02090153 (2) CITY OF CUPERTINO
BUILDING DIVISION PE IT CONTRACTOR.INFO •TION: '
f11.S123 AY I`WOOD AV PERb1 2090153
8RMT I RAYMOND M AND BARBARA APPLI(ffy 1 Oki 0 02
• PHONE: SANITARY NO. CONTROL NO. \
Oec ARCHITECTIENGWEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Z LICENSED CONTRACTOR'S DECLARATION �by
az c Ihereby affirmthat lamlicensed under provisions ofChapter 9(commencing REPAIR MS BATHRM�7J?A�r�PnOR
F y C w with Saeri n 7000)of Division J of the Business and Professions Code,and my license
gyp isimfu0ruree.a j /;
rc < Daenx aeras 1C.Y+ Lic.N
Dele cc *O. ,
ARCHfl be u e DECLARATf N /
in< 1 understood my plata shall be used as public record // I a,—
r.
d E I O .Licensed Pro(essional
5�,9m tee OWNER-BUILDER DECLARATION
I hereby affirm that I nm exempt from the Cm arium's License law for the
?afollowing reason.(Section 7031.5.Business and Profession Cade:My city or county $20000
F O which natures a permit w conswtt,ally,improve,demolish,ne repair any structure
d3$ Prior to its issuance,also manures the applicant fw such patina file a signed statement �a-a1� _
V s.l hsed wit"mediathe ofD am ofthe Contractors endprLew(..CoA Valuation
(c mini¢nc ns with Section.7(1I10)of Dwsion 3 of the Business and Professmns Cade) I f s
err Not he a exempt my appiV and the nos s for the alleged exempuoo Any vmoeatimn '" " "'
of Section 7031.3 by any ePPlicohrform pennirwbjtts the applicant avdvil Penaltys
of Out fro.Nan five hundred dollars 6300). 101 Afi .. Occupancy Type
❑Lasownerof Ne property,err my employees with wages as their sale compensation, 102 - 'PIERS
--will Co'Ne work:'and me wuchme is norintended of offered for sale(Sec:700];'
'Baamesrand Profession.Cade:The Cm mctmrs Lsoemse Law ace,act apply to an _ Required Inspections
owner of property Who milds or imprmvcs thereon.and who does such work himself 104 - REBAR
asthrough his own employees,provided Nat such impm namens me tan intended or -
':dReiea fo Idlf;however,the builmng or'mpmvemem is wId w thin Dm year err ""--10 5" ——ANCHOR—BOLTS "' -- _...__ ..... .......
'
completion,me ownenbuildcr will haw the burEen of proving that Im did not Wild or 10 6 — SEWER & WATER
improve purpose of ante
_. _._....._....2.02 _ ..UNDERFLOOR..-PLUMBING
b I sow of lh p pertY exdus IY mrmung th licensed can---no
c mitt the project(Sec 7000,Business and ssm PrefemCade)no
Commew s 203 — UNDERFLOOR MECHANICAL :CAL -
Lcenas Lawmen nm I m m ownar tar ~,. ."
appy pmprny who builds or improves Herron,
and
cmmans tic tach p s-wnh a comta<wrin.licensW pursuant tame. _._._..._..2 D_4._.--. .UNDERFLOOR...FRAME.._-
C mmmraLice 205 - UNDERFLOOR', INS,ULAT.TON
m
!Ad ec ' B k P for a reaxn
301 - ROUGH PLUMBING
- 'WORKERSCOM SATIONDECLAR ON 302 - TUB & OR SHOWER
I hereby affirm a penalty of p drey one of me following dedammont:- 303 - ROUGH MECHANICAL
❑ I nave;dd wurmmnmm'a`ccaaanteor'c'ansenrto selcmwre for Workers 304 - ROUGH ELECTRICAL
Compensation, as Provided for by Section 3710 or Ne Labor Cade, for the 305 — FRAME
per(o ce f the work.(or n h Nis pens t s issued..
❑Ibae d'willmananW gorse aammisur �. - 306 _ . H0,14DOWNS
x for section -INSULATION
Joao My ober coder theperrmmmmee of the work Ter men this permit ma 307 —
rWorkers
cEpcmnpasatmmnlamn«aan anEPminr - nerar<: . 3OZ__....SHEETROCK_.., .. .
o RTIFICATION OF EXEROM WORKFfRS '. '
Elf TER IbR,!LATH, ;.
COMPENSATION INSURANCE .__3.1.0-.. INTERIOR-..LATH
fah secimn need mol be completed tithe permit is foram hundred dollars 311 "= 'SCRATCH COAT '• �: 1 r
ISllpl rl 1 � .
313.,. ,,.RQD.E..,
1«n f}thrum rh peiforris f tali!wo k for�w�p lith perm t is issued.t
iba to to y ay nmr '1 T?)a"pa% ttanmew kern 50l FINAL ELECTRICAL:,ENERGY-
Co.pient
e _ f 'comm. at 502 — FINAL PLUMBING ENERGY
I NOnCET0 per t auk gthuCmfict fEenpt youshould503" - FINAL "MECHANICAL ENERGY - '
Z become bject t me Wdtk<es Compensation p ms erns of the lobo code.you must
O O f rtb th omplywrN cbp ons or this perms hall bedeemed re ked 504 - FINAL BUILDING ENERGY
505' FINAL"ELECTRICAL'
�'„�„m �' ''� CONSTRUCTION LENDING AGENCY ��� � -
ai m- Ire by Ifihn th t there fiiaaat ton lendingag my for the performime � 506 - GAS TEST
bf the w N at which th s peon r ri imued IS -J09].Civ C) '
y�.0 land Nm ... .. ..........-507"-- -FINAL-PLUMBING..._----
.0 p -"' • 508 - FINAL MECHANTCAL'' .
I comfy mal I have read this application and sate that Ne above information is 5 0 - NAL GRADE
OGia:F c.,1 agree to comply with all,city and county ordinances and state laws relium,
(V mbu'Idmgconstruction. dhertbyauNone prcsemetive fthis ctymenterupon 510 - NAL P ING
'�a.W the hove nlionerl p pert fo inspectio purposes
p. 0. (We)agree in safe,indemuryand keep harmless the Cay ofCpeninoigaimu 51 - NAL LI RKS
Fm
CA liabilities jdgmens cot and open to which may in any ay a ago sl said
C ty to consequence of the granting of Ili perm L -
APPLICANT UNDERS TA VDS AND N ILL COMPLY'H'ITH ALL 10N-POINT.'`
SOURCE REGULATIONS Issued by-
Date
Sgml of Apphcantrcnmua tar:. .... Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ':;' I.
W'11 the'applicant or Forms Wilding accapent store tar handle hazardous mumd, .. . 'Type of Roof. ._.
as defined by the Cupertino Municipal Cade Chapter 9.13 add Ne Hnith and Safety
.Coda Section
23331(oI . .. .
Elym
_.All roofs shall be aspected prior to any roofing.material being installed
•
Will m Opti mminc n,a building ed by a ay A m i eat li do,an awhich If a roof is installed without first obtaining an inspection;I'agree'to remove
District,
Y the Bay Arc A Quality Management g
oyes all new materials for inspection. Applicant understands and will comply with
emu za tar co mm t o defined
all non-point source regulations
1 have lead S lid and us acli .ls qd 25533 and 25 Chapin 6.95 of the '
Californiaebuilding
ing dolkh de Saf ry Codi.Slalom 03,t I i aril 355]6.Lunde not f that
if the buildin8 does not cutrendy years ,mal it is my responsibility todaify NE
sec tel t of the requirements ich mu i P'or,to issuantt of Cmifi a of
Occupncy I .
�. Signature of Applicant Date
:,. :; ownercra ta : gent m All roof coverings to be Class"B"or better'
l
CITY OF CUPERTINO
CUPE�INO PERMIT APPLICATION FORM
APN# r Date: R 2. 31
.
Building Address:
Owner's Name: Phone#: 2s _ vis
Contractor: License#:
/:�-wlP�r PCCC d- Lon .
Contact: Phone#:
Applicant/ ontra or: Fax#:
Applicant/ 1
ing Permit Info:(I
1
Bldg Elect Plumb Mech
o escription: iZt�a/ , GhC/S 'n� Cr
dentia]: $ " Commercial:
Sq.Ft.Floor Area: $/Sq.Ft.:
Arch itect/Engineer: Valuation: f y �
Type of Construction: Occupancy roup:
(juanfity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances 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 <= 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
BMITIGATR Res. Housing Mit Fee BUILDING•
BMNEWMULTI New Multi-Family Res MECHANICAL
BNEWMULTI New Multi-family Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
• BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
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