03020045 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMI CON'CR`ACTOR INFUItMA`C :
BUILDING ADDRESS: � PERMIT NO.
20305 NORTHGLEN SQ Q302004-
OWNER'S NAME: APPLICATION SUB DATE
SPRINGER LARRY A 02Z12/2003
PHONE: SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o
class, LICENSED CONTRACTORS derp DECLARATION
I hereby affom that 1 am licensed under provisions of Chapter H(commencing ver ( s Job Description
with Section 7tXlp)of Division]of me Business and Professions Calc,and my license is
in mumL�d
�] � KITCIAQW
F Z�Z License t
ate aCm ore r N CONT
D L ATION CONSTRUCTION INC.
oI used as pis tic recnNs 1 —
cto.WC Licensed Professional V',.9� 3 r 2003
iOWNER-BUILDER DECLARATION
�<x 1 hereby affirm that I am exempt from the Contractor's License Law for the
a a m 0 following reason.(Section 7031.5.Business and Professions Code:Any city or county BUILDING
a� m
� which requires a permit to construct,alter,improve,demolish,or repair any structure
s,Zy prior to its issuance,also requires theapplicam forsuch permitto filea signedstatement
that he is licensed pursuant in the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
$ (commencing with Section 7")ofDivision3 of the Business and Professions Code)Or
y mm he is exempt therefrom and be basis for the alleged exemption,Any violation of $56000
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number not more man fire hundred dollars S500), Occupancy Type
❑I.as owner of Bre property,or my employees with wages as their sole compensation, 31641060 . 00
will do the work,and the swcture is not intended or offered for sale(Sec.7014,Business
and Professions Code:The Contractor's License taw does not apply to an owner of 101 - FOUNDA'� ed Inspections
properly who builds or improves thereon,and who docs such work himselfor through his
own employees,provided donsuch improvements are not intended or offered for sale.If. 102 — 'PIERS
however.the building or improvement is sold within one year of completion,the owner
builder will have me burden of proving that he did not build or improve for purpose of 103 - UFER
104 - REBAR
❑L la owner of me properly,,B exclusively contracting with licensed
onment tors to 10 5 - ANCHOR BOLTS
ccow tat me project(Sec.0 an Business and property
whodm Code:)The Contractor's nd
who
Lawdoes r such apply maOwner with aotpmpertywcenseddsorimpto INContogand 106 - SEWER & WATER
'.who contracts for ouch projects with a conuactor(s)licensed pursuant to me Contractor's
License L.W. 202 - UNDERFLOOR PLUMBING
❑Ivo exempt under See. ,B&PC for this reason 203 - UNDERFLOOR MECHANICAL
Owner Dam 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of me following declarations: 205 — UNDERFLOOR INSULATION
I have and will maintains CenNca¢of Conicat aelf-insure for Worker's Comped- 301 — ROUGH PLUMBING
cation,as provided for by Section 37W of me Labor Code,for the performance of me 302 - TUB & OR' SHOWER
work forC]Ihav aiehmiaparmiinWored. 303 - ROUGH MECHANICAL
❑1 have end will maintain Worker's Compensation Insurance,h required by Section d. 3 04 - ROUGH ELECTRICAL
3700 of me labor Code,forme performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy
ynnur(ry/her . 305 — FRAME
cco: 0.\2��wld Policy NO.:` Q�3.Q�s,
CERTIFICATE OF EXEMPTION FROM WORKERS' 3O6 — HOEDOWNS
COMPENSATION INSURANCE 307 - INSULATION
Itrless.)(Thisscnion mOdnotbccompleUdifthe permitistoronc hundreddollamplod) 308 - SHEETROCK
certify that in the performance of the work for which this permit is issued,)shall not 309 - EXTERIOR LATH
employ
anyperson in any manner sa as In becomesuhject to the Workers''Compensation 310 - INTERIOR LATH
Lawso
Laws of California.Delc
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 313 - ROOF NAIL
become tome Worker's Coons or this
permit
steal of the LahtivckCode,. must 501 - FINAL ELECTRICAL ENERGY
O Q becomforthwith comply with suchWorker's
provisions natio ppro isions f the Lab revoked.
z CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
gs r per 503 - FINAL MECHANICAL ENERGY
94 J Ifar which
h'hi me,ermere issued eetion lending a enc to, formanee of
x > thndc,'ae work urwhichthisprmilisi ucd(Scc.3097,Civ.CJ 504 - FINAL BUILDING ENERGY
0.Wi Q Lender's Name
Z)z
LenderE Address
505 - FINAL ELECTRICAL
U 0 _
U O I Gerrity that I have read this applicationandstate that the shove information is 506 — GAS TEST
Cts F coroner.1 agree to comply with all city and countyy oNinances end stale laws relating to
OU building conswcuon,and hereby aur ire representatives of mis city to enter upon the 5 rIz FINAL PLUMBING
W above-Inerimed property for inspection purposes.� O$ FIN' y (We)agree to save,indemnify and keep harmless City of Cupertino against CNG
in
liabilities,judgments,costs and expenses which may in any way accrue against said City 55 N
V 7 in consequence of the granting of this permit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL,�ION-POINT Issued b 51YDale
Re-roofsof
�15ignatureOlAppicartiCialmeter
Oare HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be,applicant or future building occupant store or handle h omr ims material
as defined by me Cupertino Municipal Code,Chapter 9.13,and the Health and safety
Code.Section 25532(a)7
❑Yea an All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future buildin Occupant use a If a roof is installed without first obtaining an inspection,I agree to remove
g pan a Air Quail
g p g
•mitrict? usair cdnmminantsasJefncdbythe Bay AreeAirQualityManagcmem all new materials for inspection.
District?
❑Yes Nd
I have read me hamrdnus materials requirements under Chapter 6.95 of the Califon
nia Health&Safety Code,Sections 25M5,25533 and 25534.1 understand that if the building
dors not c0h eptly have a No art.Nat it is my responsibility 10 nnufy c occupant of the
ircmenta which mustM el prior to issuance of a Cenificam of 0. ancy,
Signature of Applicant Date
��Owner orauthodmedagent One All roof coverings to be Class"B"or better
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x� CUPERTiC /� 3
r M
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;IGNOD) -_ ecifications Mui'
-- —
IS set oft r s urat all times and it is un _ }
oe kept on it, changes or alterationWDPR.Egs H,
an ermission fras� i
lawful to naihout written D G
$CUPS— U W OZK' on same C)ept, City ertino.
of CuP ecitications PPS
he buiiding
— r of this plan and sD
CtA gINF—TS r tq F�Utelt^' � ut. o
/ l_L r to be 2T
O3o S GVoEfGlEn�,��;
SHALL NU e bel' t any Provision" SQ0A'Z4E
r he violation
"FiqP 'r rdinance or State
• �( any uty
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Cat),jTeg- ela-cut, \,JlC? F-c..r_
•ITY OF CUPERTINO
RINO PERMIT APPLICATION FORM b
COPE OF
• APN# ! Date:
Building Address:
� Cu
Owner's Name: Phone#:
Contract License#:
r oN
Contact: Cupertino Business License#:
o, „r.o. (4"` 1-1\0-9 17
01
Bginrmit Info:
B Eact P b ech
Jtion�/"
Residential Rr TC_VwA Re-Nbv4TbtA Commercial ❑
q. t. Floor Are : $/Sq.Ft.:
Cost oft ject: Occupancy.Group:
00 P.�s�aQa
Type of Construction:
Quandt Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler—> IM to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
BCONSTAXBQ Con. Tax for BO Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
13ELEC1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGYEner BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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