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04010041
CITY OF CUPBIL'I'INO � CONTRACT BUILDING DIVISION PERMIT' OR INFORMATION 7?, f4wkrA BUILDING ADDRESS: PERMITN0. ERIC F ANDERSON INC 04010041 OWNER' NAME: PERMIT ISSUE DATE NE: SANITARY ONTROL NO. ARCI IITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 �Oo LICENSED CONTRACTOR'S DECLARATION Up I hemby air,.mut 1 am licensed ander ons of Chapter Y(commencing Job Description �W wi hSentn7 OufDiAtion 30fthtimsi=, fessiuns Code.and my licenmis in full fns i sOil effcc P25LI� ;'q? L CO.,T LX.X REVISION--IN HOUSE USE ONLY ,—o Dam — e cmnbae e " ti Ka NO NEW PERMIT ISSUED/ORIG. $ 03120107 ARCHITECTS DECATION w u 1 uMeaunJ my plans shall W used ie records ;�� Licensed Professional `n < OWNER-BUILDER DECLARATION 9 s 4 1 hereby affirm that I am exempt form Ne Contractor's License Law for the O o following mason.(Section 7131.5.Business and Professions Code:Any city or county K m which¢quires a remit to construct,niter,improve,demolixh.or repair any structure °=�, prior to its issuance,also requires the Applicant forsuch permit to file a signed statement nt< that he is licensed pursuanuo the provisions of the Com.eturi Licenu law(Depter 9 Sq. Ft. Floor Area Valuation$3.2. xHn (commencing with Section 7(I(10)of Division 3 of the Business and Professions COJe)ur Y i $ that he is exempt therefrom and the basis for the alleged exemption.Any=of 'Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type not more Nan five hundred dollars(350). 1.u owner of the prop=ny,o my employ=ea with wages u their sore compensaumn. 3 5917019 . 00 will do the work.and the swdum is not intended or offered for sale(Sec.7014.Business and Professions Code:The Contractor:License Law dors nut apply m an owner of Required Inspections own cr y wbm builds or improves thereon,end who am osuch work himself or tluough hu ownemployees,provided that techimprovementsin not intendedmpledodroe owner. builder .Nebuilding uden of pmetn is soldwithinane year of completion,be owner. builder will have the burden of proving Nat he did not build or improve Or purpose or sale.). ❑1,as owner of the property,am exclusively convening with licensed contractors to emiswn the pri(Sec.7044,Business and Professions Code:)The Contractor's Li. Cease law does not apply to in owner or property who Wilds or improves thereon,and, CO who concocts for Such pro*u with a contractor(s)licensed pursuanuo the Contractor's [D IaSm Law. ❑ am exempt under See. .B A P C for Nis rcasnn \ ' Owner Date WORKERS COMPENSATION DECLARATION I hereby affimt under Penalty of perjury one of the following declarations: I have and will maintain a cemacem a Cmment to self-item.fur Worke6 Compere cation,u provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker:Compensation Insurance,ss required by Section 37000(the laWr Code.for tW perfmmmce of Ne work for which this pc.it is issued. My Warkeli Compensation lost7 camicr and Policy number art: Ca : 1�IPol �ie F"N ityWm.:S�Io0101`j0 CERTIFICATE OF EXEMPIIt)yFROM WORKERS' COMPENSATItlOKKllNN66URANCE mus section need not he compined if tie permit is for one hundmd d011am(6101) or less.) 1 certify Nat in the performance of the work(or which this permit u mixed.1 shall not employ any person in any manner m is to hemme subject 0 the Workers'Compemation Laws of California.Date Applicant _ NOTICE TO APPLICANT:If,after making this Cenificam of Exemption.you shmuld become subject to the Worker'a COmpetuation provisions of the lalmr Codc.you must .J O forthwith comply with such provisions or this permit shall b=deemed.vokcd. Z Vy CONSTRUCTION LENDING AGENCY (. I Mmby affirm that there is a comtrection lending agency for she Performance,of a ? Ne work for which this pemdt is issued(Sec.3097.CO,C.) LQ 0 Lender's Name 4' Lenin's Address U 2 1 certify Net I have mad this application and said Nat We aWve information is f' correct.1 agree to comply with all city and county Ordinances and sum laws relating to 0U building convection,and hereby authorize represcnmtives of his city to enter upon the } W aWve-mentioned Property for hersotion purposes F (We)agree to save,indemnify and keep harmless the City of Cipmino against j1' N liabilities,judgments.costs and cxycnus which may in any way accmc against said City / U Z, in conseque the Starting mf this permit. ^' APPLIC AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOJJQ J2 ONg. 444f (57 SSS •� (—n—ov goam?E of Applicam/Cmnvactor Date Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future Wilding occupant stare or handle EanrdOus material m defined by the Cuycnmo Municipal Code,Chapter 9.12,and the Health and Safety Cole. Vet 255)210)? da All roofs shall be inspected prior to any roofing material being installed. 7ni. Will thea applicant or rutore building occupant use e t or devices which If a roof is installed without first obtaining an inspection,I agree to remove rap s p ysipm=n aiamoes air conummants u defined by he Bay Ama Air Quality Management all new materials for inspection. c0 •L•Y•rt// 0 Ycs I have read the Worardous materials requimmenu under Chapmrb 95 of We Califon alN St SafetyCac.Sacts.n91515533 and25534.I understorm Nu iftW Wilding not c have a tenant.that it u my eupmedibility to amity the a[uPant of he rtm= veli: �^^ tpWrtoissaanamfleenR=ammrOcemnan=y' On-tureofApplicant Date r mmrivcd agent Dam All roof coverings to be Class "B" or better CITY OF CIJI'EIYI'INOoaa�A71 ,r ' "`' BUILDING DIVISION CON112ACfLOR INr'004 PERNO 4, BUILDING ADDRESS: PERMIT NO, .. ERIC F ANDERSON INC 04010041 O NER'SNAME! PERMIT ISSUE DATE NL SANITARY 1 2ONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECII 0 t� Q00 LICENSED CONTRACTOR'S DECLARATION Job Description wp 1 hereby.(Firm that 1 am ns liceed untie,provisions of Chapter 9(commencing P iW with Seaipn 190(l)of Division 3afth2 Business abgProfessium Codd.antl dr,he..is n<n in durfeeLi Lica P,LS40 REVISION--IN HOUSE USE ONLY -OOUjZ License 1 s ;moo Dam '— 'I--. cummesy�r 'iL F_ z:a pqg NO NEW PERMIT ISSUED/ORIG. #03120107 L Wy 1 ARCHITECTS DECL`AKArea y < Irodcnnand my plans shell he used as`pulfle rdcnrdx LxUy LL N Licensed Professional x.011 OWNER-BUILDER DECLARATION `)y a Y 1 hereby.firm that 1 am exempt from the Commetor's License Law for the 0 0 following m n.(Scedun 71313,Business and Pmfcssm iuCode:Anychy or county K m which requires a permit m cnnstrvn,alter,improve,dcmnlieh.or repair any toward °i„ Prions its issuance,also inquires the applicant for such Permit o file aligned statement etSC that he is licensed pmsmnuothe provisionsofthe ContractorsLicense law(Chapter 9 Sq.Ft. Floor Area Valuation$32 ad (card dimming with Stenon 700(oof Division 3 of the Business and Professions Code)or .- that he is exempt thcrefnsm and the basis for the alleged exemption.Any violation of 'Section 7031.5 by any applicant for a permit subjccu the opplicanuo a civil penalty of APN Number Occupancy Type not more than five hundred dollars($500). 01,as owner of the property.or my employca with wages as their sold compensation, . 35917019 . 00 will dea Ne work,and as swcture is not intended proffered ficaudd(See.7044.Business and Pmfcssions Cod Code:The Contactors License Law does not apply to an owner of Required Inspections property who builds or improves mereon.and who does such workhimselfor through his own employca,provided that such improvements are not intended or offered for st If. however,the building or improvement is sold within one year of completion.Ne owner- builder will have the burden of proving that he did not build or improve for purpose Of salcJ. ❑1.as owner of the pmpeny.am exclusively connecting with licensed eontaaors to construct die project(Sea 1044.Business and Professiors Cade:)The Contractor's Li Come,law does not apply b an Owner of property who Wilds Of Improves IIKnam.and, who contracts for such projects with a simusctor(s)licensed pursuant to the Contractor's Line ve law. ❑I am exempt under See, ,B&P C for this Mason Owner Date WORKER'S COMPENSATION DECLARATION I hereby afliml under penalty of perjury one of the following declarations: 1 have and will maintain a CeniGnle of Continuo self-insure for W9rlon s Compen- sation,as provided for by Section 3700 of did labor Code,for the Performance of did work for which this IOM it is issued. ❑1 have and will maintain Worker's Compensation Insurance,as requited by Section 37W of the labor Code,for the performance of the work for which this pemnit is issued. My Worker's Cnmpensa n I eamer ns and Policy number am: ea S(RTC r�N ePmmy o.:S7100i01`(U CERTIFICATEOFE%EMA WORKERS' COMPENSATI URANCE Cleo section need not Mcomple¢d if tit permit is for one hundred dollars(SIM) Lo-less.) 1 certify that in the performance of the work for which this permit is isudd.I so.11 not employ any person in any manner so tu Bt become subject to the Workers Compensation Laws of California.Date Applicant - NGTICE TO APPLICANT:If,after making this Cer ifieem of Exemption,you should - income suhjcct to the Worker's Compensation provisions of the labor Crot you must .J O forthwith comply with such provisions or this Permit shall M deemed revoked. z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a coatrvetion lending agency for the Performance of a the work for which this permit is issued(Sec.3197,Civ.C.) 12.1 A condo's Name gY, Lender's Address U t7 1 certify that 1 have read this application and sure that Ne above information is m/ correct. cons agree m comply hereby someone and county ordinances and smc laws t r upon to the 0 U building coniwclion,and hereby aothori>e rtprcsemalires of this city menmr anon the I3] a1ovcmentiuncd property for inspection pugwses C. (We)agree m save,indemnl ry and cep harmless the City of Cupcnino against t F' N liabilities,judgments,cusu and ex pensms which may in any way accrue against said Ci try / U z in eonscroma eo(the Sonata,of this Permit. .r APPLIC U, FJISTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date _ S�O,�} .RE U IONS 1}-0LI Y.L ��p " .� ( Re-roofs Signature of Applican✓Contactor I Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant Lir future building Occupant, tore or handle havamous mammal as defined by the Cupertino Municipal Code,Chapter 9.11.and the death and Safety Code,Stiction 25532(.)] All roofs shall be inspected prior to any roofing material being installed.❑Yes d�u Win the applicant Of future building oecu ant equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove v use yaiPmen mit hazardous air conuminanu ss d fined by the Bay Arca Air Quality Management all new materials for inspection. District? Yes I have mad Ne havardnus materials rcyuincomms under Chapter 6.95 of the Cali for nice Health&Safety Calc,Sections 25505,25533 and 25534.1 undersand thn if the building docsnot cu LL M1ave a¢na 4 NT it u my revlxmsipility In nndly IhC iv:cupanl of Ne - equherde hi y�sr�c,n5tpnlonui,avatdenraeertiadatenradupatey' Signature of Applicant .Date 1 owner ,Imria.cd agent Date All roof coverings to be Class "B" or better O* 1 "(+E©�- CITY OF CUPERTIN ,,�')� ' 2— � CITY OF PERMIT APPLICATION FORM CUPERTINO APN # D Date: Building Address: 1Otl S (, e- A vZ2A p uDi Owner's Name: Phone #: R,_S- ;1.56- 0666 L De+GS )r,,6 $%ores �1^'�• Contractor: r�Crit F, ALicense #: ,�erso� Contact: Cupertino Business License#: Building Permit Info: / Bld lect ❑ Plumb ❑ / ch ❑ J6b Description: .� Residential ❑ o er i 1 S,q.Ft. Floor Area: S/Sq.Ft . c / Cost of Project: Occu ancy Group Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING 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 Elec 600V <= IOOOA ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING zz/ 1 of3 ��, l�✓��