05080273 CITY O CUPERTINO ,i'
BUILDING DIVISION PERMIT COL�PTRACTORIIVFORMATIQN
BUILDING ADDRESS: 4HEATHER SIMMONS PERMrr N005 O 80273
1C) RTTRR RT)
OWNER'S NAME: PERMIT ISSUE DATE
H HE 5
NE:
SANITARY NO, CONTROL NO.
(408) 253-0618
ARCHITEC(ENGINEER; BUILDING PERMITINF0w
BppppLrrrDG ELECT POMB MECH
.,o Wy affirm
CONTRACTOR'S DECLARATION Job Descrl0(IounPj
B -
OF 1mbm thu od
1 am licmmad or pmvWms of Chip.9(commoclnt ((�r((
^= riWSttioniviaionloflmBvdntaWPraftabuCode.ndmyfianxn REMODEL MS BATHROOM . V1,In full Tom aM pIc(t cffof D
'�d� n•'•
NON-STRUCTURALDisc Contractor
ARCHITECTS DECLARATION
Iondem.odmypWuJlMsdpncrta
DHu
`n LirucE Professional
O
OWNER-BUILDER DECLARATION
1 hemhy•R�cm 1 1m ceempt from the Canimot Co :Any c Law for Ne
p fohiowimri.i. l anti,o]0313,Bualmsa and Pmfostlau Coes:MY oily a cmnly
9 which quire.pmmit re mres tho Jsr,knfor sat acm rift or m(uir ed mime
prior bsii=.,.de.nooquirt th isioicun for Rchpermitb Lk.JLaw m¢neon
FZ JwhmencinmedporsomtbWepraritiotofbeCanu.cbr'sniproeLaw scodo)9 Sq. Fl. Floor Area Valila[ 6045
ft (eommc, pt Scurf.and!th tiritimJ the
NCBu.iassvd ProfA,ACade)m
3� bar be V tempt Jcmfrom W tK b.a4 for the Jkted eaempllout Avy dot.dan of
Section 7031.5 by any,appiwam fma Permit aubjmu be sppbcint W Arn(Knotty of APN Number Occupancy Type
°'maebmEwpmamaadar s5om 35611006 . 00
❑1,as owmr of the papny.Or my muployoss wiW wares as their solo ccampenuJm.
will da lW work.and We ttrunum H not lmeRaed m offend To silo(St.7066,Bwlness Required-Inspections -
and Pm(etioru Cade:The Con rc Utme Law dot mt apply b cn cn m of
pmpenyrho WiMsm hoPmK•thmeon,andwM a at Luch waft himclfofbmuth his
own employer,pmvided the mch ImProamentf art vat inluded or offered for ale,IC
hwevm.the WIbinG a hopronmeou is adtl w1d in ono year of mmpktion,thiso -
WBaer wIl W.e Into bmdrn of podnt War he did em bald m imprme for purymc of
arta)
i
,m 1.aownmojft ctpo.7()4.m itwiandmnlTln(wiW:)Th.M�Ocwsb
coutrucl the project(St.]06.1.Bwinm and ry witiou code:)The Camlcnda Li,
cons[ntr tlma sot apply n m db a of vu-wr(y who Wilda rt hnPm.v therton,ata,
MOOcontractsLiforamh pojnmaWW.cmucw(a)I{mucd punaanl bre ComrcwM1
Lk a mow.
❑1 am p ac Sec ,B d:P fo eow®
Uvw- Dau
cis.
`� -W RKERS COMPEN ATION DECLARATION-
1ho by aflhm under pm Ityof perjury ono of tK falkwint -
1 bs.e and will maimaiv•CeNnwe al comm in aeIf.i.for Worke'compm
u -
tiam,as pnd for by Section 3' ar the Mbar Cade.for One performaram of the
work for which his pmmlt is isRsd.
❑1 haw aril wi0 maintain Waked CampewJo t Insvuce.as gvirtd by section
1700 of ft L.bm Code.for tW prfor .of be for which this p,.k is iaued.
My Workce,Co orcwation Inmana conics and Pdiry number are
Cankr. Poky No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbstsa'tim Deed sot W cmpkstl BIW pmnh J fm ors hundrta dollars(5100)
a loss.)
I ratify that In We psfvno.us a ttr work for which this prmit H iuucd.1"I not
employ any person in arty mamgr apa¢n hemmc svbltt b uK Worien'camprnsatkn
Laws of CJifomia Due
Applicuu G l
NOTICE TO APPLICANT:If.afmr maki.1 this Ccr1lit.of&oon,yon shmW
Wiens avb)W b We Wmtch Conpcnutim prem wom a(the Labor Code,you mare
O foMwib comply wib such proiii..a Ina permit shill W dais mmtcd
z CONSTRUCTION LENDING AGENCY
I homby alikm the Wim is a cmwtuctim kvaint atcrcy for the performarc,or
[(> tW wurk fu which this;Pmnit is iaued(Sm.3DTl,Cir.CI .
AIsnacla Name
=z lender:AdGrs
U O I Purify,that I have rend thio applfution and auto the IK abOW ivfomn.tion la
coned 1 atter to comply with N city and county ordl..,,.ws and sus laws m)atint to
Q Wildint conwuctim,ane bemby authorise rtprtenml.a of this city to row upon lW
above-mmt oW popcny for lupcctian perp.
IWO).tme to u.e,in4mnify and Isep harvikus be City ar Copenim ataiwt
h nabililit,judtmmw,eousand!sapnstos which may la any way at=rc.ts sac!City
U ineonsti.of dm Lramin,of this permit
a"^ APPLICANT UNDERSTANDS AND WILL COMPLY WTDI ALL NON-POINT Issued by: Date
SOUER GU ONS.
02� �tx. o.� g (31/oS• Re-roofs ���
SiVollim canoComrcmc DD
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIR the aWlica••or fvbrt Wilding ombam awe or hatdk huuams musrial
as c1cimd by ttr Cupertino Muwi Code,Chapbr 9.13.and!the Nt1th and S.ItLy
Curb.Solon 25532(.):. - All roofs shall be inspected nor to an roofing material beim Installed.
pYr � Pe P Y g g
Will tW wi fu.WilWatxcup.m us egvipmcm rt dcd¢s wpkh If a roof is installed without first obtaining an inspection,I agree to remove
n nafuanus Jr canumiunu u by the Bay Ate AI taohty Mm.iemmt all new materials for inspection. -
Disuin
❑m
1 have tail ds nuudmsmucrials rtqu'ucmcnu under Chapkr6,95 arts C.IIo.
Ida Health&Slay Cade.Sccvwn25505.25533 am125534.1 ondeiumd bnifdc Wikfmt
Joon teunmdy haw.taunt bar it my marPomibility W ratify tic occupant Of the
q hkh emctpwrtanatt,maoracetwtteof - Signature of Applicant Date
w ^'�� S�si All roof coverings to be Class"B"or better
owvervwtlwJr<e.Lem - Da¢
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35611006 . 00
DATE ISSUED. . . . . . . : 08/31/2005
RECEIPT # . . . . . . . . . : 31027
REFERENCE ID # . . . 05080273
SITE ADDRESS . . . . . : 939 BUBB RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : HEATHER . SIMMONS
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4965
RECEIVED FROM . . . . : HEATHER SIMMONS
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ------ ---- ---------- ---------- ------ - ---
BPERMFEE VALUATION 6 , 045 . 00 137 . 16 0 . 00 137 . 16 0 . 00
BPLANCHK PERMIT FEE 137 . 16 183 . 04 0 . 00 183 . 04 0 . 00
BREMVENFAN NO UNITS 1 . 00 45 . 39 0 . 00 45 . 39 0 . 00
BSEISMICRE VALUATION 6, 045 . 00 0 . 70 0 . 00 0 . 70 0 . 00
BENERGY PERMIT FEE 137 . 16 65 . 84 0 . 00 65 . 84 0 . 00
ELECTRIC SQUARE FEET 60 . 00 4 . 80 0 . 00 4 . 80 0 . 00
PPLBG SQUARE FEET 60 . 00 4 . 80 0 . 00 4 . 80 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMFEE SQUARE FEET 60 . 00 4 . 80 0 . 00 4 . 80 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
-------- - - ---------- -------- -- ----------
TOTAL PERMIT 561 . 64 0 . 00 561 . 64 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
---- - - ---- ------- ------------ ------ ------------
OTHER 561 . 64 561 . 64 VISA
TOTAL RECEIPT 561 . 64
•
acCITY OF CUPERTINO 27.3cuEr�TiNo PERMIT APPLICATION FORM
APN # 3 S6;, I ( O 06 Date: 31 OS
Building Address: Mailing Address (if different from building address):
93� B R�
Owner's Nag: Phone#:
ke"taz .ot s . 5(�D4 6532
Contractor: n...)0`8(Z • Q License#:
Contact: Phone:S6y 6$ 32- Cupertino Business License#:
RCA.i i Su.n,oerS Fax:
Building Permit Info:
Bldg ❑ Elect fid" Plumb � Mech V
Job Description:
Residential ❑ ( l1(���^ �oa� #t Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.: 6 O
Cost of Project: - Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard Laze ❑ Major ❑
Ouantitv Fee ID Fee Description Fee Grou
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elee 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
#
lof3 � ( /
CITY OF CUPERTINO
CUPEf�0 PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMTTIGATC Comm. Housing Mit. 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
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Repie Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER InstaWAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfin MECHANICAL
BREMAIREAN A/C Units<= 10,000 efin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
(� CITY OF CUPERTINO
CUPEI�- PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Sigris Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
/ BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
6 ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
G 0 MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMUTFEE Plumbing Permit Issue PLUMBING
�d PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Pi-anning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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• �'�' �� RECF►ti' �;j
AUG 3 0 2005 I
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CUPERTINO
Assessor's Parcel Number: 3S(D l l Ooh
Name of owner. kLQA:�)bM t TAN S'(XAJC)>J S ,
Project address. l )9
Contact person. P-,�,er Phone. S�>4 h� �2
Fax.
Net square footage of lot.
Existing Proposed.
Square footage: First floor:
Second floor:
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 N
On what floor(s) is work being done? 22
Brief description of work. M • S--x, O
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
CoN '� tr S'1e�T-Z,'DrNDS .
e
Plan Review Process Work Book Page-8-Revised 4/28/04