S 4330 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILITMG DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4330
BUILUING PROJECT IUEN'FIFTCATION
RU ILUING ADDRESS: SANITARY NO. APPLICATION SUBMI'FI'AL DATI'.
? OG2�/��
OWNER'S NAME: PfIONE: CONTRACT'OR'S NAME LIC NO:
_^C .1 N/C CONTROLM
CllrI iCHENGINEER: ,LIC NO: ADDRESS: ❑
oN1'ncr; PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG RLECT PLUMB Mli H
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby mfinll that 1 am licensed under provisions or Chanter 9(cnmmeming JOB DESCRIPTION
❑aZ with Section]0g0of Diem i 3ofthe 11 al and Pmfc...or,Code.andlny i tem."ix gF41D .
{00 PERM]L ISSUANCEi _._ENTIAL,
a:• m full force and effect. ❑SPDWL CHEN REMODEL
FQUV License Class Lie. APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
N 6 a Dam Cemracar
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
'M,, PANELS MOUIPICATION
ZOLeZ Iunderstande,plans shall re axed as publicme,ed.
O
UP 1021X1 AMPS Z—� ❑INTERIOR ❑S CHIMNEY
MINGP OL
FM~u1 Licensed Ymfersional 2111-1fXX)AMPS IMPROVEMENT SWIMMING POOLS
ZyE; OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEI/REPAIR [I DEMOLITION
a W 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
y3 Ar N fallow ing mason.(Section]031 5,Business and Professions Coda,Any city or county SIGNS ELECTRICAL ❑OTHER
O,Z which requires a permit to ronxtmcl.eller,in.pnae,demolish,or apair any"recu re
prior o its issuance,also requires the applicant for such permino file a signed sentiment SPECIAL CIRCUITIMISC.
Shy den he is licensed personal to the provisions of the Central License Lar.(Chapter 9
al�p0 (commencing with Section]000)of Division 3ofthe Businessand Professions Ced0or TF,MP METER OR POLE INST. COMMERCIAL:
icy ca that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION ❑DEMOLITION
i( N
Secant 7031.5 hyanyapplicant for u permit xahjednlhc applicant In it od pemdtynf POWER DEVICES ❑FOOD SERVICE
W not more than five hundred dollars 15500. 1
FZa ❑I,ax earn of tie property.or my empinyces with wages as the irsdremor,nsetion. SWIMMING 11001,ELECTRIC
�F=.O will do the work.and the strvcmre is net intended or ffered for sale Xcc.]BLI,Business ❑GTHIiR
L 3 m and Pndessionx code.The CentralLicense Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or Improves Iburemt,and who docs such work hi cif or Ihnmgh
his own employees,provided that such ilnprovcmentx are nor intended or offered for NEW RES1DIiN'I IA1,ELECTRSQ Pr.
ni
sale.IL however.the building or improvement is sold within one year ofenmplearm.the Q .R A VSQ'FL
wnenlmilder will have the burden of proving that he did not build or improve for put-
pose oLde.).
❑ I,us valuer of the prnpeny,am exclusively contracting with licensed contractors to TML:
construct the p]ect(Sec.71144.Husinon and Pmfcsxioms Cale)The Contractor's Li- 0
x law ales not apply to an owner of property who builds or improvcslhcreon.and QTY. PI,UMBI T FEE
who candrues for such projects with a colmmalons)licensed Pursuant o the Contractors
License Law. . PERMIT ISSUANCE.
1 ani exempt under See. .B A I'C for this reason
N:1'IIR-DRAIN ffi VIiNT-WN'IiR(EA VALUA'I'I(lN
ltfi)
ner Dare r
WORKER'S P COMPENSATION DECLARATION PACK FLOW PROTECT.DEVICE; 1{,/[�
I hand will under penalty of(it Conury Consent
of the Minns re for Worker
ru `
Ihave and will maintain a Ceni ficamef Continuo Club,to, for Workers Crucified- DRAINS-FLOOR.ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
ine,its provided for by Section 3]1X1 ul'dhe Labor Cnde,!rhe pertimnance of the
;r_c ad willsmaintatin Worker's Compensation Inormal as required by Section
PI%'TURES-1'IiH'1'RAP
of the lcatMC.lrr Clark.far the perfom...cent the work far which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP AIIN
My rrier: Pof YrNtu num r-IS
GAS-EA.SYSTEM OVER a(EAL
C17RIHil CAI'E 017 EX HN PTI(IN FROM WEIR KERSGRIiAS1INUUSI'RI.WASTEIN'I'I:RCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(ITissecrion needful becomplcted ifthe permit is for.hundred dollars(SHXB GREASETRAP
or IcsxJ PLANCHECK ME
I cenifylhat in the pcammararof .the work for whichlhis permil is issued.[,hall SEWER-SANITARY-STORM PA.200 FT.
urn mushy any Peron in any mann",so rte or became xuhjcct m Ill.Workers'Cortina. ENERGY FEE
0 Z cation Laws of Calimmia.Date WATER BEAT, WNGY'1'113Lf:C'TR GRADING FEE
Z. O Applicant
Nano;TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSIEMOREATING
a ; beeom
c subject to the Worker's Compensation provisions of the Labra Cala,you most 50145 FEE
W fnnhwidl comply all xrich prosi i nx or this artaii shall he deemed revoked. WAI 17R SERVICE
0
aZ C(1NSTRUCI'ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.1T. PAID Date
U0 Thereby affirm that them is a mnsttvction lending agency for the performance of
the work far which this permit in issued(Site309],Civ.CJ
C U LeaTOTAL
der',Name TOTAL:
W Lender's Alto... I,:
Ll I
S I certify that 1 have mad this application and stale that Ibe uMrve information ix BUILDING FEE
N "alma.I agree locomply with all city and county ordinances and Num laws relining to QTY. MECHANICAL PERMIT FEE
UZ building construction.and hereby authorize representatives ofthisciry menterupon the SEISMIC FEE
tMau.I armored prnpeny Lor inspection purposes. PERMIT ISSUANCE
(We)agre ., ndclaoily and keep burndexs the City of Cupcnino agaiml ELECTRIC PELT
liahilidirvjudgmeo,,enosand experoes which may many way ua rml against said City ALIBI<OR ADD TO MECH.
PLUMBING FEE
in consequence of the RSTAN of This permit.
nPPUERE IATIONXNDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL GLi
S CF RE .ATIONS. / p
AIR HANDLING UNIT(OV13H Id1,I0I CFM) CONSTRUCTION'lA%
Signature nanVContrador Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WI the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I00.000 HIVE
s defined by he Cupcnino Municipal Code,Chapter 9.12,and the Henhh and Safety
Cate,Senior 25532(a)1 HEXI1NG UNIT(OVER 10l BTU)
❑Yes ON. PAID
VENTELATION FAN(SINGLE RF'_SID) Date Bcza IN
Will the applicant or future E ilding wVel use equipment nr devices which BUTLER-COMP UMP OR I(XI,IXXI PTU)
it hozardoes nit connotations as defined by the Hay Area Air Quality Management TOTAL'
rxtri'0 11011.17R-COMP(OVER 10I,0001{'IU)
❑Yes 0 N
I have real the hvtdo
aus materials ncquimmantler Chapter 6,95 of Ile Cali- AIR CONDITIONER ISSUANC/�J�p}a,�J,)�C�/\//
amor Ilealth at Safety Cade,Sections 25505.25533 and 25534.1 understand that if[tie NE!W RESIDENTIAL MSCI I. SQ.FT
baild'ia,docs nd eumn0y hes mm�um,that it is illy N-spateibllhy m nudity the occupeot
it the requirements whish 11 she mrd prior,led, she mrd"'i...1, M'o Cenilicumill-(k uPuncyM'o Cenilicu¢nl-Oc uPuncy.
Owner or turholieW agentOsvner agent One
ISSUED TOTAL: ISSUED BY:
OFFICE
BATH
by Remodeling Specialists j(, 2 _/,0';0,0';0 � Yq
1422 SARATOGA AVENUE • SAN JOSE, CA 95129
TELEPHONE (408) 378-6700 CONTRACTORS LIC. 0674083 Date (7
//j'/vii L 11I/I/ - I ._.{.._ 112
.
S
I r �
etCC! 0 21999 .
NSPEC 1
CIIYOFCUP CFPgHIMtNr
I
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19
I I
3G 17 OCA T�! PERMIT
APPLICATION FOR C TY OF CUPERTINO NUMBER R"
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Zl)SS DO RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME U �i roof assembly is required.
NO ❑ Intbal I.C.B.O.if
ADDRESS Z-)) > EXISTING ROOF COVERING
PHONE �P ' D NUMBER OF EXISTING COVERINGS r TS ZG
CONTRACT '
NAME�O�T�P�1'/U xSS4�X'e ��i9'L TO BE REMOVED 70 BE RETAINED
ADDRESS � Al ��++ TYPE OF ROOF C V RING
CITY 8 ZIP ZZ✓z �/�[.O/!�/ ANay li CA
/',,r' , yy EXISTING 2/
PHONE 1L -O(o BUILT-UP ROOF
LICENSE ❑ V
NUMBER to ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full farce and
effect' �( WOOD SHINGLES ❑
License Chas Lic.Number 0
DateCoContra,.,,,c / OTHER(SPECIFY) ❑
OWNER-BUILDER D CLAN PROPOSED
I hereby affirm that I am exempt from the Contractor's kens Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,ager,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
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(commencing with Section 7000)of Division 3 0l the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES p
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
Bions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑
such improvements are not intended or offered for sale,Il.ill however,the building orImprovement
n sold tbuild or
year of for purpose
f the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or improve for purpose of safe.).
❑I,es owner of the property,am exclusivelywith licensed contractors to construct
the protect(Sac.7044,Business and ProfessionssCode The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to c of owner of property whobuildst or improves thereon,and who contracts for such protects
with a contractors)licensedrSe pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
p 1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
0ihave and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance carrier and P 'cy n mb r era: Q /
Carrier Policy No. 5AC4Z3Y200 PERMIT AUTHORIZATION DATE
CEMIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed if the permit is for one hundred dollars(8100)or less.) nz � r'
I certify that in the performance of the work for which this permit is issued,I shall not employ rHo
any person in any manner so as to become subject to the Workers'C mpensatmn Law,of can- All roofs shall be inspected prior y rooting material being
ramie. installed. If a roof is installed without first obtaining an
Date_Q�� Applicant inspection,I agree to remove all new materials for inspection.
NOTICET APPLCANT: If,after making sCertll' eofExa .-YYou scams Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the abor C , u must I with comply PP P Y
with such provisions or this permit shall be deemed revoked. source regulations.
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 stale laws relating to building construction,and All roof coverings t b lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, / (�
judgments,seats and expenses which may in any way accrue against said City in consequence SIGNATU O APP ANT A
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-P OGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
If DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY