02080111 CITY OF CUPERTINO
BUILDING DIVISION PE IT CONTRACTOR INFOR TION:
BUILDING ADDRESS: PERMIT NO.
20651 MC CLELLAN RD ARMSTRONG INSTALLATION 02080111
0IWNAME: APPLICATION SUB DATE
LANG 774 HARRISON ST 08/20/2002
PHONE: .(415) 777-1234 SANITARY NO. CONTROL NO.
'
q 0 Oz ARCHITECT/ENGINEER: a BUILDING PERMIT INFO
kL"
to C BLDG ELECT PLUMB MECH
tai r- u u L_I C_J
LICENSED CONTRACTOR'S DECLARATION
z S ot z 1 hereby a rm Utas I am liecnud under s of Chapter 9(commencing Job Description
p`°"'i°" p ( g REPLACE WINDOWS (4)
fir=�� with Section]000)of Division 3 of the Business end Profexsiorta Code,end my license
u it fu .n
ad eR / ALE®
0 K Datanu Lh!x S L I
KK Date con or
to I understand my plan shallW cud as public records O r 1 r 1 Q 2002
r la U
ip O Licensed Professional
OWNER-BUILDER DECLARATION
so 1 hereby easo .(firth Nat 1 ore exempt from Uta Casson, o License Low for the BUILDING $6150
(;Z G following recon(Section 703 1.3.Busher. and improve.
dammi Code:Any city or county
r which its sire n permit ne construct cher,impmve,dpermit,fi repass any overture
� prior to ill issuarxrt,also requires the appliaana for'such permit a file a signN statement
a 3 duuW is liewded.purstianuorhe gtvisitns of the Contrecmri Littme Law(CTaprcr 9 - -- V -
(commencing with Section]000)of Division 3 ofthe Business and Professions Code) f ;,•.,-q't35`d911>FFO �F,�Ffa„ ,f;,• Valuation
or Nal he is eiempr therefrom and the basis for the alleged exemption.Any violation -of Section 7031.5 by any applicatt for a pemut subjme the applicant to a civil penalty
of not more than five hundred dollars($5130). l O 1APNAIPJ INUATI ON Occupancy Type
❑I,as owner of the propany,or my employees with wages u thcir sole mmpossation, 102 — PIERS
will do the work,and the scucme is not intended W offend for sale(Sec.]Baa. 103 - UFER Required Ins ectionS
Business and Professions Code:The Contractor's License Law does na apply to an fI p
Owner of property Who builds or improves thereon.and who does such work himself 104 — REBAR _
or through his own employees.provided Nat such improvements we not intended or
offered for sale.If,however,the building or improvement is sold within one year of 105 - ANCHOR BOLTS
completion,the owner-Wilder will have the burden of proving mat he did not Wild or
mprovef°rparpoa<ofrale.). 106 — SEWER & WATER
❑1,as owmr o(the property.am cwins ivdY camrecting wiN li¢md contractors m
202 — UNDERFLOOR PLUMBING
:. '
anew.,the project(Sec.7(v44,Busitess and Profcssiom Code:)The Cowtracmra 2 03 — UNDERFLOOR MECHANICAL
License Law docs not apply man owner of property who Wilds or improves thereto.
.and wet contracts for such projects with a cOnuacmr(s)licensed pursuant m the .. _ .. 2 04 — UNDERFLOOR" FRAMECommc . ....
r)Iam ormptumdc Sec 205 — UNDERFLOOR,'INSULATION
O 1 am exempt under Sec. ,B&P C for Nis reason
Owner Data 301 — ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
Ihereby emrmunder penalty ofprdtigone ofthe fonowingdeclarations! 303 — ROUGH MECHANICAL
❑ 1 have and will maintain a certificate of Consent to self-macre for workers 304 — ROUGH ELECTRICAL
Compensation, es provided for by Section 3700 of the UsWr Code. for the
performance of the work for which this permit is issued. 305 - FRAME
❑1 have and will maintain Worker i Compensation Insurance,as asolmm d by Section 306 — HOLDOWNS
3700 of the Labor Code,for the performance of the work for whim this wrout is 307 — INSULATION
issued.MY work is Compensation Insurance c e and Policy number arc: _ .. . ...... ...... ... .-
308 — SHEETROCK
CERTIFICATION OF EM ON FROM WORKERS' `3 0 9' .-]'EXTERIOR ',LATH;-
•/ COMPENSATION INSURANCE ., 310 - INTERIOR -LATH
(This union need not be complacd if
($1001 Or less) the permit is for one hundred dollars 311 — SCRATCH COAT
313 — ROOF NAIL
1 certify that in the perfmoo,nce of the .,it for which this permit Is Issued,1
shall not employ any person in any manner s°as to become subject to the workers 501 — FINAL ELECTRICAL-'ENERGY
pplmnLawatrcaliftmia.0ate
Applicant
502 — FINAL PLUMBING ENERGY. .. .
-
NOTICE TOAPPLICANT:If,afit,maung this Certificate of Exemption.you should 503 — FINAL MECHANICAL ENERGY
OQbecome subject to me Worker's Compensation provisions tf the LaWr Cale,you must
forthwith comply with suchprovisimoorthispermhshallhedee_me_drevok_ed_. _ 504 — FINAL BUILDING .ENERGY
~ CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
1 hereby eifum mm there is a communion lending agency for the performance
a 7
Of the work for which this permit is issued(Sec.3097,Civ.C.) 506 — GAS TEST
y z Under'sAeme 507 — FINAL PLUMBING
Z Lender's Adders v -
U O 1 certify mat 1 have read this application end state mat the above inmrnattw is 5 0 FI NAL MECHANICAL
correct.I agree a comply with all city and county aeinancea arta nate laws to wing
5 9 — INAL G E
O V to building connmction.and hereby authorize representatives ofthis city toenter upon 5 0 — INAL NG
>a W the abovemetnioned property for inspection purposes.
E a (wc)agmeto ts.avetsandnpenses hihemyinaless nwayacrueninoagvna 51 — INAL RKS
V] liabilities,judgments,costs end expenses and which may in any way acerae against said
V z City in consequence of the granting of thispentut.
APPLICANT UNDERSTANDS AND WILL COM TTH ALL NON-POINT Issuedb Date
SOUR^""' ' -'""113. Y
_ n�'-�cI.O
Date Ke-roofs
HAZARDOUS MATERIALS DISCI-0 RE ,
Will the applicant or future Wilding Wcupant start or handle haxerdous material Type -
u definW by the Cupertino Municipal Code.Chapter 9.12,and the Health sed Safety
Cade,SWuon 25532(.)'.. . _ I . i N t• ... I h t': •' ;
oyli All roofs shall be inspected prior to any roofing material being installed.. .
Will the applicant or future building occupant to equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hnamdous air contaminants as defined by Or Bay Area Air Quality Management
District all new materials for inspection. Applicant understands and will comply with
°Yea "° all non-point source regulations.
1 have read the harudous materials requirements under Chapter 6.95 of the
California Health R Safety Cod,Sou..25505,25533 and 35534.1 understand teat
if the building does not currently have a nowt,that it is my responsibility to notify the
occupant of the requirements which must W mer prior to issuance of a Cerifcwc of
Occults
Signature of Applicant . Date
Ow euth
—� All roof coverings to be Class"B"or better
Date
r OFFICE '
C+_C�'-- CITY OF CUPERTINP
CIT
CUPEIkT IN® PERMIT APPLICATION FORM
�T
APN#
Buil ing Address:
20 GSI /W,- Cle /ah
Owner's a"'e: Phone#:
L"
Contractor: License#:
Contact: Phone#: A/
T
Applicant/Contractor: Fax#:
Bu, Permit Info:
Bldg Elect Plumb Mech
Job De ription: ,e–e
Re • ntial: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valua : / I �0• '
ype of Construction: 2 9 Occ ancy Grou
QuantityFee 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 BtALDING
BELEC1000 Elec 600V<= IOOOA 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
13NUCOMMP New Comm Plumb PLUMBING
( R qY3
1 of 752- 73 - 7,5—
APPROVED
IN ACCORDANC. WITH CITY OH
CUPERTIN ORDINANC
DATE
SIGNED
This set of am a specifications MUST
be IN
on the I ' at all times and it is un
SUBMITTAL lawful to make any changes or alteradonS
on same without written permission fro{n
the building Dept., City of Cupertino.
The stamping of this plan and specifications
SHALL NOT be held to permit or to be an
ipproval of the violation of any provlalonr
„r any City Ordinance or State Law,
cop
W �
AU 2 0 2002
11 Cs�