03070026C1'1'Y OF CUPER'FINO
* "-^I S, n , V 1 •'r"+> ' "
CONTRACTOR INFORMATION
BUILDING DIVISION PERMIT
.'£:
BUILDING ADDRESS:
ALL SEASONS
REMODELING
PERMrf N003070026
WNER'S NAME:
219 DEMPSEY
RD
PERMIT ISSUE DATE
"E'
(408) 586-8004
SANITARY NO. CONTROL NO.
A RCIf1TECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm Net 1 am licensed under provisions of Chapter 9 (commencing
p
wish Scclion7 Bal'Division3ofthe Business apdpra C"do.and my licensers
nw Lk. Yfeuiom
irem.fres
Liceucc C
PATIO ENCLOUSER(221 SQ.FT.)�0P4AFFt3
cm
Da Co .
ARCHITECTSO ATION
ecrstand my plensshall he used., pulic records
JUL Z9 2003
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby .I'ftrm that 1 am eac.pt fru. Ne Contractor, License Law far the
BUILDING
allowing..ann. (Section 703 I.S. Business and Profession Code: Any city m,aunty
which requires a permit in consumer, slier, improve, demolish, or repair any structure
prior to its Issuance, also requires he applicant for such permit to file a signed statement
that he is licensed pummnt m theprovisiomnfth, COremctur. Licanx law( Chapter 9
Sq. Ft. Floor
Area
Valuauon
(commencing with Section 7") of Division 3 of the Business and Professions Cade) or
Not be Is eminu Ncmfrom and d,e basis for the e11C,td ..Coalition. Any vlolatian or
36226042.00
APN NumberOccupancy
'
Type
Section 7831.5 by any applicant for a permit subjects the applicant to a civil penalty Of
not more N0).'an five hundred dollars ($50
I,unwner or Ne pmpcny. or my employcu with wagesutheir role eompenutlOn,
IUI _
d Inspections
will do the work. and Ne structure is not intended or offered forsale(Sm. IDM, Business
and Profeuin. Code: The Contractors Liceox law doa not apply m an owner of
102
PIERS
p.peny who builds or improves thereon, end who doesauch work himself or through his
-
Own employees Invited Nat such improsemenu an not intended or offered for isle. If.
103 —
UFER
however, the building or improvement is sold within am Seu of completion. the owner.
builder will have the burden of proving Nat he did not build or improv for purpose of
104 -
REBAR
la')'
105 -
ANCHOR BOLTS
El 1, as owner of the property, am exclusively Contracting with licensed convectors to
Construct the pmject (Sm. 7044. Business and Professions Cede:) The Contracwh Li
10 6 -
SEWER & WATER
cense Law does not apply(" an owner of property, who builds or improves Oemon,and,
202 —
UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to On, Convector's
License Law,
203 -
UNDERFLOOR MECHANICAL
❑ I sm eaempt under Sec, B A P C for this reason
204 -
UNDERFLOOR FRAME
"Da
205 -
UNDERFLOOR INSULATION
WORKERS COMPENSATION DECLSRATION
Ihereby affilmunder Penalty ofperjury amofthem8awingdeclsetlons:
301 -
ROUGH PLUMBING
I haveand will maintain aCenNcate ofConsenttoselFinsure for Worker's Compen.
302 —
TUB & OR SHOWER
action, u provided for by Section 37M of the labor Code, far Ne p do... of the
3 03 -
ROUGH MECHANICAL
work far which Nis permit is issued.
3 04 -
ROUGH ELECTRICAL
❑ 1 have and will maintain Worker's Compensation Insurance, u required by Section
311 of Ne labor Cod., for than Performance of the work for which this permit is issued.
3 05 —
FRAME
My Wark CnmpeneationrJpsu(once carrier and Pali nu am:
0�
306 —
HOEDOWNS
Ca r. / d/nFE Po11cYN �
CERTIFICATE OF EXEMPTION FR w RXERs'
y
307 -
INSULATION
COMPENSATION INSURANCE
308 -
SHEETROCK "
This maim, need not acompleted If the permit is foram, hundred dollars(S1aB
309 -
EXTERIOR LATH
310 -
INTERIOR LATH
I certify
1 certify that er the performance or an work for which this permit is issued, 10,11 not
employ snypanun in any manner .aztO become subject to Workers'Compcnalion
311 —
SCRATCH COAT
Lawsar calaarnic°am313
Applicant rot
-
501 -
ROOF NAIL
FINAL ELECTRICAL ENERGY
NOT
NOTICE TO APPLICANT. this Certificate of Exemption. should
WoIf. sCorf.ekingt,
the Critic. you
of the rablu rmin you muse
become smahj"I . the Workers or is Permit
forthwith comply with such provisions or lora permit ma0 be deemed munked.
SO2 —
FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503 -
FINAL MECHANICAL ENERGY
I hereby affirm Net there is a construction lending agency for the performance of
504 -
FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 30107, Civ. C.)
Lender, Mme
505 7
506 -
FINAL ELECTRICAL
GAS TEST
Lander. Address
I certify Nat I Mw read this application and rose that d„ above information is
507 -
FINAL PLUMBING
correct. 1 agree to comply with all city and county ordinances and auk laws elating to
building construction, and hereby authotne reprnematiws of this city to enter upon the
C6CAL
ahavememiuncd property for inspection purposes.
(We) S. m sew. indemnify and kap harmless the City of Cupenino against
liabilities.j.d,num", Costa and eal>.,whi,h may m any way.ecme against said Clty
%&FINME
NG
nconxgaeO vfthegamingonnisp fres.
APPLIC DERSTAN ND COMPLY WITH ALL NON -POINT
Issued b y;
C WORKS Date
E^ LA'I90N
Re -roofs
Type of Roof
° �0
_URC
Nre ornppfi.anvc.nv .r etc
HAZA OUSMATERIALSDISCLOSURE
or handle hu material
WIII N. applicantorfuture building Occupanthp(
rstore9.1
u earned by the Cupertino Municipal Cade, CMPIcr 9.1'3, and the Hcallh end Safely
lIh and
'
Coale, Section 255320)7
All roofs shall be inspected to any roofing material being installed.'
❑yes g�
prior
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
n h .... do.. air Cameraman; ss defined by NC Bay Arm Air Quality Management
all new materials for
inspection. .
isvic4
❑Yes
1 he,. and the haaardnusoman,4ls equi.menu under Chap¢r6.95 of the Califon
nia Health "Code,seNm.25585, 3 and 25534.1 understandblifthe Wilding
dib mol ma Y haw a tenant at i respmunilily. nadfy the axupm, of Ne
eq . nia hich.ua),i,e uan..f. nifieeueof0,up. .
Signature of Applicant
Date
Z
All roof coverings to be Class "B" or better
er authorivcdegcnl
CITY OF CUPERTINO
BUILDING DIVISION PERMIT.
BUILDING ADDRESS:
LOCKFOR CT
ALL SEASONS
REMODELING
PERMIT 110 3 070026,
-7571
OWNER'S NAME:
k PTAMP rT,RMMTT
219 DEMPSEY
RD
PERMIT ISSUE DATE
o7/n?/?nn'�
PHONE:
{408}586-8004
SANITARY NO. CONTROL NO.
ARCHITECTIFNGINEER:
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
with
in'
PATIO ENCLOUSER(221-SQ.FT.)
License
ARCHITECTS DE ATION
"
nderstand my plans shalt be used as p io recnrds
Licensed Professional
OWNER -BUILDER DECLARATION
I 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 to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft, Floor Area
Valuation
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
36226042.00
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 703L5 by any applicant for a permit subjects the applicant to acivil penalty of
not more than five hundred dollars ($500).
0 1, as owner of the property, or my employees with wages as their sole compensation,
iOl -
YOUND"R99d Inspections
wi 11 do the work, and the structure is not intended or offered for sale (Sec. 704, Busiftesss
Professions
and Code: The Contractor's Lice= Law does not apply to an owner of
102 -
PIERS
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale, If,
103 -
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
0 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 Sc WATER
cense Law does not apply to an owner of property who builds or improves thereon, and
202
UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
203 -
UNDERFLOOR MECHANICAL
0 1 am exempt under Sec. B & P C for this reason
204 -
UNDERFLOOR FRAME
Owner Date —
205 -
UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
301 -
ROUGH PLUMBING
0 ]have and will maintain a Certificate ofConsent to self -insure forWorkersCompen-
302 -
TUB & OR SHOWER
sation, as 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
304 -
ROUGH ELECTRICAL
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued:
305 -
FRAME
My stmince carrier and Policy n; aE=:.
306 -
HOLDOWNS
;Wrk
r..Compensationa
4; -
ow. _i
d Policy N, .:
4_
307 -
INSULATION
W RK
CERTIFICATE OF EXEMPTION FR W RKERS
COMPENSATION INSURANCE
308 -
SHEETROCK
(This section need nothe completed ifthe permit is fortme hundred dollars ($100)
309 -
EXTERIOR LATH
orless.)
310
INTERIOR LATH
I certify that in the performance of the work for which this permit is issued, [shall not
employ any person in any manner so as to become subject to the Workers' Compensation
311
SCRATCH COAT
Laws of California. Date
Applicant
313
501
ROOF NAIL
FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT. If, after 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 bcdcomed revoked.
502
FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
FINAL MECHANICAL ENERGY
I hereby affirm that there is a construction lending agency for the performance of
504
FINAL BUILDING ENERGY
the work for which this permit is issued (See. 3097, Civ. CJ
Lender's Name
SOS —
506 -
FINAL ELECTRICAL
GAS TEST
Lender's Address
> I certify that I hive read this application and state that the above information is
507 -
FINAL PLUMBING
4 correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
nT, t
WCA
FTN.Jl MECHA L
above-mentioned property for inspection purposes.
VT
agree to save, indemnify and keep harmless the City of Cupertino against
09
F
liabilities, judgments, costs and expenses which may in any way accrue against said City
5
NG
in conscrIump the granting of this permit,
0
LICC T�ERSTAND ND COMPLY WITH INT
Issued by: 5V
WORKS Date
C W
A R , L.
E LAPIONS�
Re -roofs
Type of Roof
G7
Sre of Applicant/Con for ��me
)WIU HAZAYGUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandic hazardous material
as defined by the Cupertino Municipal,Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)l
All roofs shall be inspected prior to any roofing material being installed:
0 Yes 121�-
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant or future 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?
❑Yesrva
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &A@ty Code, Scefi tons 25505, and 25534.1 understand that if the building
mP§?3
so, 1
does not rre lily have a iI responsibility to notify the occupant of the
req ire tts hich mus{ -be i I , suance of aIII ' "uP/. -
Signature of Applicant
Date
,7�
41-1101-3
All roof coverings to be Class "B" or better
'er br
OWh'auth nd agent rAc
Cx fY OF CUPERTINO
CUPS ISO
PERMIT APPLICATION FO
APN #
Date:
Fee Group
Building Address:
Owner's Nape:
Phone #:
7MECHANICAL
�IIIILDING
Contractor:
License #:-
C tact:
Cupertino Business License#:
Building Permit Info:
Bldg 2-' Elect E? - Plumb ❑ Mech ❑
Job Description:`
Residential 2'" '� Commercial ❑
Sq.Ft. Floor Area:
$1Sq.Ft.:
Cost of Project: -�''
Occupancy up:
Type of Constructs n:
Boiler > 500K to IM713tu
Fee Group
. • r
c ••
7MECHANICAL
�IIIILDING
�DE
Bldg + .. •foot
i ►
i! Btu
MECHANICALME
iR
�i �R�.�
s • is i
♦ '
BBOILER3
Boiler > 500K to IM713tu
MECHANICAL
lYtJ: +i •.11iollll
\• 1.75 Btu
MECHANICAL
f iOO R
Boiler 1.75M Btu
♦ }
BCONSTAX
Construction Tax
Con. Tax for BQ Zone
Hotel and Motel
111
Elec 60 i11•
'
:�" �l
Elec 611 OOOA
BELEC200
Elec Svcs 600V <-- 200A
ELECTRICAL
BENERGYADD,
Energy Add Mult.L---
•
r
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D
CITY OF CUPERTINO _ =
&CITYOF
CUPET�TiN+C� PERMIT APPLICATION FORM
1�Fee
Descripti6n
Fee p
Power Devicq/A
ELECTRICAL
.'c '
Relocation of ###
A A
MU -1a a•7 \l%
Repair/Alter
mdI ranch
R Signs Add B
UP
•' • lNu.. ■...
RemodelSigns,M-13• # _..
•. A.
Theatrical Ligh g Fix
• agmagm,
vent• Single
�M001F.AiN A
BREMVENSYS
• {\f•K��'
A
S6 _Spqecific Plan
'. B
BSEISMICRE
Seismic Fee Res
a *40491
-----Special hispection
01313 1 UV
Swimming Pool
Temporary Bldg Pertnit
_��Ixpjlgg
Temp Dist Svcs
-__0 tom
Business r
i !
! • •jElectricali
foot
ELECTRICAL
Elec Permit Issuance
.j
ELECTRICAL
+ A
i •
1 Permit i