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07100039 CIT�' OF CUPERTINO ° ' BU[LD:tYG DIVI5!AN PERMIT �� * ` ..; ;< _.>_ ___,. PERMIT NQ. BUILD �N��i1p�ESS�ITNEY WAY CUPERTIrO PLUMBING 07100039 . ti PERMIT LSSUE DATE OWNER'S NAME: , DORCHAK SARA J TRUSTEE 1300 DEI�L AVE 10/03/2007 SAMTARY NO. CONCROL NO. NE: (408)25_-0618 BUILDING PERMR 1NF0 ARCHITECT/ENGiNEER: BLDG ELECT PLUMB MECH � 0 0 � i p Q LICENSED COMRACTOR'S DECLARATION JOl] DCSCilptlOil � V� 1 hcrcby affirm that I am liccnscd undcr provisions of Chapicr 9(commcncing ;_� with Sccuon 7IX1U) of Divisian 3 of �hc Busincss and Profcssions Code. and my Iiccnx is C 0 P PER F; P I PE , WATER MA I N WATER HEATER ;� y in full Corce and eCte � - � v� Z Licensc Cisss L�. � :� „ r p Da�c a� T— �- Contractor �:. . v�..._ ±� ARCHITECTS DECLARATIO 7� a 1 undcrstanJ my plans shall Ac uuJ as pubiic rccords )p,U ' u. y Liccnsed Pmfcssional 9 � < OWNER-BUILDER DECLARATION �h� 1 hcrcby alTrtn that 1 am cxcmpt Crom thc Contractor's Liccnsc Law ar U�c � p O Collowing rcason. (Scctian 7t)31.5, Busincss and Pro(c.csions Codc: Any ci�y ar couniy �,°, � which rcquiccs a permit io conswct, aitcr, improvc, dcmolich, or repair any structurc �' N rior ui ils issuance, aLw rcquires ihc applicant (or such permit to Glc a signcd su�cmcm ` Valuati on '?< t hc is iiccnscd pursuant to t h c pmvisions o C i h c C o n v a c t u r' s L i c c n s c [. aw (Cha ptcr 9 C�. FI. FIOOC AI'CS $ 5 O 0 O Y H� (commcncing with Scction 7000) of Division 3 of ihc Busincss and Prokssions Codc) or L�� U�at he is ezempt tAc�cfrom and the bazis Cor the allegcd ezemption. Any violation ot Oceupancy Type Section 7031.5 by any applicant for a permit subjects thc applicant to a civil penaity of Number n o t m o r e t h a n f i v c h u n d t e d dallars (5500). 3 6 9 3 9 O 2'�� 0 I. az owncr oC ttie pmpecry. a my employces witA wages as their solc compensadon. will do ihe work, and ihe stiucture is not intended or o[fered [or sale (Sec. 7044. Business Required Inspections and Protessions Code: The CanuacWr's Licenu Law docs nat apply w an owner of propeny who builds or improves thereon, and who daes such wort himul[ or Uuougd his own employccs, providcd U�at such improvementc are noc in�ended or o[fered far saie. If, howevcr, the building or improvement is sold within one year of complc6on, the ownu- builder will have the burden oC proving that he did not build or improvc fw purpo.0 of sa1cJ. . Q I, as owner of the property, am acclusively conuacting wiW littnsed conuactors w conswct ihe penjea (Sec. 7044. Business and ProCessions Code:) The Convacwrs Li- ccnse Law docs no� apply to an owner of property who builds or improves �Aereon. md , who convac�s Car such projects with a coniractor(s) licented pursuant to �he Contracror's License Law. Q I am aempt under Sec. . B& P C[or this reawn Ownu Date _.._ _. WORKER'S COMPENSATION DECLARATION I herc6y afficm under penalty o[ perjury one of tlx following declantioos: � i hs+e and will maintain a Ceni6cate of Consent to self-insu�e for Warkefs Compen- sation, as provided for by Sec[ian 3700 oC the Lahor Code, far We performaocc of �he work (or which Ihis pertnit is issucd. ❑ I havc and will maintain Worker's Compensadan Insunnce, az rcyuired by Scction , 3700 0[ the Labor Code, for the performance of the wwlc for whicA �his peemit is issued My Worker's Compensation In�sur c�arrier and Policy number are: Cartier. L�./ �'�'� �'`�-� Policy No.: � �'s — u � � CFRTIF[CATE OF EXEMPI'(ON FROM WORKERS' COMPENSATlON INSURANCE (This scction necd rrot be completed if the permit is for onc hundred dollars (5100) or Icss.) I cenify thxt in thc performance of thc work for which �his permit is issucd. [ s6a11 na - enploy any pccson in any manncr so as to bceomc su6jcet to the Workcrs' Compcnsatiaa Laws of Califomia. Datc Applicant NOTICE TO APPUCAM: If, a(tcr making t6is CcniCcatc of Ezcmption, you shoulJ become subject m the Worker's Compensation provisions of the Labor Code. you must �,z forthwith comply with such pravisions or this pecmit sha0 bc dccmcd revokcd � O CONSTRUCTION LENDING AGENCY H � 1 hcre6y affirm U�at thcre is a consuuctian Icnding agc�y Cor thc perCormarKe of n; � ihc work fur which ihis pertnit is issued (Scc. 3097, Civ. C.) , W Q t,endcr's Namc a z LendersAddress V � ( ccriiCY ihal I have rcad this application and siatc iha� �hc abovc infortnaaun is � F cortect. 1 agrce to comply with all city and coun[y ordinances and s�ate laws relating to � J building conswction, and hcreby authori�e rcprescntativcs of Ihis cily to cntcr upon �hc � W abovc-mcntioncd properry for inspccuon pur{wses. a (Wc) agree to save, indem�ity and kecp hartnless ihc City of Cupertino agains� „r'", � liabilitiu,judgmen�t, costs and expenses which may in any way accruc against said City � U z in consequence oC Wc gran�ing of �his permiG Date �(/� = l/ � �+ APPLICANTs1N NDS AND WILL COMPLY WITH ALL NON-POIM Issued by: sau�� , ; . �� — J� Re-roofs ��G/ s� �' o° `o` °'� T of Roof HAZARDOUS MA7'ERIALS D[SCI.OSURE YP Will Ihc appticant or [uture building occupant uorc or handlc harardaus mucriil az deftncd by lhe Cupenino Municipal Cadc. Chaptcr 9.12. and �he HcaIN and SaCety c� Scction 25532(a)? All roofs �hall be inspected prior to any roofing material being installed. ❑ Ycs � . Will thc applican� or fuwrc building occupant usc cyuipmcn� or Jcvices which If a roof i� installed without first obtaining an inspection, I agree to remove emit harardous air con�aminan�t a5 ckfincd by thc Bay Arca Air Qualiry Maoagcmcnt all new m aterials for inspec[ion. Disuict? ❑ Ycs Nu � I havc rcaJ the ha�ardous materials rcyuircmcn�c undcrChap�er6.95 af ihc Califor- nia Hcalih & Salety Codc, Scctions 25505 533 anJ 25534. I umicrstand ihat iC ihc building docs not curtcntl ea Uiaz'i`' my o �ht . noul'y �hc occupant nf Ihe � r,�,,;�W ;�hm� me�P ��,,;SS ��;r�e�ora�� r. Signature of Applicant Date j� � � All roof coverings to be Class "B" or better Owncr or orizcd agen� Datc i�/' I l U U�-� �`� �� CITY OF CUPERTINO � ��Y �F PERMIT APPLI CATION FORM CUPEIi�TINO �PN # � o � Date: , 0 b 1 U � 3- c:-� r7 Building Address• IVlailing Address (if different from building address): �— • �t� n Qv � c� wner's Name: Phone #: c�.c�.- f ��--. 2 S T7 _ v5 �3 � Contractor: /'� License #: 4 � � 1�[.�-.3 t" �,'-rl��t � � T / `�� Conta t: Phone: �ro�3 -�U`� -3y/� Cupertino Business License#: �� Z �„� ,,� �. Fax: Building Permit Info: Bldg ❑ Elect C9___ Plumb �° Mech Cr Job Description: n Residential � �` �`�- � �� Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: S �. d �� "�! " Occupanc Group: Type of Construction: Please check this box if the project is a '� V second-stor addition: � �'roject Size: Standard ❑ Large ❑ Maj �r ❑ Quanti Fee ID l�ee Descri tion Fee Grou BAPPLOTHER C)ther Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boilei > 100K to SOOK Btu MECHANICAL BBOILER3 Boilf;r > SOOK to 1M Btu MECHANICAL BBOILER4 Boile:• > 1M to 1.75 M Btu MECHANICAL BBOILERS B��iler > 1.75M Btu MECHANICAL BCONSTAX ('onstruction Tax BUILDING BCONSTAX IncJOff/Coinm/Quasi BUILDING BCONSTAXBQ Co�i. T�x for BQ Zone BUILDING BCONSTAXH �otel and Motel BUILDING BCONSTAXR Cor�stax — Resi/Mobile BUILDING BELEC1000 Elf;c 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD F nergy Add Multi BUILDING BINVESTIGA nvestigation fee BUILDING < �7g"U �G' �-- 1 of 3 � t A CITY OF C'UPERTINO CU TiNO PE�IT APPL�[CATION FORM � Quantity Fee ID =Fee Descri tion Fee Grou BMISCELL 1�liscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME Nf;w Comm Electric ELECTRICAL BNUCOMMM Ne�n� Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME In �pection Overtime BUILDING BPBACKFLOW Atinospheric Vacuum PLUMBING � BPCESSPOOL Cesspool PLUMBING BPERMFEE E:ld Permit Fees BUILDING BPFIXTURE Pbl Fixture PLUMBING BPGAS Ga� Piping System Fee PLUMBING BPINTERCEP Inc. Waste Interceptar PLIJMBING BPLANCHK :Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Pla�i Check Repeat Fee BUILDING BPREPIPE R�� i e Of Fixtures PLUMBING BPSEWAGE '�ewa e Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn Sprinkler/Backflo PLIIMBING BPSTORM Storm/Rain Water PLUMBING BpTRAP Kitchen Trap PLiJMBING BPVENT A: t of Drain & Vent PLUMBING ' - Inst<<lUAlter Water Pi e PLUMBING WHEATER W ater Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT ]Zeinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL BREMAPPLI .�ppliance Install MECHANICAL BREMBUSWAY R_emodel Busways ELECTRICAL BREMFIXT l�ighting Fixtures ELECTRICAL BREMFURN Re:.ocation of Furnace MECHAI�IICAL BREMFURNOV Relc� Furnace > l OK btu MECHANICAL BREMHEAT F[eater Installation MECHANICAL BREMINHOOD In.�tallation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res A pliance ELECTRICAL BREMPOLE Po le/Platform Fixture ELECTRICAL BREMPOWER PowE�r Device/A aratus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Rf:pair/Alter Heating MECHANICAL BREMRESAPP Reniodel Res Appliance ELECTRICAL 2 of 3 � � � a ; -,�: CITY OF C'UPERTINO � ��a� PERMIT APPL�[CATION FORM �UPEI�TINO �uanti Fee ID E'ee Descri tion Fee Grou BREMSIGNAD Rmcll Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR The atrical Lighting Fix ELECTRICAL BREMVENFAN Ve�it Fan Sin le Duct MECHANICAL BREMVENSYS Vf�ntilation S stems MECHANICAL BSCBLVD .`�cb Specific Plan BUILDING BSEISMICOM Se smic Commercial BUILDING BSEISMICRE � 3eismic Fee Res BUILDING . BSPECIAL � pecial Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP � Tem orary Power ELECTRICAL BTEMPPERM Tem orar Bld Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC l3usiness License BUILDING ELECTRIC Blectrical sq foot ELECTRICAL � EPERMITFEE Elcc Permit Issuance ELECTRICAL MPERMFEE N[echanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plu mbin Permit Issue PLUMBING PPLBG Pl.�mbing Fee sq foot PLUMBING PLLONGRNGC Plannin LR Comme/ Multi-Fam PLANNING PLLONGRNGR Plannin Lon Ran e Residential PLANNING :� of 3 CITY OF CUPERTINO 6 ITEMS OF 6 PERMI'I RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk.: Lot: APN ......... 36�39022.00 DATE ISSUED.......: 10/03/2007 RECEIPT #.........: BSC00002882 REFERENCE ID # ...: 07J00039 SITE ADDRESS .....: 10_`�80 WHITNEY WAY SUBDIVISION ....... CITY .............. CU�'ERTINO IMPACT AREA ....... OWNER ............: DOf�CHAK SARA J TRUSTEE ADDRESS ..........: 10_`i80 WHITNEY WY CITY/STATE/ZIP ...: CU]'ERTINO CA, 95014-4442 RECEIVED FROM ....: FR1�TK CARDIA CONTRACTOR .......: CAIZDIA, FRANK L LIC # 612 COMPANY ..........: CU]'ERTINO PLiTMBING ADDRESS ..........: 13�)0 DELL AVE CITY/STATE/ZIP ...: CAI'IPBELL, CA 95008 TELEPHONE ........: (4�)8)253-0618 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 BPWATER UNIT 1.00 9.00 0.00 9.00 0.00 BPWSVCS WATER SERVICE 1.00 9.00 0.00 9.00 0.00 BSEISMICRE VALUATION 5,000.00 0.50 0.00 0.50 0.00 PRWHEATR UNITS 1.00 24.48 0.00 24.48 0.00 TRAVDOC FLAT R.ATE 1.00 40.79 0.00 40.79 0.00 TOTAL PERMIT : 118.63 0.00 118.63 0.00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 118.63 VISA --------------- TOTAL RECEIPT : 118.63 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- -------------- 301 ROUGH PLUMBING 502 FINAL PLUMBING ENERGY 507 FINAL PLUMBING Community Development � � 10300 Torre Avenue ��" '�';s- ' Cupertino CA 95014 :,;�. ° Telephone (408) ?77-3228 C(TY OF Fax (408) 777-3333 �UPEI�TINO Buildin De artment JOB AD �� PE�I� �� O v 3 � QJ�c�� z��nE OWNER'S NAME: � �.- C �C.... PHONE # � � , . = c"� i - . � GENERAL CONTRACTOR C� ��sw PIt�•.�� FAX # I am not using any subcontractors: �`"`� �� _ � d� 3" a"7 �-%�i �nature Date Please check a licable subcontractors and com �lete the followin information: SUBCONTRACTOR BUSIl`1ESS 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