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CITY OF CUPERTINO
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} BUILDING DIVISION PERMIT
Cd ;._
BUILDING OGRESS:
ROSALINE MANLEY
PERMIT NO.
-
PERMn asUEb"3 0 073
NAMH:
SANITARY NoQ 3 J. 3 t6kWLNO.
ARCHITECT/ENOINHER:
BUILDING PERMIT INFO
BLDG HIFCI' PLUMB MECH
LICENSED CONTRACTORS DECLARATION
lob Description
1 hereby &Man Nu 1 am Remold under pmv bsua of CW prer 9 (mmmenclne
with Section 7000) of DMdon 3 oftin Buaineae and Professhom Cox, she mylicmlse k
In full forco and effea.
Lleenla elan Cont
Dan ContractorDEC1F�
ADD .530 SQ. FT. /REMODEL. C /� ��®
ARCHffanuse DECLARATION
r'�
I undemand my Plan slWl be used a Public record.
MAR 2 b 2002
LicensedPrornWontl
OW NER.BUILDER DECLARATION
1
1 hereby a01nn that I em taempt from the Contrulors License law for the
..
-
i following reason. (Section 703 1.5, Bmin°u and Proraaaom Code: Any city or county
which require a Permit to eavlma. ainr. Improve, demolish, or repair any structure
Sq. Ft. Floor Area
. Valuation
100000
+ pd. in Its iuunco. also requires the applicant for much Permit to rile. signed smoment
puranOo dusP ndoes of the Camramurs Ccense law(Chapter 9
thathelsllcemcdmu
m cing th lection 7000)of DlvWon 3 of de Bastin. Cid Pmfudou Coda) a
3 (eamenwi
. that W is camnpa thmefmm and she bask for the staged umnptlon. Any violadan of
0 0 Occupancy Type
Secdon 7031.5 by any applicant for a perme.ubjecu the applicant m a civE Penalty of,.Spilt-j5trrm}rer.
not mom Wan Ew hundred dollars (S300)•
.3 Ci�Sl�t�
1
❑ I, u owner of theproperty, army employers; with well u their.10 Compenuxn.
will do the wart and the structure Is ret intended or offered for sale (Sm. 7011, Budrcaa
101
,,.w,,�,,gg Inspections
— FOUNDA4gBaJNY p
and Professions Code: The Contracroel Limac law dm nal apply to an Owner or
property who builds or Lmprowa dommn,and who doe.suchwort Mrtuelr(rthmuehbk
102
- PIERS
two employ=, prodded dat such lmpmwmcnl the nm intended mortared for nln a,
however, 0. Wilding or impmwmanl k said within oro Kar edcompletbe. 0m awam-
103
— UFER
Wilder will have the burden of proving that be did nor build or improv for purpose of
104
— REBAR
)ffi I, a now of the property. am eauushvely centraetiag with Iteeased ammicmn m
105
— ANCHOR BOLTS
mmanrm the project (Sec.7044.Bui••.. trod Pmraadam Cade:) The Cmvcmt's U-
106
— SEWER & WATER
caw w donot apply err property who Wilde our Improve, Merton, and,
Law l n an owrcr
who contracts fm such POO)Leu with aeonuaetm(s) licensed Pmwum so Oat Coous"I
202
- UNDERFLOOR PLUMBING
Lice.Uw
I am eaempt a dm ea . B & P for W reason
203
- UNDERFLOOR MECHANICAL
f� 0)
411!110)
204
- UNDERFLOOR FRAME
ERS MPENSADONDECLA N j 1
205
- UNDERFLOOR INSULATION
Ihereby&Man under penalty of perjury, am or -he olbwingdeclantiane
301'.
- ROUGH PLUMBING .
w and will ..[.We sGAficets arComent to selr4clum fm Wahab COapan-
302
— TUB & OR SHOWER.
n, u pmvidod for by Section 3700 of she labor cox, ror the perfarmaunce of the
303
— ROUGH MECHANICAL
wok for which W. Permit is Issued.
❑ 1 hew and will maintain Woraces Compensation Instance, as, required by Secdon
304
- ROUGH ELECTRICAL
7700ofthe letters Cade, for tha ped°Imanaa afthe work for which this Forma is issued.
305
- FRAME
My Worker. ComPenation Inwnroe cornier and Polley number ase:
306
- HOEDOWNS
carder PolicyNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS
307
- INSULATION '
COMPENSATION INSURANCE
308
- SHEETROCK
(This modes need notbecompleted true permRkrarsne hundred x0an(SI00)
309
— EXTERIOR LATH
or tell.)
c
I cudfy ren In the parmrmance of the work fm which Iso permll is Island. I shall not
310
— INTERIOR LATH
employ layperson In any a., se, u to became abject to dnwahxrf Cmnpemation
311
— SCRATCH COAT
Laws of Califamia. Dan
313
501
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
t
1ianOTICEubj APPUe wGdkc scompe satsing this Certificate of Laked Exemption, yaou mlW
N
became subject m the WOrterk ComPcuallan provtsioas Of the laMm Code, you most
forthwith comply with such provisions a.this permit shall be summed resulted.
502
- FINAL PLUMBING ENERGY
y CONSTRUCTION LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
1 hereby affirm that then is a cmuuunion lending agency for the Performance of
> the work for which Oil permit kiuueA(See3097.Civ. C.)
504
- FINAL BUILDING ENERGY
a feeder. Name
505
- FINAL ELECTRICAL
Lender'. Addru.
506
— GAS TEST .
z
yIardlfythatIh.roadthisapplicWon&adSWOdustth,-WaC1nfamWbnk
correct, I agree to comply with all city and county Ordinances and stns laws mining to
507
- FINAL PLUMBING
Wilding consuection, and hereby audeadm rtpresenutiws or this City m enter upon the
J
0
FIN MEC CAL V
.Wed-mendorod ro n for Inspection u
P rc Ypurposes.
y(Wo) agree m nal, indemuify and lamp harmk[a the City err CupeNco agalmt
0 9
F I /7
rA IhMlhies,Judgments, core and eapeuas which may many way.mase agalnu Mid sty
In consegmroe of the ennune of this rcnnit.SM
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -P INT
Issued by:
NG Date
S. ]
Re-roofseanrc°"
Type of Roof
to °
HAZARDOUS MATERIALS DISCLOSU
applicant or future Wilding oceupsntiama a handle haraedam mandde
rROO
CupeNno Municipal Cox. Chapter 9.12. and Ibe Health and Sorely
25532(,)?
All roofs shall be
inspected prior to any roofing material being installed.
j rWille
a roof is installed without first obtaining an inspection, I agree to remove
applkant err mmm d nal rg cecup[m an egmPmom err xrixa whichIf
s air contsminanto as defrost by the Bay Am Air Quality Management
all new materials
for inspection.
❑Yes XNo
I huo reed the harardmemaledW mcluimmo nuunderChapu:rd.95 orthe Califor.
n4ficalm& SafmyCedq Sxtiam25505.23533 and 25534.1 understood thatlfte bulking
data not cunently hew a u nand, Ne it la my re.pmulbilly to rally tho aceup., of the
some"" bemelprnttolasasnceafICenifcanerfDoe°
a
Signature of Applicant
Date
All roof coverings to be Class "B" or better
Owner or..nd. ent an
f �
cITX o CUPERTiNo �.01 Il wpm!
BUILDING DIVISION PER1V1IT ... ri.,:. .:..:?. ..
BUILDING ADDRESS:
..:.:::.,.,..:.. ........
ROSALINE
PERMIT NO.
MANLEY
PERMIT issulib" 3 0 0 7 3
OWNER'S NAME:
SANITARY NO L NO.
PHONE:
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
JOE} Description
I beteby affirm that i am licensed under provisions of Chapter 9 (commencing
with Section 7000)of Division 3 of the Business and Professions Code, and my license is
in full force and effect
License Class: Lie. ff
,ADD 530 SQ
. FT . f REMOLDEL
Date Contractor
ARCHITECT"S DECLARATION
! I understand my plans shall tie used as public records
i
-
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
> following reason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit 10 construct, alter, improve, demolish. or repair any Structure
„ prior to its issuance, also requires the applicant for such permit to file a signed statement
9
3q. Ft. Floor Area Valuation
r that he is licensed pursuant to the provisions of the COntmctOes License Law (Chapter
Code)
$100000
(commencing with Section 7000) of Division 3 of the Business and Professions or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
J �1 lr. 0 0
Occupancy T)rpe
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty ofe7
not more than five hundred dollars ($500).
[_j 1, as owner of the property, or my employees with wages as their sole Compensation,
10
— FOUNDg ( Inspections
wiltdo the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Conuactoes License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himselfor through his
102
_ PIERS
own employees, provided that such improvements are not intended or offered for sale. if,
10 3
— UFS R
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.).
Xi, as owner of the property, am exclusively contracting with licensed contractors to
105
- ANCHOR BOLTS
Onnstruct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li•
106
— SEWER & WATER
cense Law docs 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 Contractor's
2 0
r^
UNDERFLOOR PLUMB I NG
License Law.
® 1 sm exempt under em( B & P C for this reason
203
- UNDERFLOOR MECHANICAL
j\ % /3 03
204
- UNDERFLOOR FRAME
KER°s MrEl1sATioriDEc-iyoN
2.05
- UNDERFLOOR INSULATION-
✓./'!�`II hereby affirm under penalty of perjury one of the following declarations:
301
- — ROUGH PLUMBING "
0 ) have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
302
— TUB Sr:. OR SHOWER
salon, as provided for by Section 3700 of the Labor Code, for the performance of the
303
— ROUGH ME CHAN I CAL
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
3 0
ROUGH ELECTRICAL
3700 of the Labor Code, for the performance of the work for which this permit is issued.
305
— FRAME
My Worker's Compensation Insurance carrier and Policy number are:
306
HOLDOWNS
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
307
— INSULATION
COMPENSATION INSURANCE
308
— SHEETROCK
(chis section need not he completed if the permit is forone hundreddoliars ($100)
309
EXTERIOR LATH
H
or less.} .
I certify that in the performance of the work for which this permit is issued, l shall not
310
— INTERIOR LATH 4
employ any person in any manner so as to become subject to the Workers' Compensation
311
— SCRATCH COAT
Laws of California. Date
Applicant
313
- ROOF NAIL
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workces Compensation provisions of the Labor Code, you must
501
` FINAL ELECTRICAL ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
502
- F I NAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
— F I NAL ME CHAN I CAL ENERGY
—� I hereby affirm that there is a construction lending agency for the performance of
504
- F I NAL BUILDING ENERGY
i the work for which this permit is issued (Sec. 3047, Civ. C:)
p Lcnder'sName
505
- FINAL ELECTRICAL
Lenders Address
506
- GAS TEST
z
O
I 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 t0
/ryy
507 7
PLUMBING 7}�pg7� 7 7 7
F I NAL P L U L' B 1 NG
U
building construction, and hereby authorize representatives Of this city 10 enter upon the
above-mentioned property for inspection purposes.
0
— FIN MEC I CAL .
ICAL
agree to save, indemnify and keep harmless the City of Cupertino against
in accrue against said City-
0 9
F I V/3/liabilities,
judgments, costs and expenses which may any way
5
NG
�^+
inconsequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
Date
SOURCE RE O S. � t� (�
Re -roofs
nature o A tcanttCant tar Da
HAZARDOUS MATERIALS DISCLOSUR
Type Of ROOF
Will the applicant ar future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
All roofs shalt be inspected prior to any roofing material being installed.
nYes XWO
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding 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?
p Yes XNo
I have read The hazardous materials requirements under Chapter 6.95 of the Califor•
Ing
niaHealth & SaletyCode, Sections 25505, 25533 and 25534.1 understand that if the build
does not currently have a tenant. that it is my responsibility to notify the occupant of the
'
Date
irements be ret prior to issuance of a Cettricate of 0CCU nc 0.
Signature. of Applicant ...
"B"
?Owner
All roof coverings to be Class or better
or ant ..it .ed agent itte
CITY OF CUPERTINO
PERMIT APPLICATION FORM
APN # —I g
Fee Description
I Date:
Building Address:
Ilelo M4p4h-,<0
Other Appliances
Owner's Name:
Phone #:
�z- 2& -6907
Contractor:
ti LLJN�_
License #:
Contact: 10 1A/ /,/Gp-
Cupertino Business License#:
Building Permit Info:
Boiler > 500K to 1M Btu
I F."Ve I W. -I
Elec
Plumo� MechA
-BldgK,
Job lbescription:
N
1011%
Lmerci
Residential El
Sq.Ft. Floor Area:
$/Sq.Ft.:
Cost of Project:
7V
6rVrZ> Z12__Ubccupancy Gro
Type of Construction.,
�- I
2l3 37
I of3
Fee Description
Other Appliances
Bldg PerrnitN. foot
Boiler <= 100,000 Btu
m-11i'm
Boiler> I OOK to 500K Btu
�ivilxoi.
Boiler > 500K to 1M Btu
I F."Ve I W. -I
Boiler > 1M to 1.75 M Btu
kyl I I NO 2,
•
Boiler > 1.75M Btu
Construction Tax
MIR
Con. Tax for BQ Zone
Hotel and Motel
------------
RVIC12,
Constax — Resi/Mobile
ar
OWNtil
ee 600V <= 1000A
Elee 600V > 1000A
BELEC
Svcs 600V <— 200A
ELECTRICAL
-oleo I
—Elec
BUILDING
EnLrgy Add Multi
Sell m��
•
Investigation fee
BUILDING
ll
�MMIMM! WIN m
2l3 37
I of3
CUPERTINO
VV
i I i ♦ , !
Fee Descriptidn
gal
Powerl)evic�/Apparattis
ELECTRICAL
yti,
r
Switch & OutletsMWELECTRICAL
rtrr �� LOCA
Relocation of •!d11
a a
�_ry�,irVrlI �Rt`yy
�1
Remodel Res Appliance
Zip gawn
B ! a
r w
• a!! s
ELECTRICAL
�,
t R fY.iu'i#liii
Remodel i
ELECTRICAL
Theatrical Ligj!��
Vent Fan _ i
a a
SUEZ
Ventilation Systems
gal
BSCBLVD !I
Scb Specific Plan
BSEISMICOM
Seismic
•Seismic
Fee ..
,
tSwi
ool
ELECTRICAL
BTEWPERM
Temporary B14S `
f
BTENPSVCS
Temn Dist Svcs
ELECTRICAL
r
Business ..r. .
*. ;
ELECTRIC
Electrical sq �Foot
ELECTRICAL
` •ElecPermitELECTRICAL
t t
t
Mect Permit
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