 00 0 .50 0 . 00 0 .50 0 .00
1BUSLIC FLAT RATE 1 .00 114 . 00 0 .00 114 . 00 0 .00
1WINREP EACH 8 1 . 00 380 . 00 0 . 00 380 . 00 0 . 00
-- ------ ---------- ---------- ----------
TOTAL PERMIT 495 . 50 0 .00 495 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 495 . 50 VISA
---------------
TOTAL RECEIPT 495 . 50
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JUL Q 1X009
- MODIFICATION RE0 1JEST FORM
sociation Name: Park Villas Association- Ridncres t Date: g "71r, Vi 0o
homeowner Name: F_i Ko LQeber Address: 22065 McClellan Road,
Cupertino,CA 95014
Phone Numbers: 4' $ ' -LS 3- &5 6v
Description of work proposed: 1;h oW5 YeblAt eh�fnfi pau6�E�an�\/�nyl 1 � :5
Please attach a separate sheet with a sketch or pla)es for the work you are proposing.
A licensed contractor must perform the work. �' e 7 Q )- 5 -)-S 7
'Name: LA't MDy110- (L0,0M C,YeM1E)K$ q-og --31 b -6--q3
Contractor's License number,phone number and proof of insurance must be provided.
IMPORTANT,please note the following:
1. Applicant agrees& understands submission of this farm alone does not fulfill all
requirements for approval.The Board may require additional information in order to make a
decision. Until you have received written Board app royal, the application is considered not
approved.
2. Applicant understands modifications or special conditions may be placed on completion of
work at the applicant's sole expense.
3. Applicant understands all necessary permits must bE pulled from the City at the applicant's
sole expense prior to the initiation of work and after Board approval has been given.
Applicant will need to call the City's Building Department to determine which permits, if
any,are necessary.
4. Applicant also understands construction of said prof!ct entails continued maintenance of
said item for the life of the item.If the ownership of the unit is transferred,this responsibility
m st bwdiselosed as it does transfer to the new homeowner.
(Homeowner Signature Only)
Return to Affirmative Management Services,P.O. Box 477,Campbell,CA 95009-0477 or Fax:408-2444090
♦......................*.........................................
(For HOA Use Only)
/6\Approved "
❑ Approved with Contingencies:
❑ Denied -
❑ Denied as additional information is required (as highlighted):
matter was reviewed by: black rk V 'Cr PyV"Ci i
o1/0� ��
t CITY OF CUPERTINO
C
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 5 / 1 :� o a 5 Y 0 0 Date:
Building Address:
220&,S- &1,7,
Mailing Address (if different from bui din address):
Owner's Name: C�,Akb we%. Phone#:�,o� X53.C�SIo0
HOA: (Exterior work only) iYesk' No ❑
If yes, provide letter from HOA
Contractor: wvav aA ��� e!mol, 5 Phone: 100 ��(�• nu
Ci Fax:
Contractor License#: Y15W57
Cupertino Business License#:
Contact: &� Phone: Of,?16•�2�3
Fax: L/ey0q
Residentia Commercial El
Job Description: �/4d//'tom �i�� �(�y L! �� le��o—77 /
Building Permit Info:
Bldg [ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A5 I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-:3 [l�
Valuation fZ F0 Square Footage:
Project Size: Express Standard ❑ Large 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.buildit2r�,-en.or
Revised 02/05/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 3 windows)
1WINMEWSTR New Winiow-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
I PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stsmd alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
/ l BSEISMICR Seismic Residential B
IBSEISMICO Seismic Commercial B
I TRAVDOC Travel & Documentation B
` 1BUSLIC Business License B
5 of 5
ao
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�MkTINO
Building Department
JOB ADDRE S: PERMIT #
-),20 ��'
OWNER'S NAME: yV PHONE 4'4 16 �Z
GENERAL CONTRACTOR: ZS;? I FAX # O 5� ;3—y' 0
r .4 ��r-r Gjr S
I am not using any subcontract rs: - J 7
Si;;na a Date
Please check applicable subcontractors and complete the following information:
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 Signature Date