09100207 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22840 STONEBRIDGE ST CONTRACTOR:PERRY IRMA TRUSTEE PERMIT NO:09100207
OWNER'S NAME: PERRY IRMA TRUSTEE 22840 STONEBRIDGE DATE ISSUED: 10/29/2009
NER'S PHONE: 4084464525 CUPERTINO CA,CA 95014-5643 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.#
MECH RESIDENTIAL f- COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NO OUTLET BEING CHANGED OUT,ADDING 6
(commencing with Section 7000)of Division 3 of the Business&Professions RECESSED
Code and that my license is in full force and effect. LIGHTING AND 2 PENDENT LIGHTS IN KITCEN;NO
STRUCTUAL&NO RE-ROOF
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$5000
permit is issued.
APPLICANT CERTIFICATION APN Number:34213040.00 Occupancy Type:
I 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 constriction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. � Z�1>�
Signature Date Issued byL_-�.__ �"� ____-� Date:l�
). OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must Owner authorize gent:
forthwith comply with such provisions or this permit shall be deemed revoked. �1't ty, ti r Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
in-+Amnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
c ind expenses which may accrue against said City in consequence of the
gi..__ang of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18. I understand my plans shall be used as public records.
Date -2-
&
Signature "4 t ��" 1 g Licensed Professional
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 34213040 . 00
DATE ISSUED. . . . . . . : 10/29/2009
RECEIPT #. . . . . . . . . BS000009076
REFERENCE ID # . . . : 09100207
SITE ADDRESS . . . . . : 22840 STONEBRIDGE ST
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER PERRY IRMA TRUSTEE
ADDRESS 22840 STONEBRIDGE
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5643
RECEIVED FROM . . . . : MS IRMA PERRY RN
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY PERRY IRMA TRUSTEE
ADDRESS 22840 STONEBRIDGE
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5643
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 000 . 00 1 .00 0 . 00 1. 00 0 . 00
1BPFIXTURE NO OF FIXTURE 1 . 00 8 .00 0 .00 8. 00 0 . 00
1BREMFIXT NO. FIXTURES 1. 00 63 . 00 0 . 00 63 . 00 0 . 00
1BSEISMICR VALUATION 5, 000. 00 0 .50 0. 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 42 .00 0 . 00 42 . 00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 198 .50 0 . 00 198 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 198 .50 VISA
---------------
TOTAL RECEIPT 198 .50
CITY OF CUPERTINO
ADDITION/REMODEL
OF
CUPERTINO PERMIT APPLICATION FORM
APN # 4 Date: 10
Is a 2" unit being added? Yes El No If yes, please fill out the permit application for 2 nd unit.
Building Address:
�ZaJ f0 5 i0/Rbrcd e. , C.k��e Ctzt? 6 (?� qt To 1 c{
Mailing Address (if different from building address):
Owner's Name: Phone#
A -i rn-i a !��Y r -IOF 4 q to-L1 5" S" 4u '7a:3-
Contractor: Phone#:
Ocune,r bu�ldE✓ Fax #:
Contractor License#:
Cupertino Business License#:
Contact: Phone#:
(az Fax#:
Building Permit Info:
Bldg. ❑ Elect. ®� Plumb. ( Mech. ❑ Hillside E]
Job Description:
Addition-What is being added?(Be Specific):
110 0 ct 4 l t t d- 0 u- /�cf d u7 �r ud�k
ur)d A pt),764klf tL4h4.l L/1` AC4 tO-)t d,
What is being remodeled(not including addition)?
Remodel Includes Re-Roof: Yes ❑ No yes list number of squares
Remodel Includes Structural: Yes ❑ No
Do you have the pre-application planning approval? Yes ❑ No ❑
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 ❑ I1/III B, IV-HT, V-B ® --- P --1
Valuation: s oo — Please check this box if the project is a
second-story addition ❑
Project Size: Express EJ S a-ndard ❑ 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.
***For Office Use Only***
F-1Revised 07/06/09
Over-the-Counter
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1 REMRES2 Remodel Residential B
Greater than 1000 sq ft
1REMRES3 Remodel Residential B
Greater than 2500 sq ft.
1REROOFRES Residential Re-roof Each B
100 SF
REMODEL PLNCK
ISTPLNCK(1-3 for Standard Plan Check B NOT FOR OVER THE
remodel) COUNTER PLAN CKS.
WINDOW/SLIDING 1R3SFDREM
GLASS DOOR
1 WINREP Replacement windows B
(ea 8 windows)
1 WINNEWNSTR New Window(non- B
structural)
1 WINMEWSTR New Window (Structural B
Shear Wall/Masonry)
1 WINBAYSTR Bay Window (Structural) B
SKYLIGHTS 1R3SFDREM
1 SKYL<10 SF Skylight less than 10 sf B
1SKYL>10SF Skylight greater than 10 B
sf or structural
1STAIRS Stairs-first flight/ea addt'l B
r 1 EPERMITFEE Electrical Permit Fee E
I 1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln E
Ck (hourly)
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1 MECPLNCK Stand Alone Mechanical M
Pln Ck (hourly
IPLMPLNCK Stand Alone Plumbing P
Pln Ck (hourly)
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE Seismic Residential B
ITRAVDOC Travel &Documentation B
1BUSLIC Business License B
��,LA,
I'
RESIDENTIA .r PROJECT COVER SST
Assessor's Parcel Number: ?3 3-6 q 0 -0G
Name of owner. I r m a- lie- v-y
Project address. 2�Z(4 0 S Tc,n e b Y-L e
Contact person. !Sa m e- Phone. 9 C)S y(4 (o� 4 oQ5 A) 6-3
Fax.
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
re there at least two 10 foot by 20 foot clear spaces inside the garage? Y-�
Is privacy protection planting required for the project? N
On what floor(s) is work being done? l sT V1 go v-- L,+ch en
Brief description of work. TU,"-U ktfVJ1 4 L1 L,-pd-g-T,,- &UAWk A�h E4 1
1�f5 w r _,77 e v t ' t jj n.» e
h�.P16c/-nq 4-0(c- sa")-t )0s1ttilk• I-aks &U."��yj (_hO�rt�Eil 0-u i"
Code editions:2008 CBC -N)2008 CFC -N)2008 CMC (Y-N)
2008 CPC -N)2008 NEC &9-N) 3
Effective 1/1/08 :.,,us :.% .
H THE CITY OF
IN �r F7—
CUF( (I AND ORDINANCES
DATE
SIGNED
This set of plain;an�spe�jns MUST Y
be kept on the I1,t)at all ti ,.,«•s and it is
unlawful to make ary ch e kjw,or alterations
on same without wnt1w.pe�fmission from
the Building Dep,W-40. City c)f Cupertino.
The stamping of this pian ant specifications
SHALL. NOT he he4f ti,permit or to be an
approval of mei 10,0--of 1 'y provisions
of any City ur *ate Law.
Plan Review Process Work Book Page-8-Revised 1/1/08
Kitchen
At least 50% of the total wattage is high efficacy:
Fixture Type High efficacy Relamping x Quantity = High-efficacy or Low-efficacy
(y/n) wattage wattage wattage.
1�161�7 5- 136 or
J 44to e 2_41 x
x Z = 7d or
x or
x or
(Complies if A z B) Total: A: B:
Compliant? YES [3 NO [3
Additional requirements YES N/A NO
Recessed fixtures installed in insulated ceilings are rated ICAT and certified
ASTM E283 or equivalent. Installation is airtight(caulking, gaskets).
High-efficacy and low-efficacy fixtures are switched separately. 13 13
6d Bathroom(s) YES N/A NO
All light fixtures are high efficacy.
Incandescent fixtures are switched with manual-on/automatic-off occupancy
sensors. [3 13 0
Recessed fixtures installed in insulated ceilings are rated ICAT and certified
ASTM E283 or equivalent. Installation is airtight(caulking, gaskets). ❑ 0 13
High-efficacy and low-efficacy fixtures are switched separately. 13 13 13
51 Laundry ROOM / Utility Room YES N/A NO
All light fixtures are high efficacy. 13 13 13
a)
72 Incandescent fixtures are switched with manual-on/automatic-off occupancy
=3
sensors. 0 1:1 11
Recessed fixtures installed in insulated ceilings are rated ICAT and certified
ASTM E283 or equivalent. Installation is airtight(caulking, gaskets). 0 El 13
0
0) High-efficacy and low-efficacy fixtures are switched separately. D 13 0
4-J
IYI
JZ_ -
Garage Y, W NO
All light fixtures are high efficacy. n [3
a)
Z3 occupancy
Incandescent fixtures are switched with manual-on/automatic-off occupa
sensors. 0 13 13
Recessed fixtures installed in insulated ceilings are rated ICAT and certified
ASTM E283 or equivalent. Installation is airtight(caulking, gaskets). [3 13 D
High-efficacy and low-efficacy fixtures are switched separately. ❑ D 13
:1" '7 777777
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. ✓All the work authorized by this permit
B. _ A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signature: -c a Ck I)LV _J_ Date: 0-1?1 8-D c1
Job Address: a�S yb SI a i)elpr(dQC, � L ��U f-L�*f) Permit# - 0,2 0-7
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.