03110017CITY OF CUPER'PINO
BUILDING DIVISION PERMIT
.CONI RACT(7R INFORMATION ''d
BUILDING ADDRESS:
PERMIT NCA 3110017
NANIE:
PERMIT ISSUE DATE
JOR CLARK
4 2003
PUER'S
NI:
SANITARY NO. CONTROL NO.
ARCHITEC AINGINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I affirm mal I am fiecoBed ower proviah,ma ercnamer 9 commencing
p
whh senor 1 Dor Divi.donJor the Bad, pQra and Prafcssions Code. and myliecnsc is
io 7 uN
in full fn¢ Jcf t.
Li«n g e L;e.N 7TION oz�s
FUNDATION UPGRADE
CONTRACTOR: CONSTRUCTION TECHNOLOGIES
_
Dam ca a. cw
ARCIIITF.CTS LARA< i+c�n�if
undersmud my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hcrchy affirm that I a crop, From the Cnmmemr's License Law for the
following mason. (Section 7031.5 eBusincas and Professions Code: Any city Or county
which mquir a peford m construct, offer, improv, demolish, Or repair any indenture
prior to its issuance, also inquires the applicant for such permit to Ole a signed statement
that he is licensed pursuantothe provisions or the Comment's License Law (Chapter 9
Sq. Ft. Floor Area Valu$t1op 000
e
(cd ting with Section l(ks))of DivisionJnf the Business and Professions Code) or
that he is exempt flu mfmm and be 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
34%TNM7dcr00
Occupancy Type
P )' yP
not more than five hundred dollar, ($50y.
❑ I, as owner of the pmpcny, or my employees with wages as their sole compensmion,
will do me work. and the swerve is not intended or offered for sale (Sec. 70l,L Business
Required Inspections
and Prorcedum Code: The Conmctors License law aces not apply to an owner of
property who builds or improves thereon. and who docs such work himself or through his
own em plorcos, provided that such improvements are not amended or offered for sale. IL
however. the building or imprevemenl is sold within one Year of completion. the owner
builder will have for, burden of proving that W did not Wild or improv for purpose, of
e�aW
1, as owner of the propcny, am exclusively contracting with licensed contractors 1.
■■®®��g
cons nmL the project (sec. 7044. Business and Professions Cade:) The Contractor's Li.
vee law does not apply to an owner of properly who Wilds or improves thereon, and .
1 O
JAN
who contracts for such projects with a convactor(s) licensed pursuant to the Contractor's
fl 1
L2004
Lice me Law.
❑ I am exempt under Sec. ,B& P C for this reawn
'BUILDING .
Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRtm order penally of perjury one of the fallowing declarations'.
I have and will domouin a Cer ificam of Cmvenl to self -insure for Workers Compcm
satlon, u provided for by Section 37W of the I:Wthm
r Cade, for e pcoonarre of the
work for which Nis Permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
POO of Ne labor Code. for the performanec of me work for which this periodis issued.
d.
Com_pmJs cion lamormee correier and Policy number art:
m r of '-e retic{ Pit74 �_
10
CERTIFICATE '
CERTIFICATE OF EXEMITIO
COMPENSATION INSURANCE
This section need not W completed flat Permit is foram hundred dollars ($1 00)
or less.)
I cenify thin in the perromm do or the work for which this permit is headed. I shall not
employ any person in any manner ao as to become subject o the Workeri Compemalion
Laws dr California. Data
Applicant
.
NOTICE TO APPLICANT: If, a@r making this Cenificxm of E.cmp(mn, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall W deemed mwimd.
CONSTRUCTION LENDING AGENCY
I hereby affirm mat them is a construction lending agency Ior the performance of
Ne work for which this Transit is issued (Sec. 301 Civ. C.)
lender's Name
Lender's Address
I cenify that 1 have read This application and state that the aWv. information is
correct. 1 agree to comply with all city and county ordinances and stale laws relating to
building construction. and hereby anhorim repreunutives of this city to enter upon the
.hove -mentioned properly for inspection pdToses.
(we) agree to save, indemnify and keep harmless the City of Cupertino against
liibilitim,jud ments. costs and expenses which may in any way acerm against said City
in ca etc of the granting of this for t.
UNDERSTANDS W COMPL WITH ALL NONPOINT
Issued by: Dale
GUL TI NS.�_y—o3Re-roofs
Type of Roof
App nUConmaar I DateHAZARDOUS MATERIALS DISCLOSURE
applicant or future building Occupant store nr handle hvarduus material
rOURCE
y the Cupenino Municipal Code, Chapter 9.12, and the IlcaOh and Safety
rection 255J2(a)?All
cithe
roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
applicant or future Wilding dcedpanl use expupmenl of devices which
o d air contaminants as defined by the Bay Arta Air Qualify Managc neat
all new materials for inspection.
es
1 have mad the hazardous materials requirements under Chapmr 6.95 of the Califon
Dia Hca, ctycdde, Sedom25N)5.2S5BJmd255Ja. lunJcrsundthmifore Willing
does t a nay have amoan al it is y responsihilily to nMfy the i toper of the
m tswhiehmust tlan ananraeenih morOeeupanay
1�
Signature of Applicant Date
All roof coverings to be Class "B" or better
eta as arise.) agent D,m
""ITY OF CUPERTINO,
7
PERMIT APPLICATION FORM L
APN #
r/
Date:
14
-7,T)-
— c)-,3
Building Address:
Offer's Name:
Ph ne
Qontractor:
License—cense #:
Boiler <� 100,000 Btu
Contact*
Cupertino Business License#:
Boiler > 100K to 500K Btu
MECHANICAL
Building Perm ll Info:
Bldg ,��tlect El Plumb El Mech El
Job Description:
Residential 'Nr el er
Sq.Ft. Floor Area: r
$/Sq.Ft.:
�Fwj'wlq
Boiler > 1.75M Btu
Cotof Project:
Occupanc up:
roup:
e
-"
to
Typ Construe '
lnd/Off/ConyrOQuasi_
is
i.
BAPPLOTHER
Othe
MECHANICAL
BBLDGFEE
Bldg Pennit sq. foot
BUILDING
Boiler <� 100,000 Btu
BBOILER2
Boiler > 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 500K to IM Btu
MECHANICAL
Boiler > 1M to 1.75 M Btu
MECHANICAL
�Fwj'wlq
Boiler > 1.75M Btu
�01;111MW
��10 Rww
onstruction Tw
E.
lnd/Off/ConyrOQuasi_
Con. Tax for BQ Zone
Hotel and Motel
Constax — Xesi/Mobile
1-01:14
Elec, 600V <= I OOOA
Elec 600V > 1 OOOA
�Lvv ZEN
ILI
ELECTRICAL
EneEgy Add Multi
Investi__
g
m
COMM. 110USIL.Eg NJ
N
L 2-1
1 of 3
CITY OF CUPERTINO
BUILDING DIVISION
BUILDING ADDRESS:
YV
PERMITNL
OWNERS NAME:
PERMIT ISSUE DATE
CLARK
11/04/2003
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOWS DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Berlin 7 )Of Division 3 of dic lh!�*% and Professions Cana, mid my license is
off, 1 1) 2-
71
FUNDATICN UPGRADE
a
,Fd
Date - cc lac
CONTRACTOR: CONSTRUCTION TECHNOLOGIES
ARCHITECTS LARATION
understand my plans shall be used as public records
Licensed Professional
OINNERBUILDER DECLARATION
I herchy affirm that I am exempt from the Contrai;tur's License Law for the
following roaqon(Scc�on 7031.5, Business and Prorci;idons Code: Any city Or county
which requires a permit to crounruct, altar, im, rove, demolish, or repair any structure
prior to its issuance. also requires the applicant for such permit to file asigned statement
Contractor's License Law (Chainct-9
Sq, Ft. Floor Area
Val u$tjoD 0 0 0
that he is licensed pursuaruto the powisionsofthe
(commencing with Section 70M) of Division 3 ofthe Business and Professions Code) or
that he, is exempt therefrom and the basis for ft alleged exemption. Any violation of
3 42MIGJ71riberO 0
Occupancy Type
Section 703L5 by any applicant for a permit subjects the applicant to a civil penalty Of
not more than five hundred dollars ($500),
1, u Owner of the property, or my employees with wages As theirsole compensation.
Required Inspections
will do the work, and the suAchim is not intended or offered for sale (See, 7044, B asinesS
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, And who does such work himsel f or through his
own employees, provided that such improvements are not inurided or offered for sale, If.
however, the building or imprivernent is sold within one year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
[3 1. As owner of the property, am exclusively contracting with 1; nsed contractors to
construct the project (See. 7044. Business And Professions Code:) The Contractor's Li-
cense Law don not apply to an Owner of property who builds or improves thermi% and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Lov,
0 1 am cxcm pt under Sec. 3 & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
sation, as provided for by Section 3700 of the Labor Code, for the performance of [be
work for which this permit is issued.
0 1 hm and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for ft performance of ft work for which this permit is issued.
Vy rker's Compensation Insurance Carrier and Policy number are:
Policy
CERTIFICATE OF EXEMPTIOPOM WORKERS'
COMPENSATION INSURANCE
Crhis section need not be completed if the Permit is for one hundred dollan, ($100)
or less.)
I certify that in the pufumance of the work for which this permit is issued, I shall not
employ any person in any mAniter so As to become subject to the Workcrs'ComPeasatioll,
Laws of California, Date
Applicant
NOTICE TO APPLICANT: if. after making this cerlificatc of Exemption, you should
become subject to the Worker*s Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shall it-- deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ, Ci)
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state lawis relating to
building construction, and hereby atubori7z representatives of this city to enter upon ft
above-mentioned property for inspection purposes.
(Wo) agree to save, indemnify and keep harmless the City of Cupertino against
flabditi.sJud ments, costs and expenses which may in any way accrue against said City
SCIE_ hi
I C YAU , Wf4 COMPLY WITH ALL NON -POINT
NDERSTANDS
Issued by: Date
G TR
Go FZ
Type of Roof
/ HAZARDOUS MATERIALS DISCLOSURE
zamflicant
will or future building Occupant store or handle hazardous material
as defined by the Cupertino lvftoucipal,CodcChapter 9.12. and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
L] yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant x,futurc building occupant use oquipmen i or devices which
amit hazardous Air contaminants As debited by the Bay Area Air Quality Management
all new materials for inspection.
Dyes
a Hell I ety Code, Sections 25505 25533 and25534. I understand that ifthe building
ffnily`3
Signature of Applicant Date
"I
All roof coverings to be Class "B" or.better
0,Cner or a orized agent Date