07100065 CITY OF CUPERTINO � ` h,� ` `
BU[LDInG DIVISIO:V PERMIT ���������'^�����`
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PERMIT NO.
BUILD B� DR TOM BAT S 0 710 0 0 6 5 .
OW IYER'S NAME: PERMIT ISSUE DATE
TOM BATES 20077 J�)HN DR 10/08/2007
NE; SANITARY NO. CONTROL NO.
ARCHiiECT/ENGINEER: BUILDWG PERMITINFO
BLDG ELECf PLUMB MECH
� � � �
i p o LICENSED CONTRACTOR'S DECLARATION
� V C 1 hcrcby a(Grm that I am licenscd undcr provisions of Chap�cr 9(comma�cing Job Description
; z� with Sccuon 70oU) of Division 3 of thc Business and Profcssions Codc, and my Iiccnse is RE P LAC I] 1G EX I S T I NG H EA'1' ER
;� y in full forcc and cllect
� � ? Licensc Class Lic. il
: F, r p Datc ConuacWr
±� ARCHITECTS DECLARATION
i a a I undcrswnJ my plans shall bc uuJ as puAlic reconis
)yU
' u. y Liccnsed Pmfcssionai
� y � OWNER-BUILDER DECLARATION
I hcrcby a17rm lhat 1 am ucmpt Gom �hc Conlraaars Liccnsc Law Cor Ihc
� p O follawing r,:azon. (Sccuan 7()31.5, Busincss and Profcssions Ca1c: Any city or county
�,°, � which �cquims a pc�mit to consWCt, altcr, impmve, dcmolish, or rcpair any st�ucture
° Z y prior a i�s issuancc, alsu rcquires U�c applicant for such pertnit m filc a signcd statemcnt
a tha� t�c is IiccnscJ pucsuant to �hc provisions of �hc Conuactur's Liccnsc Law (Chaptcr 9 ; iq. Ft. Floor Area Valuation
,� t �(commencing wi�h Scction 7000) of Division 3 of �hc Busincss and Profcssians Codc) ur � 1 0 � Q
y�� �hat he u ezempt the¢from and �he buis for the allegcd exemptioa Any violaUon af
SecGon 7031.5 by arry applicant for a permit subjccts �he applicant to a civil penalty of Number Oceupancy Type
not more U�an fivc hundred dollars (5500). 3 6 9 3 3 �' . ���
❑[, as owncr o[ Uie property, a my cmployces with wages u their sotc compensation,
wiA do the work, and ihe stcudust is notintended or of(ered far sale (Sec.7044. Business Re uired Ins ections
and Peofcssions Codc: The Conuactors L'uenu law does wt apply w an owner of 9 P
propeny who builds or improves �hereon, and w6o does such wo�lc himself ar tlwugh Ais
own emplayccs, providcd �hat such improvemenLS are not intended or offercd far sale. If.
however, �he building or improvement is sold within one year oC complction, d�e ownu-
buit will have the burden of pcoving that he did nat build or improvc [a purpose o(
sak. .
t, as awner of the property, am ezclusively conuacting wi�6 ticenud conuxtas to
wnsuuct Uie projett (Sec. 7044. Business and Pro[essions Code:) The Conuacwr's Li-
ccnse Law docs nol apply to an owner of propeny who builds ar improves �haeon, and ,
w6o convacLS far such projects with a rnntractor(s) licensed pursuant w �he Convactor's
Lkense Law.
❑ I am r Sec. T �.-�.= B& P C for Wis icason
Ownu �/�i� 7 lC- '�� T Date /� — 8 �
� WORKER'S COMPENSATION DECLARATION " � ,
I hereby �rm under penalty o[ perjury one of �he folbwing declaruions:
❑ I h:ve and will maimain a CertiGcate of Consent to self-insure for Worlrefs Compen-
satian, as provided for by Sec[ion 3700 of che Labor Code, for thc pedarmancc of the
wak for which ihis permit is issued.
❑ I have and will maintain Worker's Compensadan Insurance, as �equired by Section
3700 oC the Labor Code. Coc the performance of �he work for w6ich �his permit is issued.
My Workers Compensadon Insurance cacrier and Poliry number are:
Carticr: Palicy No.:
CERTIF[CATE OF EXEMPfION FROM WORKERS'
COMPENSAT[ON [NSURANCE
(Tha scaion necd not be completed if the permit is [or anc hundred dollars (S 100)
or Icu) '
1 ceni[y thxs in thc perfo�mance of ihc work [w which Wis pertnit is issucd, 1 shall na
e�ploy any perso ' ymanner;q az m co e, ject w the3Tdorkers' Canpensation
Laws of Califo tu ��/ 4C
Applicant �-�"� y ' ('
NOTICE TO PC.ICANT: If, af�cr making �his CcrtiCcatc of ExcmpGon, you shaulJ
bccome subjcct w thc Workcr's Compcnaation provisions of Wc Labor Codc, you muu
� O foMwi�h comply with such provisions or Uiis pecmi� shall be dxmed revoked.
z '"'' CONSTRUCTION LENDING AGENCY
[- �-�. I hcrchy affirm ihat thcre is a conswction lcnding agcncy I'ar tAc per(ormancc of
C.�. � �hc v+ork for which Utis permil is issued (Scc. 3097, Civ. CJ
W Q Lendcr's Narnc '
a z Lender's Address
(� � t cenify U�at 1 have rcad �his applicadon and sutc that thc abovc in(ormaaun is
�►-� cortect. 1 agree �o comply with all city and county ordinances and sute laws relating to
.J U building conswction, and hcreby authomt reprcuntativcs of this city to cntcr u�mn thc
W abovc-mcmioncd property for inspcction puriwses.
�'' a (Wc) agree to save, indcmnify and kccp harmleu the Ci�y oC Cupcnino against
H � liabilitiu, judgmcnLC, costs and expenscs which may in any way acccuc against said City
U'�" in consequence oC �he gronting of Ihis ���. Date �
►'� APPLICAM UNDERSTAN ILL COMP WITH L iVON-POINT Issued by: e� -��
SOURCE REGULATION 'y
�u�-r � _ � � o -� Re-roofs ` Z— "
Signuurc of npplican onvacior ° a` Type of R�of
HAZARDOUS MATERIALS DISCLOSURE
Will lhc applipnt or futurc building occupant storc or handlc haiaridous ma�cria!
az dcfined by Ihc Cupenino Munici 1 Codc. Chap�cr 9.12, and �he Hcalth and SafUy
Ca1c. Section 25532(a)? � All roofs : hall be inspected prior to any roofing material being installed.
❑ Ycs
�11 the applicant or future building occupant usc eyuipmcnt or dcviccs which If a roof i: installed without first obtaining an inspection, I agree to remove •
cmit hvardous air contaminan�s as ek6ncd M1y the Bay Area Air Quslity Managcmcn� all new m iterials for inspeccion.
District?
❑ Ycs �o
I havc rcad the t�a�arCcws ma�crials requiremcn�s undcrChap�cr6.95 of ihc CaliCor-
nia Hcal�h & Satcty C Scctions 75505, 25533 and 25534. l u �and �hat iCthc huilding
docs no� �a �caan4 �at it is my �csponsiAil' to 6oti(y �hc occupant nf ihe
rcyui cn�s m�u x�� P � ar a_a� ora��r. Signature �f Applicant Date
��� � �� All roof coverings to be Class "B" or better
Owncr or authorizcd agcnt ���
� �7locac���
�
. :. �;�.� CITY OF C'UPERTINO
1' Q�.J 1���! ��
CUPEi�TINO PERMIT APPL:[CATION FORM
APN # Date:
.3� �.3�os/� � a c - � - o�
Building Address; ��
�df�,1V < Z..
Owner's N - . _ Phone #: �
-�%� ` / � r7 � r y I (�( ��r�J7 �l O/� "1 _ U�, � 7 /�` � � �
Co cto : Phane: License #: �
11 ��� v�'/f 3 r�- r9/ �i1' 6 � � 2D 2 o5'QS j r ��� �oQ�a
Contact:�--, Phone: � Cupertino Business License #:
C�/1 I � �
Building Permit Info:
Bldg ❑ Elect ❑ F'ltunb ❑ Mech ❑
Job Description• � —' ' -- � i� J � I ►'
� (� ��. �Ci �ll� /��/ S � � J�l � c�-
Residential Commercial ❑
For Residential Inst llations:
Attic � 1 St floor � 2 floor �
Adhere to min set back requirement ❑
For Commercial Installations:
:eplacement same weight ❑ Additional weight (s �jctural calcs) �
Structural Calculations required for new installation
New installation Planning Ap roval Required ❑
Cost of Project: Type of Construction: Occupancy group:
11�
Strapped ❑ On Platform ❑ Bonded C� Sq.Ft. oor Area:
New Location � Re lacement �
Qty. if
Applicable Fee ID Fee Descri tion Fee Group
BENERGY Energy BUILDING
BREMFURN Fi �mace MECHANICAL
BREMACOVER A,'C Unit > 10,000 cfin MECHANICAL
BREIVIAIRHAN A,'C Units <= 10, 000 cfin MECHANICAL
BREMRECEPT R�;c tl, Switch & Outlets ELECTRICAL
BSEISMICRE SE:ismic Fee Res BUILDING
BSEISMICOM SE:ismic Commercial BUILIDNG
EPERMITFEE EJ ec Fermit Issuance ELECTRICAL
MPERMTTFEE Mech Pernut Issuance MECHANICAL
PPERMTTFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bld Permit Fees BUILDING
BPLANCHK Pl �n Check Fee BUILDING
BPGAS G�s Piping System Fee PLUMBING
BUSLIC B�zsiness License BUILDING
CITY OF CUPERTINO
6 ITEMS OF 6 PERMI`� RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng Sub: B1] c: Lot:
APN ......... 36'�33051.00
DATE ISSUED.......: 10,'08/2007
RECEIPT #.........: BSi)00002927
REFERENCE ID # ...: 07:_00065
SITE ADDRESS .....: 20�)77 JOHN DR
SUBDIVISION .......
CITY .............. CU:?ERTINO
IMPACT AREA .......
OWNER ............. TO]7 BATES
ADDRESS ........... 20�)77 JOHN DR
CITY/STATE/ZIP ...: CU:'ERTINO, CA 95014
RECEIVED FROM ....: THc)MAS E BATES
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: TOI� BATES
ADDRESS ........... 20�)77 JOHN DR
CITY/STATE/ZIP ...: CU:?ERTINO, CA 95014
TELEPHONE .........
FEE ID UNIT QUANTITY :�MOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1.00 34.86 0.00 34.86 0.00
BREMFURN NO UNIT 1.00 14.31 0.00 14.31 0.00
BSEISMICRE VALUATION 1,000.00 0.50 0.00 0.50 0.00
EPERMITFEE FLAT R.ATE 1.00 40.7.9 0.00 40.79 0.00
MPERMITFEE FLAT R.ATE 1.00 40.79 0.00 40.79 0.00
PPERMITFEE FLAT RATE 1.00 40.79 0.00 40.79 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT : 172.04 0.00 172.04 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 172.04 VISA
TOTAL RECEIPT : 172.04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL