05120029 CITY OF CUPERTINO �7 ?
BUILDING DIVISION PERMIT CONTRA�'TaRNX'U,�L1VS.ATIO�,,N .
BUILDING ADDRESS: RAVIN CHECKER PERMIT ND.05120029
OWNERS NAME: PERhffILgUE DATE
RAVIN CHECKER 12/06/2005
SANITARY NO. CONTROL N0. -
ARCHt7ECT/FNCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MCH
(� C= 1� 0
3Oo LICENSED CONTRACTOR'S DECLARATION Job Description
I bcmby affirm thu l am E osmdl umkr pmviriaa,or Ch.pin 9(cmo
nmcncint
IN Sation 7").f Dmzicm 3 of do Iltm.all Rvfavou COEt,.all my II¢rus is
REMODEL BATH (1ST FL) , INSTALL
Dam Conuacm SHOWER W/TEMP. GLASS, MOVE SINK/INTER. WALL.
'C ARCNnEC"PS DECLARATION
0 1 mMauand my pato Null h turd u public tttvxJ, ryTg�
ion^ Lfavcd Pmfavonal {�'�ff—%
OWNER-,mm"frDECLARATION
.cALED
oo 1 ht,rtby.tTrm But 1 1. e,cmpt from ttr Cohuxtor',l:Ary c taw f.cr 0t,
coo f hkhint tiro pornit U, 03 cormor,Butircu W Profravav b.or n,ny city«rnmty
$� vhkh rtyulma.pmmit m aawu..ltu,hnprore,drmull$o rtpas enY NNGurt
Zi Prix w ita inuucc,also r,uirta the,pplicam fm,uch permit to fk„ItMd nnlemmt
�o tw nealiat..m purw.mbltn�pm.a,lotR orDN camr,clar',I�a�I.rfot,plm9 Sq.Ft.Floor Area laluati$d O3O
$ (commcoclnt with Stair 7000)N Divimm 3 of tYC Balreu and Prorc<,ioru Col)m
_ But b,I.ezempt htnrrom rol Ibe huu for We Wgcd room int.Any violation of
Seddon 7D315 by any applicant for.pemLL svbjecu the appllant In a civil pcahy of APN Number 0Type
nor conte WaO Dae"aMmd dOlLn(SSOD>. 34245014 . 00 -
❑I.u owner or tut pmputy,or my emP)oym Weh vats u Nth mk compeaNbn,
mala do tis Wort..rtd the mtame I.star Immdcd or ork d for Sak(Sec.7ON,Buo.
all Proluslom Caoa am:The Coc=mr•,T R,=Law dea"W,n O arm Required Inspections
pnO y who bund,aimprowe thertum,and M,o aoe,wrh wmlhim+elrm through hat
awn employca,ptovlded that mach Impro. .la art Wt Intrrtrd oralrerW for sal If,
however.the htdldint or impowrouR u sold vithm arc K ofcompkUmi,theOmer-
hulldc will base We batdcrt of proving that be did tr boW or improac for purpo,,of
sky
❑I,as awmer of tk ptopeny,am eaclu,hdY cona.dint Mth He tud conuadors to
construct the projat(sec.70.10,Butinm W Profcviane Cork:)The Conro 's LJ-
cmue lar don not apply 0 an.Of propoty.wh i bond,to unprovn theran,and.
who cmtruvfor,umL prakcta viol acontndor(,)Ifanted Puuu•mW COnvr'ImY
(Jcstvc law.
❑Lmcz� ndc�� ,BdPCIm NIa t�
Ovnter r Dae 6J
W 5 it ATION DECLARATION
bcrtby aro.under pemlty or perjwy.m the r011owms declvath..
rt.nd w 11 maintain.Cmift^'•a Corvert m self-invert for WurtcS Compen-
u poovicicfl for by Sectlat 3'100 M We Labor Cock,for tk perform.na of We
wort for v ch Dti,permit is haurd.
❑1 haw W will maintain Wortcr',CoonKnvtion IBvu. .u rmIubcd by So,tlon
3700 a We Labor Codc.for We p forrooea or the wort for Which Nu P—U Is Issued.
My Worker's Coopau,. Inwmta artier tool Policy mmmbcr are:
Cu .. Policy N.,
CFRTOCAM OF]EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
mos stttlm nod not betnmpked B the pmmlt W Intent,hulled dohs,($100)
Or lot)
I cuufy,abut In We Mr...of tho wort ror which thio(crit ta issued.I shall ma
TPloy ar7 pcoum In my mantcr m.,b Vmarc,uat}St to r.. ft Watcrs'CQII_ ^ nn
Laor�al��r�, a+ / 1JiFRI
Appliam �X m ` I'ir—�-f_-�
NOTICE G .aPcct`oolong thH Caufuve or Eacmpti you W
bccvne to thep&kCt Compcmatian proviuom of cite labor Code.YOs mat
,JO Forthwith th comply witb etch provi, or Nis remit,hall be dammv
cd kc& _
'Z N CONSTRUMON LENDING AGENCY
1 bmoby a1Br llw dere ta•ccmmocdan ladinl agency to the pmfamnsac of
y t7 tho vurt for which W l permit i,issued Soc.3097,Cin C.)
fit Q Iandclt Name
a. z Li,nom`.Add.
U0 I certify Nat I haw call this application Nol mto that tho about,information I,
L, H conch.I arra to comply with 01city all camty OtNnucet and auk laws rtI.dng to
OU building muruciion.std hemby authorize mptcvnwiw or Nu city to cneon Inc
r upon
W .bare-mentiotcd propdty for tmyecilm purlexs.
(Wc).tome to uvc,irdcarm y aotl tap harkss We City of cuputitto agaimt
bytiablDtimjudtmcou,coram,1c,pcnu,which may In ury,wyamte against Wd City
U Z in
ANT UNDERSTAN S ccc of the tnartirts Of AND WILL COMPLY WITH ALL N N-POIM Issued by: Date
SW ECU N
t IS Re-roofs
Sml Appl AZARDOUS MATFRLILS DISCLOSURE D Type of Roof
WUI dtc applicant or futurt holding oc Wa^t sac Or budle harm6mo m.erW
u dernoA by tho CupW no Municipal Cock.Chapter 9.11,artl the F th and Stray
cute.Sadicm 25532(.)+ All roofs shall be inspected prior to any roofing material being installed.
❑Ya PNa
veil We applicant or fuhvc wmmng aaultam=cgoprmmi or dads Which If a roof is installed without firs[obtaining an inspection,I agree to remove
LI?boos air comamianu as dcfited by ft Bay Arta Air Quality Manatcmcu all new materials for inspection.
7
E]Y. ON.
1 haat,mW the h,and rmamizltrtyuhancw tmk C7upim&95ofWeCalifor-
nitFWUIW&Safay Go�,Satbn+]5505,15533 aM25511.I uotderaNN Wrifde building
dna not cuncnily haw a�t than it u my raponOhlllty to m fy the ornvtvnt Of the
ht,mel to i:.vana ora Cdtif, NO oro. i Signature of Applicant Date
(f moAll roof coverings to be Class"B"or better
or au gcnt m
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONR°ACT'nR1NFOMAT7, , &
BU IIDING ADDRESS: RAVIN CHECKER PERMIT NO.05120029
OWNER'S NAME: PM8 151 DATE
RAVIN CHECKER 2005
ONE SANRARY NO. CONTROL NO.
ARCfDTFLT/FNGINEFR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�+oo LICENSED CONfHACIDR'S DECLARATION Job Description
�� I hmby affirm Nu I am Boonad undi providvu of Chapmr 9(mmorancig
U
nwidnS titin 1000)of Div Won 3 of the Buea+tinand Pmfaskns Code,and my at.is
i
in in mufra.rul freal REMODEL BATH (1ST FL) , INSTALL
baa
GmCan( SHOWER W/TEMP. GLASS, MOVE SINK/INTER. WALL.
O Dem DECLARATION W ARCHITECTS DECLARATION
7< IUNcrmna my plvu.nall he wedupublic reercdt
U
o C liauea amreatiaw
OWNER BUILDER ro DECLARATION
a�co I hcrtby alftem that I em exempt
from the Cmhuactoft liven¢City
o far ty
_p D fo,,h 036 trm,. (S.U.1031 . 4 i m na Rofd mut Code:Any city ar roomy
$� whkh rtytntq a pomp m cmumc4 alcor,inpwc,dcmWish,m rtpalr'any utatwc
_�; priamiu v sae. 4o quiet b apples tfa bpmnmElca pd ummrnt q, Ft. Floor Area Valuati$4030
< NU K 4li¢nscd purwam to the pravislpu of Nc Cotmactai U..Lar(Chaper 9
ytomt$ (cammeaiag with Semon 70M of D im 3 of 0e Butinea and professions Cock)or
3..
dust h 4 uwpt d m d.and de bade for de stand Pdon Any via4d'on a
Scott.7031.5 by atryappllant far a Pramlt subjccu thin HWp 'to-cIvll Pcnahy of APN Number Occupancy Type
at mesa than eK mmdrta"has(S500). 3 4 2 4 5 014 . 0 0
I,uancr oftK propmy,amy wployca wkh waguutKtr mk mmptmum,
will do lh wart.ad Oe mHo,4 tat Woonfed aroffcrW forsak(Sa.104,4,Btaltas Required s CL10D5
aM Profudom Cade The Conuactara I.IAw don oat apply m an awoer M q
proWty who buths or firsithcmn,and wbodpa such watt himu)fan through his
own
,w,mP,oyrn,posidd Nata¢hcm is ss:d witmo not lmmmdcd m offccd far ink U.
boics a Iehuildingaimpossmmtiscold did
not yan of canpkum,de owaa
buiWo wiB lose the buNrn of posing Nu k ala w land a Impose far pvpoa a(
C]1,
❑I,u owner o(mt p 704,.B incl arl contraning wiN l)Thin co—W'as ' O�
const,La tins am (Sm1010,Basinr Hoa Professions Cndc)The CmbammoaIJ
venue Law dons na apply m n with
o<papmr w'bo ids p Imposes tC.0 W.
Liao contracts for such prvpv rIN a cmtnrtor(s)licensed puraunt w Nc Cmttanart
LieneLaw.
❑lam"eh[,
n �S Bk PCfa ththatroam
Owrcr Dam _ s`�IFoS
W S M ENSATON DECORATION'T _t 1_
laomay alliin under p®lty of perjury oro of the following declvatims:
❑1 ha.a ad will maintain aCeNRate cfCmsw to scif-Iuae for Wankeft Compo,
aadm,as pa idcd fa by S oo 3103 of the Mbar Code.fa Nc pdormana of de
w fa which Nu permitn lard.
❑1 lase and will maintain Wai Campcuauom hosanna,u r*Hol by Scrim
3103 of the Labor Codo,for in,pcfamuec of d wart for which aris permk 41a met
My Wontds Corr'' sadm Bauratee attic and Policy number ane:
Catr'ii Policy No.:
CERTIFICATE OF EKEM MON FROM WORKERS
COMPENSATION INSURANCE
(This sevum ted amt bccanpktcu 0 the Iaxmh 4 Bar.hvnNd dollars(SIM)
a laa)
I anufy Not in the Wormanec of tk work far w Wla N4 Panit is L do,I shall not
wPloy airypnan lln�laatny�m�anne�r sin u m hccme wbjatm the wcracor Cgvptwum
Applian �A �X r1AA^`�H �1�T1 1�ii�aTTtt
NWcmc s LICA .Coorm—anti ,p Ci,i.of a( Ulan,Coast,
you lhwld
bttarc )cot b tnwwlch mr,mma,.his
n omnis ha of the LJbor Code,you moa
,J Z foMwiN mmplY LIN such praaitians a N4 permit shall be domed rooked.
zO l CONSTRUCTION LENDING AGENCY
Eiya
r. I hertby afrc ,tlut dert h a constroNnn kMing aKncy fa 0e prfamana a
> Nc comm,fa which th4 pvmh h issued(Scc.3091,Civ.C.)
C~aLior iName
= z Lcndcfs AM. .
V O 1 a fy that 1 hasa rad this aPplicauon ad sum Nu tic above Infomtadun b
Y. F" cantos 1 agra to comply wida all city and county mrditurac0 aro state 4ws rtlating to
pU buildin( o).,euro.and
.Bilbynifyanx«preaamrass Om City city agcn upon
l
�F.U .bout-rncmi.d vi far impaction putPnsca
(Wo)agme to use,indcttmify ad keep larmlcu the city of Cupnire ageiut
,T/1 IiabRma,Judgmcou.cops and capnxt which may to any way aatuc against said City
V imcorucqucoaofthcgramingof N4prmiL
^' APPLICANT UNDERSTANDS AND WILL COMPLY Wmi ALL N N. INT Issued by: Date
SOURC EGU rPN5.
L ds Re-roofs
S' AtRDS MATERIALS DISCLOSURE Da Type Of ROOF
Via Ik appiioant M rut=Writing oavrynt sac or hardlc harudom makr all
u defined by Be Cupnlm Municipal Cods.Chaper 9.12 said!the Ika)N and Safcty
Coda,Scnion]5532(a)7 All roofs shall be inspected prior to any roofing material being installed.
C]Y. PN.
If a roof is installed without first obtaining an inspection,I agree to remove
Will 0e aPplkvu or futum building ottupani sae Wulpmmt or devises which
emit hanndmn air cmtwinanu as dcnad by the Bay Arta Air Quality Manasem"t all new materials for inspection.
C4 ict9
CYa 2N
1 have maJ Nc harudau materials mryirttanu untkrCmper M1.95 of de Califor-
niaFidNd:SafctyCode,Scrums]5305,25533 am125534.lundcs d Natlfdtc Wilding
docs not currcNly haw a ananL Net It 4 my ccspoulhlllty to mufy the oaupont of Nc
txmotortaivaantcemraeeNraeorOc i Signature of Applicant Date
All roof coverings to be Class"B" or better
25W*W s.! agert I Mir,
CL OF CUPERTINO
CUP TYOF O PE APPLICATION FORD oS
1
Ir N# J9 2 z.) � � L Date: 4.6 .0.0!9-
Building Address:
Mailing Address f different from building address):1Q�7C Gtt-4sty
Owner's Name: 9MIN Phone#: �09' 2-S--3- 2-56y .
Contractor: SELF License#:
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ElectW Plumb Mech
Job Description:REK-eoW g rsM17,yrrW ntheIII s r ss o✓
Residential 0'
Slwt Commercial��y rvw+
Sq.Ft. Floor Area: M2.1zef k d y f�} q.Ft.:
Cost ofProiect: $dOv0 Occupancy GrouD:
Type of Construction: e v_r,,,,deG' Please check this box if the project is a
I second-s6addition: ❑
ro'ect Size: Standard Large ❑ Major ❑
uant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1-.75 M Btu MECHANICAL
BBOILERS Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BDNVESTIGA Investigation fee BUILDING
].of 3 � �
�r CITY OF CUPERTINO
CUPERTINO PERP* APPLICATION FOR
Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDII\TG
BMComm.
TIIGATC ComHousingMit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum . PLUMBING
13PCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLMBING
BPINTERCEP Ind Waste Interce for PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Futures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawns rink]erBackflo PLUMING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER IastaWAlter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUAIBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspectiou Fee BUIL DING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN AIC Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY .. Remodel Busways_ ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREWURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood 11llECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BRENU RAP Rem Non-Res Appliance ELECTRICAL
BREMPOLE PoI&TIatform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREI`I ELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2of3
F CITY OF CUPERTIlV�
CUP
11
PERMIT APPLICATION FORM
QuantityFee ID Fee Descri tion Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems 11IECHANICAL
BSCBLVD Scb Specific Plan BU]LDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSVaM SWimn1iDg Pool BUILDING
BTENIP Temporary Power ELECTRICAL
BTENIPPERAI Temporary Bldg Permit BUILDING.
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERNUFFFEE Elec Permit Issuance ELECTRICAL
Q MPERIAFFE Mechanicals . foot MECHANICAL
MPERNMFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/ Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Change BUILDING
•
3of3
K
g0 4 F4a ?�Kv�Y`� yYYG ��''� T ,„Z�`'`}L ' ,.
Y�'"A - r '" zri - ' �4t
• CC ' RESI-DENTI'` 4 PROJECT COVER4SHEEI
CITY 0 T<s�_ Y�'i' a :n!.�.' `•` flyy 6' i� sic. ,n .n14 4..�'E�:d"�-=i �01 s $Y4,_
CUPEkTIN0
Assessor's Parcel Number:
Name of owner. Z) Nr r hI
Project address. 10,'�76 IPFts7a D C7
Contact person. qa V i VI Phone.
Fax.
Net square footage of lot. ,J 2-gq D S5 f r LiJo C h r n l
Existing Proposed
Square footage: First floor: 1'70 4 AJo
Second floor: Q! cz
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y ON
On what floor(s) is work being done? 't ' —(100 faabQ
Brief description of work. 4d, 6L7(
Code editions:2001 CBC (Y -N)2001 CFC (Y -N)2001 CMC (Y- N)
2001 CPC (Y -N)2001 NEC (Y -N)
Effective 11/1/02 IV �,4
S�0PZ'
oi' T�jis' �✓o�J� r
=E �- OFF C E C UR
Plan Review Process Work Book Page-8-Revised 4/28/04
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