02030076 CITY OF CUPERTINO
t t'
BUILDING DIVISION PERMIT -�xCONTRAC,FOR-iINF,ORMATION " I
BUILDING ADDRESS: Rt7C CONSTRUCTION PERMIT N002030076
OWNER'S NAME: 21 MT ALPINE PLACE PERMIT ISSUE DATE
VOKACH' BRODSKY 11Z05/200'3
ONE (925) 672-8925 SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 (�
+Oo LICENSED CONTRACTOR'S DECLARATION
fF 1 horeby affirm that 1 am licensed undo,pmvkotms of Chapter 9(commencing Job Description
iag with Section 70,10)of Division 3 of the Businexaand Professions Com.andmyliccnscin
License
Class Lic.x ss erre"
i = fullforce ClREVISION (ORIGINAL PERMIT 402020069)
:moo Dam Contractor NO PERMIT ISSUED.
so ARCIIITEQS DECLARATION
ICJ I understand my plans shall be used as public rcomd,
to
u
G
Licensed Profecomil
90 OWNER-BUILDER DECLARATION
d<y 1 hereby affirm that 1 am exempt from the Contractors Lfecnm Law for the
following re (S
n. ectmn 7031.5,Busincss and Professions Code:Any city or county
20
3$ which requires a permit It,ennsuuet,alar,improve,demolish,or repair any sohm ure
¢s, primusis issuance,alwrequims the applicant for such permit to file a,signedsmmomin
gso
that hcisliccnscdPursuant oHeprovissomofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valu�t�000
�� (commencing with Section 7")of Division 3 of the Business and Professions Code)or
i R$ Nat he is accept therefrom and the animus for the Nicgcd exemption.Any violation of
Section 7011.5 by any applicant for a permit subjects the applicant o a civil penally ofv➢tuw fN Ai8t3t�er00
not more than fire hundred doilau(SSW). 8 ViOccupancy Type
❑1,as owner of the pmpcny,or my employees with wages m their sole compensation.
will do the work.and Ne awcture is not intended or offered for sale(Sec.7064,Busine¢
and Profusions Code:The Contractor's License Law does not apply to an owner of Required Inspections
pt 3perty who builds or improves human,and who docs such walk himself^,through his
own employees,provided that such impmvemeco are not intended or offered for salt.If,
however.lie building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for puryoa of
antic.).
j]L es owner of the sec.pnope"y,,B exclusively contracting with licensed cammnoss i-
come,La the project(Sec.o an Business and ny who
Code:)Them then on, Std
ace Inca tlom not apply to an owner of pmpcny who builds o,ant to
thereon,and
whocontractsLacu for such projccu with a conractor(s)licensed pursuant to lM Conoacmr's V
License
k I law.
❑l am exempt under Sec. ,B&PCfor this moan
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under peealty,of perjury ane of the fallowing declarations:
❑1 have and will maintain a Corificam of Consent to self-inau a for Workers Compem-
Sudan.m 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 Warker's Compensation Imurance,as acquiretl by Section
37W of the labor Code.for the performance of the work for which this pCm,il is issued.
My Worker'x Compensation Insurance earner and Policy number arc:
Center: Policy No.: _
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he completed irthe ionone is forme,hundred dollars($100) '
nr less.)
I certify that in the performance of The work for which this permit is issued.I shall not
employ any person in any manner set is to lsecomc subject m TM workers,Compemation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making This Ccnificatc of Exemption,you should s
become subject to the Worked Compensation provisions of The Tabor Code,you mum
z forthwith comply with such provisions or this permit shall bo deemed.voted.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency I'm the performance of '
2' the work for which this permit is issued(See.3097.Civ,C.)
:a••1 -Under'a Name
Lender's Address;
�z
J 0 1 comfy mat 1 have read this application and mum that the above information is
Fcorrect.1 agree to comply with all city and county Ordinances and state laws slating a t
0r✓ building COMITUnion,and hereby amhorim mpresemativcs of his city to enter upon the
yabove-mentioned property for impecom purposes,
(We)agree to ave,indemnify and keep harmless The City of Collor.against
ret liabilities,judgments.costs and expenses which may in any way&come against aid City
UZ in conminteee of the granting of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS.
Signature of Apphcant/Contracmr Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant Store or handle intentions material
as defined by the Cupenina Municipal Code,Chapmr 9.12.and the Health and Safety
cmm.5cetion 25532(a)?
ucYcs ❑Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment ordevfcm which -If a roof is installed without first obtaining an inspection, I agree to remove
emit ha+aAnus air contaminants as defined by the Bay Arca Air Quality Management
Dointhl all new materials for inspection.
❑Yes ON.
1 have mad the hmardouamaarials mquimmenu under Chapter 6.95 of the Califn.
nia Health h Safety Cale.Sadons 35585,25533 and 25536.1 undersmnd that if the building
Jas nol curemly hart a&nam Nat it is my m Wmibility m notily the cecupanT of Ne
requisments which mum be mat prior to umsnce ofa Certificate of Occupancy.
Signature of Applicant Date
Own.,or aothnriled ageol D,a All roof coverings to be Class"B"or better
! � CITY OF CUPERTINO , b Z�� ° ° 76
un
t• CUPERTINO ?ERMIT Ar?LIGATION FO
APN# / b Date:
' S Q-2-
Building Address:
21 S E
Owner's Name: Phone#:
Vey k — g 1 2
Contractor: License#:
RSL. Lon NL 1
Contact: Phone#:
2n �0 9 ZS b-? Z 891-S
Applicant/Contr#ctor: Fax#:
44 6I / S
uil 'ng Peirnit Info:
Bldg Elect Plumb Mech
Job cription:
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
Quantity Fee ID Fee Descri tion Fee Group
BAPPLOTHER Other A liances MECHANICAL
JBBOILER.2
BLDGFEE Bldg Permit s . foot BUILDING
BOILER1 Boiler<= 100,000 Btu MECHANICAL
Boiler> 100K to500KBtu MECHANICAL
BOILER3 Boiler> 500K to 1M Btu MECHANICAL
BOILER4 Boiler> 1M to 1.75 M Btu MECHANICALBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Conun/ uasi. BUILDING
BCONSIAABQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= IOOOA ELECTRICAL
13ELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Ener BUILDING
BENERGYADD Ener Add Multi BUILDING
BINVESTIGA Investi ation fee BUILDING
BMTTIGATC Comm. Housin Mit. Fee BUILDING
I of
/ Jax Kneppers Assolkes, Inc. joB VQXAGH — E�DS JKY RESI DENGE
Construction Consultants SHEET No. I OF
2950 Buskirk Avenue,Suite 180 CALCULATED BY WG DATE ✓�—�4—02
• Walnut Creek,California 94596
Tel.(925)933-3914•Fax(925)933-9370 CHECKED BY DATE
SCALE
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MAR 15 2002
By
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CITY OF CUPERTINO
• 10300 Torre Avenue Telephone 777-3228
INSPECTION NOTICE
BUILDING DIVISION x/
JOB Z J , 5 L /��CL'�/ U L DATE
ADDRESS TIME
DAILY REPORT O CORRECTION NOTICE O VIOLATION O
TYPE INSP.: BLDG.O ELEC.❑ PLBG.O MECH.❑
❑ STOP WORK ❑ REINSPECTION FEE
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WEATHER C�.>i�>lt. INSP.
CARD TO REMAIN ON JOB-SITE
MAR 15 2002
By
T Jax Kneppers Assocites, Inc. JOB liDKftGtf - .2�.Dskr RE"S r D ENcE
Construction Consultants SHEET NO l/J�� OF S
2950 Buskirk Avenue,Suite 180 CALCULATED BY i"�G DATE ✓�^/�—�2
• Walnut Creek,California 94596
Tel.(925)933-3914•Fax(925)933-9370 CHECKED BY DATE
SCALE
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Construction Consultants SHEET NO. `T OF 5
2950 Buskirk Avenue,Suite 180 CALCuuTED By �� DATE 3-14 —02
• Walnut Creek,California 94596
Tel.(925)933-3914•Fax(925)933-9370 CHECKED BY DATE
SCALE
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