03060068C l'Y OF CUPERTINO
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I CONTRAC„TQR INFORMATION ",
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMITN 03060068
:R'S NAME:
PERMIT ISSUE DATE
NE:
SANITARY C ROLNO.
ARCHITECT'/ENGINEER:
BUILDING PENMITINFO
BLDG ELELT PLUMB MECH
n
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirmthat I am licensed der provisions or Chapwr 9 (commencing
with Section] 1)tif Division Sof the Brat <and Prufcuium Code. and mylicenaeis
in full forte effect.
F/ 16! A ��
. I'St1 A D
udcn��Cout T o
ADD 1086
S4. FT. /REMODEL
Dam Cunmacmr
ARCHITECT'S RATION
MAR 1 5 2004
1 understand my plans shall he used as public records
BUILDING
Licensed Podcssion d
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from me Contractor's License Law Or the
following reason. (Section 7031.5, Business and Pmfecsions Code: Any city or county
which acquires a permit m construct, alter, improve, demolish. or repair any structure
prior to its issuance, also requires Ibe applicant for such permilto file a signed smrentent
Sq. Ft.
Floor Area
Va
mat he is licensed pursuant the provisions of the Contractor's License Law (Chapter 9
uauon
IMmencing with Section 7") of Division J of Oc Business and Professions Code) or
mal he u exempt tberefrem and the basis for be pllcged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant a civil penalty of
not ream man fire hundred dollars (M).
❑ 1, Ll owner of me preperty. or my employees with wages as Initial. compensation,
101
— FOUNDA d Inspections
wilt do the work. ad theswctom isnot intended ar altered mdaeb(See .)Ildd, Business:
and Professions Code: The Commodities License law does .1 apply m an net of
property who builds or inform tbenon.and whoduessuch work himselfor mmugh his
102
— PIERS
own employees, provided that such improvements are net intended or olferil for aide. If.
103
— UFER
however, me building or improvement is sold within one year ofeomplemon,Beowmer-
builder will have the burden of proving mat he did not Wild or improve for purpose of
104
— RE BAR
sack.).
105
— 'ANCHOR BOLTS
01. as owner of the property, am ucluaivcly contracting with licensed convectors ro
construct the project (Sec.70dd, Business and Professions Code) Tte Conmactor's Li.
106
...
— SEWER & WATER
me law Urea not apply m an owner of property who builds or improves thereon.and
who contracts for such projecm with a c^nvactor(s) licensed pursuant m the Conmscmea'
202
— UNDERFLOOR PLUMBING
Licedualaw,
203
— UNDERFLOOR MECHANICAL
❑ 1 am uempt under Sec. . B 6 P C for this reason
204
— UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
205
— UNDERFLOOR INSULATION -
Ihemby affirm ander ahud"of pedo, ore or me following declantiona:
301
— ROUGH PLUMBING
I'an and will maintain aCenmemetifConsent 10sdeinson,rorWorkeraCooper.
302
— TUB & OR SHOWER
aatiom, as provided far by Seetimn 37W of the Labor Code. ter the peranomee of the
3 03
— ROUGH- MECHANICAL
work for which this permit is issued.
304
— ROUGH ELECTRICAL
❑ 1 bits and will maintain Workers Compensation Insurance, u required by Section
37M of the labor Code, for the performance of IM work for which this permit is issued.
3055
— FRAME
MylWoraker's Compensation Insurance carrier and Poli numberam:
CadecJ P Police D0>0 —��
306
— HOEDOWNS
llV// CERTI CATEOF EMPT FROMwoKKERS'
307
— 'INSULATION
COMPENSATION INSURANCE
308
— SHEETROCK
(fhisaccHosioned nulbecomplereJ Kim permit is Intent, hundred dollen (SIM)
309
— EXTERIOR LATH
nr kis.)
3 10
— INTERIOR LATH
I century that in the perithroamo of the work Tor which this Permit is issued. I shall not
employ any person in any manner m as m became subject IN Workcri Compeosadon
311
— SCRATCH COAT
Laws of California. Data
Applicant
313
— ROOF NAIL
NOTICE TO APPLICANT: IL alter making this Cenificam of Exemption, you should
501
— FINAL ELECTRICAL ENERGY
became subject to me Workers Compensation Previsions of the Labor Code, you most
forthwith comply with such noviardisorOf. permhahaBNaccrued m.nkcd.
502
— FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
— FINAL MECHANICAL ENERG
I hereby affirm mat mem is a construction lending agency for the performance of
504
— FINAL BUILDING ENE RG
ds, work fur which this permit is issued (Sec. 309], Civ. CA
Lender's Namc
505
506
— FINAL ELECTRICAL
— GAS TEST
Under Address
1 Gentry that 1 have read this application and sure that the i Wve information is
correct. I agme to comply with all city and county on inaMes and state laws relating to
507
— FINAL PLUMBING
posed
building am¢kerion.andhembyathorimreoses. tirssofhis City tticntuulnnlM
FIN MEC CAL
allovCmconstud pmpany, fon inspection
(We) egrte to save, inticmnify and keep harmless the City of Cupertino against
0 9
FIN
liabilities, judgmCnLa, coact and C.pc.aea which may In ane way aceNC against Said City
5
A
N]aK
in
APPLICANTeof the granting of UNDERSTANDSthis AND WILL COMPLY WITH AL N -POINT
]SSUI:d b y'5
I
SDate
SOURCE T;DNS,
Re -roofs
Type of Roof
�w10
/1Lz
Sig Dli HAZ for Data
HAZARDOU Md IA URE
alum at al
WillyI applicantof(mum build uhapumre2. handl
uand
HealthSafety
az defined by U¢ Cupertino Municipal Code, Chapter 9.11, and Ura Hcahh and Safely
C. Section 15532(a)'
All roofs shall be inspected prior to any roofing material being installed.
c Yet
If a roof is installed without first obtaining an inspection, I agree to remove
Win mea (terms tir tum buildin Occupant useequipment or devices which
pp g Da^aAr
it haxardnus air contaminants u JcOncd by the Bay Arta Air Quality Management
all new materials
for inspection.
iamics7 L��
MYcs CM,
I have
thCeo
reand
SScecctionm
0.oifllMme
25505.ls15re5qluJi
25534.1 understand
Wildinga-
net hSafety dWc,vs
does not currently have a tenant, Nat it is my responsibility In nodl'y the the
¢qui chmost be me( pdorwissu tic. entre dmna^cy.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
wmerm I died ret Dalo
CITY OF
CUPEkTINO
CI jL f OF CUPERTINO f
PERMIT APPLICATION FORM
APN #
Date:
Fee Group
BAPPLOTHER
Building Address:
--,s 1-4- tLAYQn�--��r nom.
Owner's Name:
Phone #:
BUILDING
(40a) q G -- 3 89 4
Contractor:
License #:
Contact:
Cupertino Business License#:
'C�,A Y i D �� N �►'
BBOILER3
Building Permit Info:
Bldg Elect Plu b [X Mech
Job Description: J
� �"''" 0
Residential �K 1
Sq.Ft. Floor Area:
$/Sq.Ft.:
I Dg �o
MECHANICAL
Cost of Project:
Occupancy Group:
BUILDING
R- 3
Type of Construction:
BUILDING
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 1 M Btu
MECHANICAL
BBOILER4
Boiler > 1 M 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
BELEC 1000
Elec 600V <= l OOOA
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
I of 3
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CITY OF CUPERTINO
BUILDING DIVISIONPERMIT
CONT RACTC?R
INI+ORMATIO
BUILDING ADDRESS:
PERMIT NO.
03060068
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY O. C NTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
P
with Section 7 ) of Division 3 of the Businp.Ns and Professions Code, and my license is
in tall forces effect-
,� �? /S
License R
Lic.
ADD 1086
SQ . FT . / REMODEL
Date 'Z Cuntractor
ARCHITECTS 'RATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior u) its issuance. also requires the applicam for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractur's License Law (Chapter 9
Sq. Ft, Floor Area Va uaUon
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation.
101
— FOUNDA'd Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
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 himself or through his
10 2
— PIERS
own employees, provided that such improvements are not intended or offered for sale, If,
1 0 3
— UFER
however, the 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 purpose of
104
— REBAR
sale.).
105
— ANCHOR BOLTS
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
106
— SEWER & WATER
cense Law does not apply to an owner of property who builds or improves thereon. and .
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
202
— UNDERFLOOR PLUMBING
Lie`nexe
203
— UNDERFLOOR MECHANICAL
❑ 1 amrnexempt under Sec. , B & P C for this reason
204
— UNDERFLOOR FRAME
Owner ate
WORKER'S COMPENSATION DECLARATION
205
— UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one of the following declarations:
3 01
— ROUGH PLUMBING
❑ Ihaw and will maimainacertircateofConsent tosclf-insure for workers Com pen-
302
— TUB & OR SHOWER
sation, m provided for by Section 3700 of the Labor Code, for the performance of the
303
- ROUGH MECHANICAL
work for which this permit is issued,
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
304
— ROUGH ELECTRICAL
3700 of the Labor Code, for the performance of the work for which this permit is issued-
3 05
— FRAME
My Worker'sCompensation Insurance carrier and Poli number are: ,
CdrbC71 S./La'�i2 TZ.'1� Policy
306
— HOEDOWNS
"/J CERTI LATE OF1-XEMPTI IoM WORKERS'
307
— INSULATION
COMPENSATION INSURANCE
308
— SHEETROCK
(i-hissection need notbccompleted ifthc permit is foronchundmd dollars ($](X))
309
— EXTERIOR LATH
or los.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
310
- INTERIOR LATH
employ any person in any manner so as to become subject to the Workers' Compensation
311
— SCRATCH COAT
Laws of California. Date
Applicant
313
5 01
— ROOF NAIL
- FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT: If, atter making this Certificate 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 be deemed revoked.
502
— FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
— F I NAL MECHANICAL ENERGY
I hereby arum that were is
(Sec. 30 lending agency for the performance of
504
— F I NAL BUILDING ENERG��'
the work for which this permit is issued (Sec. 3097, Civ. C.)
s ed
��---"
Lenders Name
505
— FINAL ELECTRICAL
Lender's Address
506
— GAS TEST
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 laws relating to
507
— FINAL PLUMBING
building construction, and hereby authorize representatives of this city to enter upon theFIN
MEC C CAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
09
FIN
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
5
NG
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N -POINT
Issued by.5
C WORKS Date
SOURCE T10NS.
Re -roofs
Type of Roof
l t
SigkW pli nt/Co ctorJ Date
HAZARDOU MA IA S' ISCLOSURE
Will the applicant or future buildpant store or handle hazardous material
m defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(4)?
All roofs shall
be inspected to any roofing material being installed.
❑ Yes
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or Lureu building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials
for inspection.
District? s�
C3 Yes k[INu
r
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to noufy the oc pant'oPthc
�y
require �hmustbcmctpriortuissu ofa ertirc - c.
Signature of Applicant
Date
G
All roof coverings to be Class "B" or better
6t
wner ur t orizcd Date
r/