02110095 CITY OF CUPERTINO " -,
BUILDING DIVISION PERMIT "CONTRACTOR INFORMATIONo'
Bmg»I49ADREM ST -- KALLIO CONSTRUCTION PERMITNG2110095
IWPINWEMRS PANN 1666 ENGLISH DR APPLICATtj]11S111WC
/ 2002
HONE: (408) 873-9777 SANITARYNO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION bDe riBt �� O O O
K w F 1 nanny arum mal 1 am licensed uI&,provisions of Chamm
Chapter 9(coencing
� I,
with ScainnAXXllnfDivision 3ofmcBusi oo dPrnresaionsCode,andmylicenseis KITCHEN REMOD
in lull Tome an ell ./�1 S+-
g= License
j e Lk.a - MAR 2 5 2003
nam „ImerF p--
O i2 RC I; 'S EU7LARAT]0N--r�te-
�' K 1 n stand my plans shall he Medics pudic Meords
adi BUILDING
w 3 w 1- Licensed Professional
F=Oa OWNER-BUILDER DECLARATION
a 1 hereby affirm that I am exempt from the Conlncmr's License law for the
old
00 Olowing rex o,(Section 7131.5,Buslncssxnd Professions Ceoc:Any cityonvmmy $20000
oX m which requires a permit It,construct,alter.improve.demolish.or repair any structure
FixPrior o its issuance.also Fixtures the applicant lar such permiuo rile a signed statement
�0
That be,is licensed pursuant In the provisions of the Conlmauh License Law(Chapter 9 Valuation
(commencing with Section Total)of Division.1 of the Business and Profess ons Codc)or
i 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 penalt of
not more man f hundred dollars(SSW). y PN N Occupancy Type
102 - PIERS
L az ownerrods.the pmpeny,re my emntendedwith wages az theirat (See.
Se.compensation.
andothework,and filestructure,Concis not intendedprOffered far saleepplytBan Business
and Professions Cods:The Contractor's License taw dam not apply m an awner or 10 4 — REBAR Required Inspections
propenY.who buildxorimphases thereon.and whodnes such work hireaelfar through his l05 — ANCHOR BOLTS
own employees,provided Nal such improvements are IL
not intended or offered for sale.
however,the building or improvement is said within one year Of rnmPlction,Ne owner-
builder will have he harden of proving mat he did not mild or improwi far puridee Of 106 — SEWER & WATER
"'e) 202 - UNDERFLOOR PLUMBING
I,as owner of the prupeny,am exclusively convecting with licensed contractors m 203 — UNDERFLOOR MECHANICAL
construct the project(Sec.70aa,Business and Pro coutivas Codd:)The Contractor's Li-
cense law dors not apply to an Owner of progeny who milds or improve thereon,and 204 - UNDERFLOOR FRAME
Who Contracts for such projects with arnntrannr(s)licensed pursuant o the Contractor's
License Law. 205 — UNDERFLOOR INSULATION
❑lam exempt under Sec. ,B&P C for this reason 301 — ROUGH PLUMBING
netDare 302 — TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 — ROUGH MECHANICAL
I hereby affirm under penalty of perjury mm of the following declarations:
737(ln.f
I ham and will maintain a Cenifiam ofConsenl to self-imam for worker's Compen- 304 — ROUGH ELECTRICAL
on,az provided for by Section 3700 of the labor Cade.for the proarmaticc of the 305 - FRAME
k for which this permit is issued. 306 — HOLDOWNS
1 have and will maintain worker's Compensation Imuran¢,az required by section 3 0 7 — INSULATION
the labor Cafe,for the perfmmancc of the work fill which this pmmil is issued.WorkersCompensaman lnsamn ean;er and Parcy numneram: 308 — SHEETROCK
icr: 7t �_ Policy No '� Co 309 — EXTERIOR LATH
CERTIFI COMPENSATION MS EORKERS _ . 310 — INTERIOR LATH
(This ree pecneed not be completed if tht is for one hundred dollars(start) 311 — SCRATCH COAT
Ilea`') 313 — ROOF NAIL
employ
mloy my in the in anIf y
slue wnnmrsubjedo,pe,Worliissted,lahaumtt 501 — FINAL ELECTRICAL ENERGY
p yang person many manner arazmbecome subject to Wnrkeri Cnmpenmlion
Laws Of California.Doc 502 — FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT:if.avermaking this CenirateofExemption.you smouId 503 — FINAL MECHANICAL ENERGY
become subject to the Worker's Compensation provisions of the Labor Cole,you must
O Z forthwith comply with such provisions ill this permitshalIho,deemed revoked. 504 - FINAL BUILDING ENERGY
Z 0 CONSTRUCf10NLENDING AGENCY 505 — FINAL ELECTRICAL
Fl hereby affirm mal there is a construction lending agency for the performance Of 506 — GAS TEST
C > me work lit which this permit 1,issued(Sec.NN7.CIv.C.)
Lender,Name 507 — FINAL PLUMBING
W
7Z Lnuersnddreas 508 — FINAL MECHANICAL
U O 1 ccnify mal 1 have read this application and sure that the about information is 509 — FINAL GRADE
W F coven,t agree to comply with all city and county ordinances and stale laws relating 1t
�U building convection,and hereby authorize representatives of mis city to crier upon the 5 FINAL PLANNING
F0. above-me boned property for inspection purposes. 4 — FIN
(We)agrcaursave,indemNfyand es which harmless the City at Cupenst said Ci ly IC W RKS ��
y liabilitiesjudgment,costs and a this Permit. may in anyway acme against said City
U Z in consequence of the granting of this fermis.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
< /I Re-roofs
si of ApplicandControctor are
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future building occupant stare Or handle hvN
aum material
as defied by the Captain.Municipal Cole.Chapter 9.12,and the Health and Safely
Amowd,Section 25532(a)'
❑Yes lklo All roofs shall be inspected prior to any roofing material being installed.
Will thea rant or future Wilding acct ant use equipment If a roof is installed without first obtaining an inspection, I agree to remove
pp B p q it Qu or devices which g
emit hazardous air contaminants as Jdincd by the Bay Arca Air Quality Management all new materials for inspection.
Uislricl'!
❑yes
I have read the haiurdon's n``iamriuls reymmments under Chapar R95 of Or Califor-
awIleaW Si Solely Code.Seeuom 8515.25533 and 25533.1 undersand the ifdc thudding
reqs not eurmml haat a tenant.Nat itis my respomibility to notify the Inupanl of the
regolremc 'w c mu_nbe me priunoissuanl of a Ccnilicsu of allipancy.
- N - �Ignature of Applicant Date
Owner or authorised agent D„ All roof coverings to be Class "B"or better
^(L CITY OF CUPERTINP
�. CUPH�TWO PERMIT APPLICATION FORM D��/6/no
APN# , A r �l Date:
'B di Aldress:
Owner's Name-. r Phone#:
Coactor: G License #:
�1 D
Contact: — Phone#:
c -q77
Applicant/Contractor: Fax #:
M
ui i g Permit Info:
Bid Elect x Plumb INC Mech�X
o Description: '/
Residential: (�1 Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
Quanti Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/COmm/ uasi BUILDING
BCONSTAXB Con. Tax for B Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC1000 L Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY Ener BUILDING
BENERGYADD Ener Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. HousingMit. 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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