04030002 CITY OF CUPERTINO
' BUILDMG DIVISION PERMs CONTF"RACTOR INFORMA
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BUILDING ADDRESS: TOMLINSON� CONSTRUCTION COYD04030002
DR
OWNER'S NAME: PERMIT ISSUE DATE
SO H
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: 4 BUILDING PERM IT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
400 LICENSED CON-IRACTOWSDECLARATION Job Description
FC hc
1 mby affirm that 1 am liecns,d under pmvid.r¢of Chapter 9(commencing
iW with Section 70,M)orDlvision 3 oldie Business W!Rofcssims Code.and my liccnm is
'n<6 In full to..
5q� uanwclva, f Lk.N 3 - BATHROOM REMODEL
4Dem Contractor '
ARCHITECTS DECLARATION
e< I und�i aayTd a pas
DyU
a Lmcnsed Profcaso
o�
OW NER-BUILDER DECLARATION
a�y<II hereby reaso .lino on I tiro cBusin from COin Contractor's License Law for COc
C following reason.Permit
lln1.5,Bushot. and Pm.deo mCodc:Any city Or County
m which require•pcmit ro cones the alms hnprove,h .l t1 Of e A sig any suucmrc
primmits issuanec,also require the applinnt for such permittofIca Law statement
Net he u licensed purwanuo the provisions of be Co..,., U¢nse law(chapter Sq. Ft. Floor Area Valuation
(commencing with Section 10110)M Division 3 of the Businea and Professions Code)of
A. $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of 3M15ftagIle700 Occupancy Type
not mart Yon five hundred dollas,(WOO).
L As owner of Use propmy m my employees with wage As their vele eompewYon,
will ft the work and the awcum is not intended m offered for side(Sec.)014,Business Required Inspections
and Professions Code:Thac
Tire Comtori e Lice=Law does not apply m An owner of q P
pmpeny who builds or)mpmvea Umcrcon,and whodoessuchwmk himself.,through his
OwnOwn employes,provided COCA such improvements semcnu are net intended m plecce0 for ale If.
eser,o e buildingde improvement r old within ane year of completion.ere,the owner-
holder will)ave do,Wmen of proving Nu M did.m build or improve for purpose or
ale.).
❑1,as owner of the property.am exclusively etimucting with licensed eomracmra m
construct the yrojea(Sec.70d4.Business and Profesians Cade:)The Conuacurs U-
< ns,law does rot apply in an owner of property who builds or improves thereon.and.
who contacts for such projects with aconuactor(s)licenxd pumuam in the CanvanaYs /���
Li taw.
1 am exempt undo Se<. ,B h P C for thio recon
Owner Dam OC/
WORKER'S COMPENSATION DECLARATION
1 beuby dorm under penalty of perjury mo,or the following dodaredoe:
1 have and will maintain a Certifier.¢of Conant to self-insure for Worker's C.mpen-
cauon,u provided for by Section 3700 of Ne Labor Code,for Ne performance.f to
work for which this permit is issued.
❑1 base and will mainuin Workers Campenam.I....u rcqusmd by Section
37W of me labor Codc.fa the pedmmanee of ire work fmwhich Nis permit is issued.
My Workces CompeexYan Insuance carrier and Policy number art:
Cartier. Policy N..: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbisued.a need mtbeeonpleted lithe permit is routine hundred dollar(5100)
of lcs )
I anify Nat in the perforromme of due work for which this permit is issued.I shall not
employany,Q�cctmssyy in any mannerou to Weomewbjectaalkworkmi Compensation
Laws or Cay,IjRyna'.Dam _
AGTR: t
GTICE TO APP :IL after making Nis Cenifinte of Exemption.you should
e subject ire Worker's Compensation provisions of sec LoWn Code,you must
.J O fo wise comply with such Provisions Of this permit shall be deemed revoked.
ZCONSTRUCTION LENDING AGENCY
�
1-. Ihcmby.from COCA Vert is a construction lending agency,for ire ped....of
Ca > ire work for which this Permit is issued(Sec.3097.Civ.C.)
D]A tenders Name
0. Lenders Address
V 0 1 cenify that 1 have mad this application and sum that ire above information is
f" Comma I agree to comply with all city and county ordinances and auto laws relating to
O U albOvengcommsvud pro and hereby authomirt¢preenuYws of Nu city atom,upon Jou
DO shove-(We) o,tlpropeny rot demnify And ho,hs.
(Wc)agme to ave,indemnify and kith hay in an w City ru Cupettsna against
a /
N liabilities.judgments,ensu and expenses which may in my way acerve againstaid City /
V z APPLICAN ec UNDERSritic TANDS
of this permit.
^ APPLICANT UNDERSTANDS AND WILL C PLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU
31,11+ Re-roofs
Ngrum L6,ric,anVc.n RDD a D.a
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
II ire applicant or future building Occupant store or handle hardous mamrial
u 0netl by Ibe Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,srcdm,1553z(a)71 All roofs shall be inspected prior to any roofing material being installed.
El Y. *h
Will the applicant or future building Occupant use equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
emit U.mous is e.naMit.nu As de0ned by sec Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Nu
1 havemem ire hanrdnus materialireyuiremcnts under Chapter6.9Sof ire Califor-
niaHcaluhSa etyCWc,Sa6ons15505,15533md15534.lundersmnduatif0e Wilding
docs not cuncntly have a enant.that It OZ�y respomint y to notify the occupant of sec
mquimmentswh ee.f.C,.iAA.ofOccup.ney' Signature of Applicant Date
All roof coverings to be Class"B" or better
\ O ner uuhmircd agent Doc
fkTY OF CUPERTINO _
CITY OF PERMIT APPLICATION FORM 0= °a 6 b�
CUPERTINO
N# b Date:
Building Address: Mailing Addfess (if different from building address):
a Oct/(o Fs260 O/, l/
Owner's Na me: Phone #:
ContractorT License #:
/Oir7�/,✓su,✓ l.✓s?Rcr Tw✓
Contact: T J Phone: a 8i —73.?,6 Cupertino Business License#:
.d�l+v /gym/1�s Fax: aki- '2.3-t-6
Building Permit Info:
Bldg Ele Plumbech
Job Description:
Residential AMor7 Commercial Q
Sq.Ft. Fl oo ea: \ $/Sq.Ft.: —
Cost o Project: Occupancy Gro �2,7
Type o ConstructionPlease check th oject is a
61y"neJ second-story addition:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BB0ILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
13CONSTAX 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 <= 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
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RECEIVED
MAR 012004
CITY OF CUPERTINO
BUILDING DEPARTMENT
CITY OF CUPERTINO y'tw ` '
BUILDING DIVISION PERMIT �CONTRACp .,T,OR INFO TIONS;
BUILDINGADDRESS: TOMLINSON CONSTRUCTION CO Y"04030002
.R'S NAME: PERMIT ISSUE DATE
SOPH
E:
COODRILT, rrr7 qTJPT,T, A172 Q2'/03 12004
SANITARY NO. CONTROL NO.
4 281 -7126
ARCHITEC ,ENGINEER: BUILDING PERMITiNFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION O O O O
m❑ 1 lmmby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
ZW win Sccsion]IXk))of Division3af the Husirtnssand Profcuiam Code.endmyliccnse is
PSH ihhr meea U p
ME3K Liccslseclas W Liox_ BATHROOM REMODEL I�A�SIL�'®
\ Contractor n LWrI�
Ise dds�imyt'I ARCHITECTS DEC ATION
c_ MAR 2 5 2004
JyU a
3 LL Licensed Protests.
OW NER-BUILDER DECLARATION
a_p< Y
<I I hereby afrom that I am exempt from the Com,.,.,'s License Law for the B ILIA G
00 following season.(Section 7031.5,Business and Professions Code:Any city or county M 'Y
K 2 E� which requires a permit to construct,alter,improve,demolish,of repair any shucmm znn
,t vv prior us its issuame,also requires thespplicant for such permit to file a signed summem
�i< fast he a licensed purmant to she provisions of Ne Contractor's Liacnx Law(Chapter 9 Sq. Ft. Floor Area Valuation
m (commencing wish Seetion 7")Of Division 3 oftW Buirmai Proressimu Code)or
i Nat he is exempt therefrom and IM basis fa the alleged exemption.Any violation or
Section]031.5 by arry applicant for a Foods subjects the applicant to arnil penalty.( 3WNMM4cX00 Occupancy Type
not moa than Rte hundred dollars(S50)k
I,as owner of the property,or my employees win wage as their to compensation,
will do the work,and the stroaure is not intended or offered for age(Sec.]044,Business
and Profusions Code:The Contractor's License Law dean not apply to an owner of Required Inspections
propanywho builds.,ima.vnsnereon.and whod.cssuch werkhimulf ordrrough his
own employees,provided dim aitch improvements are not intended oroReaed torsade.If,
however,the Wilding or improvement is sold within one year of completion,the owner-
builder will have the Wrdcn of proving that he did as Wild or improve for puspue of
sale.).
Q 1,as owner or the property,am utluively contracting win licensed com actom ton
construct the pmjca(Sec.70a4.Business and Professions Cade:)M Contractors Li
cove Taw docs not apply to an owner of property who Wilda or improves themon,and
who contracts for such projctts win a communists)licensed pursuant to she Comment's
tLaw,
,am mmonprunde,Sec. .B&P C for this mason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby allirm under pcnslty of perjury one of the following declarations:
have and will maintain a Certificate of Conserv to self-iosum for Workn'sCompcn-
snsion,ns provided for by Section 3]00 of the labor Code,for the performance of the
work for which this permit is isstred.
❑1 have and will maintain WoCompensation Insurance,ns required by Section
37W of the labor Code.for the performance of the weak for which this permit is issued.
My Workers Compensation Insurance carries and Policy number am:
C.nio, Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thu acmion need nOtbecomplemd if Ila permit is for one hundred dollars(SI W)
or less.)
T ccnify nm in the performance of the work for which this permit is issued.I shall not
employ any��rsyyn��in any manner an a m become subject to the Workers Compensation
Laws of CalI. ..Date
Applicant
tJOTICE TO APPL :If,a@r making Nis Certificate of Exemption,you should
e subject dm Workei s Compensation provisions of IW labor Code.you most
.J O fo ith comply win such provisions or this permit shall W domed revoked.
'Z"' CONSTRUCTION LENDING AGENCY
'p+4 I hereby alms oat nem is a construction lending agency for sW Performance of
a> the work for which this permit is issued(Sec.3097,Co.C.)
6W.Q Lenders Name
a z Lender's Address
U C) 1 ccnify that 1 have mad this application and state that the shove information is '
u�P correct,)agree to comply with all city and county ordinances and sum laws relating to
O U building construction.and hereby authodre representatives of this city as caner upon the
r[S7 ahnve-mentioned property fa inspection purposes.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
F'faj3 liabilitins,judgments,toss and eapettses which may in any way acc=against said City /
U Z. in emembrancc ml
of the granting of this mit.
�--' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU},A}l
L 9 i a Re-roofs
ignaturc of m HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
ell Ito applicant or future Wilding occupant from or handle haaudous material
flood by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
e.Section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
Yu
Will the applicant of future building Occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
I ha'rardnus air contsmi ants ns defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes N.
1 have mad the harardom materials requirements under Chapter 6.95 of the Califor-
nia Health&SafctyC.de,Sauces 25505.25533 aa125534.1 undecorated tat if the Wilding ,.
docs not currently have a¢rant oat it is mspOnsihili y m notify an,occupant of the
mymmmentsw oant"ZIO:ftintamoroctopanty. Signature of Applicant Date
0
O mr otho,dred agent Dam All roof coverings to be Class "B" or better.