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02060041r' �ce �u a dna y pZr3 �En Y� gg O 1° u'73a E ie0 �gc 4 CITY of c DPvrsiONNO PERMIT CONTRACTOR INFORMATION:, _ BUILDING ADDRESS'. 10419 PALO VISTA RD AGE LYSSAND CONSTRUCTION PERMIT NO. 02060041 O G YOERG E AND MALLE 0 639 PARK ROAD APPLICATION UB DATE 06/07/2002 HONE: (650)366-5433 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: t BUILDING PERMIT INFO BLDG ELECT PLUMB MUCH O IUJ I-1 L_I Z LICENSED CONTRACTOR'S DECLARATION (hereby lam licensed undermid Prensof Chapter Section7")afecivisionJ Division Job De cri tiolt� P ADDITION (798 SQ. FT.)ew )of Code9(commencing of tM1e Businessand Professions Code, and my license with fall is in full force and affect. ULicense Class Cont, Data S DECLARATION y a ARCHITHCf•SDECLARATION FEB 1 1 understand my plans shall be used as public records 0 2004 suING Licensed Professional OWNER -BUILDER DECLARATION Io I hereby affirm that 1 License Law for me exempt from the Cosions 1. (Section lender Business and o < iore Code: Any city orcounty $1600 U whicfollowing tares0 ❑ with nobtares ve. de demolish or repo, swcmre waralcor mfor u npermn such n Pn t t cal 9 m applicant h permu t fl signed statement - _ _ _ _ .-__...._ ,.... . _.."..... _._...._... - that be sl gwith yMp Sectimpton (1 )P Emotions [meC Basin L La (Chapter (impairmen,Cod) nfineliged di fAnyviCede) fhe 9 fl'y �j 3r''n,�s 0]��{I�(pa s tt N + real I Valuation or 'hat he'iseemt therefrom ba p ant the basis forme alleged exemption, Any violation ...9-„ „ut+,l ' of Section 7031.5 by any applicant fora permit subjects the applicanuoacivil penalty of nut mare than fee hundred dollars es5«n. 101APN i@IftMAT I ON Occupancy Type ❑I, as owner of the property, Or my employees with wages as their sole compensation, 102 - PIERS will do the a work; and the imuode The C not intended en offered Law fur sale apply to4. Business and Profusions Code: The is or License Law tar not apply 0 an 10 3 - UFER Required Inspections Owner of property Who builds or improves thereon, and who does such work himself or through p employees provided that M1improvements are not mended or 104 - REBAR offeredpie f 1 lChu the building p mem smd within one or 10 5 - 'ANCHOR BOLTS : - larld en,npmtun, me owner bntaer will have m burden or Proving that he did our build or n build improve for purpose of sale.). 10 6 — SEWER & WATER • 1'a:o rte ofthe ..p penyem... exclusivelycontracting_,-mlicensed ooweet -sto. ... ....__2.02.=...UNDERFLOOR....PLUMBING _. ..,.; _. _:-..-.. .. onswct'he Project (S c. 7044. Business and Profess ons Code) The Contend., 's License Law does not apply to an owner of property who builds or improves thereon 203 - UNDERFLOOR MECHANI CAL` - " .and who contracts mr,acn proneus with a contraaorts) licensed pursuant.to me ' 204.. _-.-UNDERFLOOR ---FRAME--- ' Cot t License Law. UI `adders 'B&PCfar this reason 205 - UNDERFLOOR'`INSULA'TION 0 dM1'g 2liDZ' WORKER'S 301 - ROUGH PLUMBING COM ONDE LAR ION 302 - TUB & OR SHOWER I hereby affirm a rp nRy of perry y o of me following declarations: 303 - ROUGH MECHANICAL ❑ 1 h nd will an tan e'Cenircat Pe sent m elf more fur worker, 304 - ROUGH ELECTRICAL Compensation, as provided for by Section 3700 of he 'Labor Code, for the peri (conned.f thewmk for wh;cn this pe,crob e, issoee. 305 — FRAME _ ❑ 1 have ince will mai t worker's Compensation I surance, as required by Section 306 - HOLDOWNS 3700 of he Labor Code, for the performance of the work for which this permit 307 - INSULATION tissue 1 My Worker v Comp at n Insumk.cancer and Falb, be are: y ,,.. 308 '= SHyEET�ROCK ot`lk IsCERTIPICATION OP,EXBMPTION PROM ORK Eke�:I NO5' 3.09 ll�, IEA�K`IORrsL1ATH 1 COMPENSATION INSURANCE 't ERIOR--LATH , sea en need not be completes ifthe perm i s for one hundred dollars - 311 SCRATCH COAT (si(Tic _ to)o I ) s' '' 1 nit mai in � s y perfo na amdrr u r k f hich m atm it sx Workers 'sharquar erePlay e perso n panne s fyo uhledmtheWorkers' 313... - ROOF_NAIL-r .. _,.... •- - "- 501 - FINAL ELECTRICAL (ENERGY" ompe t mLaw, PP Law" Ir ° A I t ..502 ---.FINAL PLUMBING .ENERGY.. _ NQ APP ICA f h oak' gt t pb n,.y should- Hi bjecuo theta kars don creation p onsaaflh L'ab ,Coad. you must 503 - FINAL MECHANICAL' ENERGY j forthwith comply whhsuenPM,lion,cadispe.ithaubeaemedrevoked. 504_ - FINAL BUILDING ENERGY "` l 'CONSTRUCTION LENDING AGENCY 505 — FINAL ELECTRICAL I h _ by ff mat m ' n t t lenamg agency for the performance t ora work for which this permit s issued the 3097, Civ: Cr 506 - GAS TEST ' _, Lena rsN Lenders Address _-507 '_-FINAL PLUMBING...._..... _.._ .._........ _. r, 1 ¢fy thatlM1 base pplst dtt marsh 'bov f ion is 50 - FINAL MECHANICAli' rec� Iagree g e to ply ton city nacounty ordinances and state mining v�-- 5 9 — INAL GRADE l .m building construction, and hereby authorize representatives of thre city to courtroom he brdtopiary f pecepparps 5 0 - INAL N NG i (We) agree to, Indemnify and keep M 1-stheCty fC'penmoagainst 51 - INAL RKS liabilities judgment, c t, d i l nsa which may in any y against said City n q ce of thet ung of thispermit. APPLICANT UNDERS fA\DS AND WILL -COMPLY WIT LV P0, IRCER GULAG S Issued by; Dale ��lq Abp n r1 .%" LUIUOL boom pp m nmr ad- are Re -roofs HAZARDOUS MATERIAL DISCLOSURE Will m applicantor p t ire ,handl health mammal m, Type of Roof- . `JP .g-,,, ., ..._. .... cCr ode, as defrcd by th Criterion Municipal C d Chapter 9 12 d m Health and SOF ty Cod s t n 5 32(d) � I ..>. l 1: 30Y ', ,.,,f prior. .. ,.y All. roofs shall be inspectedto an roofing material being installed, wum applicant ofuture bId' g equipmentupantuse rdeaas.which mit hazardous mm ti t defined by m Say Area Air Quality Management -material. If a roof is installed without first obtainingan-ills ection;4'-a ree'to.'remove P g DismcpYes '. - - new materials for inspection. ..Appltcant understands and will comply with. N _all .. . all non -point source regulations. d the h d Materials requ ts under Ch pt 695 of the ifthel H hh&Safety Cede medeam5505it ytonoif mer if the bo Iof a red notcertainlyis ten t that t -my rc p -b ITy t mify me my resnd ponsibility Accu t f me irs p requirements ns which m into w issu tt f Certificate of �\,, ��p �� t �� I � ./Y fit\\'f�\ \\Y -}\{Alp-1s^pV )(r._.rn zVj�J - ,Occupancy I Lim �a �gnature, of Applicant„ „ „ _. Date g _._. Al] roof coverings to be Clas ' or better own o out Da g .... ,.__...._.._...OFFICE ... .. sW O tot-.. < a Ur Fa ^sg m 60WU r 96 LUsg�s00 Fez I. } M Qz 0 wA UQ wE E.4 a Uz CITCUPERTWO Y OING CONTRACTOR INFO iON: UrL DMSIOONPEl_. 'T BUILDING ADDRESS- 10419 PALO VISTA RD AGE LYSSAND CONSTRUCTION PERMIT NO. 02060041 o 'fG YO ERG E AND MALLE O 639 PARK ROAD ATE APPucA0 5/ 0 7/2002/ PHONE:'(650) 366-5433 SANITARY NO. CONTROL NO. ARCHIIEC iENGUEER: BUM DING PERMIT INFO BLDG ELECT PLUMB MECH LJ LICENSED CONTRACTOR'S DECLARATION Job De criptioIl $ I bcmby affirm that I am licensed under provisions of Chapter 9 (commencing ADDITION 7 7 8 SQ FT ' with Section 7000) ofDivhion 3 or the Busieess and Profcmioos Code, and my licenu is in full force and effect. . . License Class Lie.0 Date Conuactor ARCHn•PC7"S DECLARATION ' I understand my plans shall be used as public records Licensed professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt fmm the Contractor's License Law for the following reason. (Section 70313• Business and Professions Code: Any city, or county $160000 which requires a permit to construct, alter, improve• demolish• or repair any structure priorto its issuance. also rcquires theapplicant forsuch permitto ale a signed statement -- -- - - - - - -- - ••--• • -- - - r 0 lir ria ,. q. • ( 7 g '1 i i �+ Valuation that,hd i� licenod pursuant to tlF.pfnvisnons of the Contractors Rause Law (Chapter9 (commcacing With Scetion 7000�ofDivisioo 3 of the Business and Professions Code) or thai he is exempt therefrom and the basis for the alleged r)tempdon. Any violation _'�. {? y ,._ t�'_ ., , ` i ; . t': J.' , r of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dogars (s501)). 10 1AP-N 5 AT ION - Occupancy Type ❑ I. as owner of the property, or my employees with wages as their sole compensation, 102 - PIERS 10 3 - UFER Required Inspections -• will do the -work, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property Who builds or Improves thereon, and who does such work himself 104 -- REBAR or through his own employees. provided that such improvements are not Intended or offered for silt. If, -however, the building or improvement is sold widtin one year of 105 - ANCHOR BOLTS - coritpletion, the owner -builder will have the burden of proving that he did not build or Improve for purpm of sale,). 106 — SEWER & WATER i,esI , --fd;ter„p<rty.err;ucltuiye[y�entraactingwithli�em�de°a,r�etnt=;o -2-02 = UNDERFLOOR PLUMBING- --- Eruct the project (see. 7(FW, Business and Profession Code:) The Contractors 2 03 - UNDERFLOOR MECHANICAL License Law does riot apply to an owner of property who Wilds or improvcs thereon, .nerd "'bo contracts for sjnch projects with a contractor(s) licensed pursuant to the _ •- - 204 - UNDERFLOOR ...FRAME- - • -- ----- - • - •-'-- -- ... - Commetors License Law. ❑[amue tundcrSa. B&PCforthisreason 205 - UNDERFLOOR''INSIJT�ATION e Dart Z WOR 3 01 - ROUGH PLUMBING CO ON DE oN 302 - TUB & OR SHOWER I hereby affirm ander penalty of pejury one of the following decluadons: 303 — ROUGH MECHANICAL 0 1 have and will maintain a Cdrlficate of Consent to self -inure for worker's 304 - ROUGH ELECTRICAL Compensation, as provided for by Section 3700 of the Labor Code, for dee performance of the work for which dais permit is issued. 305 - FRAME ❑ 1 have and will maintain Work&r's Compensation )nsumce, as required by section 306 — HOLDOWNS 3700 of the Labor Code, for the performance of the work for which this permit is 307 - INSULATION issued. My Workers compensation Insurance carrier and Policy number are; ..... --... _ _ _ _ ....._... 3 0 8 - - - -• --� _. ..._ - Policy No- ICERTIF UC ON OF E][EMFCION FROM tiVORXERS'F .SHEETROCK , � - , '3.0 9 EXTTER+I0R' 1;A T. COMPENSATION ¢rsuRANcs -310 - INTiERIOR --LATH...-- -- - - -- -• - ' Cnis•section need not be eorrtplcted if the permit is for one hundred dollars 311 - SCRATCH COAT (SI00)oeless.) 1 1 313 - ROOF NAIL -• 1 certify that in the perfamwn of tine work for x§ 2 this permit a issued, ' shall not employ any person in tanner o e _subject to the Worker' 501 - FINAL ELECTRI CAL 'ENERGY Compensation Laws if t )- Appl 502 - FINAL PLUMBING ENERGY It g p y [." 'IC TO APP ICANT: • atter maki n e tm voq you should 503 - FINAL MECHANICAL ENERGY bee a subject to the Workers Compensation provisions ofthtkLaborCcdc. you cont fon4iwiih comply with such provisions or this permit shall be cierred revoked. 504 - FINAL BUILDING ENERGY_ CONSTRUCnON LENDING AGENCY ' 505 - FINAL ELECTRICAL 1 hereby affirm that there is a construction [ending agency for the perfontrnce of the work for which this permit Is issued (Sec. 3097, Civ, C.) 506 - GAS TEST ' Under, fume 507 - FINAL PLUMBING Lender's Address 50 - FINAL MECHANICAL I certify that I have read this application and state that the above informationis correct. I agree to comply with all city and county orlinances and state laws elating 5 g _ I NAL GRADE ro building construction, and hereby aurhorin trpresentatives of this city to enter upon 5 0 - I NAL NG the above-mentioned property for inspection purposes. (We) agree to save'. indemnify and keep harmless the City of Cupertino against liabilities. judgments, in 51 -- INAL RKS casts and expenses which may any way accrue against said City' in consequence of the granting of this permit. APPLICANTUNDERSTAND ANDW LCOlv[PLY L -PO WITH N d-' CER CLATI, v5. Issued by Date ✓�J Re -roofs cam; pp u ormuctar ate HAZARDOUS MATER DISCLOSURE ' Will the applicant or furwe building occupant store or handle hazardous tnazcrial - Type of Roofas defined by.thq Cupertino Municipal Code, Chapter 9.12, and the Health and Safery Cody Section 25532(x)? j i .- ; ; "• ❑Yes"° All roofs shall be inspected prior to any roofing material. being installed._ Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, -I agree to remove emit hazardous am contaminanu as defined by the Bay Arra Air Quality Management District! XN° all new materials for inspection. Applicant understands and. will comply with ❑YCs all non -point source regulations. ' I have mad the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand that if the building does not currently haven tenant. that itis my responsibility to notify the i ' (� Q Certificate of occupant of the requirements which mus) be met prior rn issuanc43f4v, lgriature of Applicant Date �Occupac �Ontriau&Miize&agem' All roof coverings to be Clan " or better Da (L`. CITY OF CUPEkTINO %-JTY OF CUP1ERTIN0 PERMIT APPLICATION FORM W- oao&04) APN # Fee Group --Z� Date: �-61 T/ EACH STORY OVER 3 Building Address: [[ L1� r l 1� y9 �� Sl P,& e, l Owner's Names/ I l � � + {— f ` �l. EACH STORY OVER 3 Ph�e��9 Contractor: X39 PR A ,� Other Appliances License #: BCONSTAX Contac . BUILDING BCONSTAX Phone #: BUILDING Applicant/Contrapt a�, �u SSQ�� J BUILDING Fax #: Hotel and Motel ui1 ing Permit Info: 13ldd Elect Plumb (—Mech BUILDING Description: Residential: j Commercial: BELEC1001 Sq.Ft. Floor Area: ELECTRICAL BELEC200 $/Sq.Ft.: ELECTRICAL Architect/Engineer: Energy BUILDING Valuation. (W. Energy Add Multi Type of Construction: BDTVESTIGA Investigation fee Occupancy Gro SrIp, BMITIGATC QuanfiV Fee ID Fee Description Fee Group APTFEE EACH STORY OVER 3 HOTELFEE EACH STORY OVER 3 OFFICEFEE EACH STORY OVER 3 BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Cornm/ uasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax – Resi/Mobile BUILDING BELEC 1000 Elec 600V <= I OOOA, ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BDTVESTIGA 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 1 of 3