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CITY OF CUPERTINO
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BUILDING DIVISION PERMITV�+Ll1�CAO
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BUILDING ADDRESS:
0770 PFNTNRTTT.AP AV
OWENS CORNING
1ERMITN0.05100084
"EWS NAME:
PERMIT DSUB DATE
JOSEPH YOUNG
3037 INDEPENDENCE
PHONE:
SANITARY NO. CONTROL NO.
925)245-5238
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BO EO PLO MEOCH
LICENSED CONTRACTOR'S DECLARATION
Job Description
O
1 hereby affum that l am licensed under previsions of Chapter 9 (commercial
P
with Section 701k8 rif Divides 3.f the Business and Pnfassinna Code, and my license is
in full roma, and effem48 2
BATHROOM REMODEL
Lic"'CI
��——Lie.{
Data �;5M t. Co..=r
ARCHnECrS DELLA A ON
I understand my plans shall bo used an public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am nempt from the Conuatmes License Law for de
following mason. (Section 7031.5, Business and Professions Cade: Any city or county
which mqulm a permit in cnnmuck slur, improve, demolish, or repair any structure
$25000
pilar in ILL issuance. a1W requires the applicant farsuch remit to rile a signed WNmcel
that he is licensed pursuant to the provision of the Connector's anse Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Profession Code) or
that he is esempt durcfrom and But basis for the alleged exemption. Any violation of
30
Occupancy Type
Section 7031.5 by any spplinnt for a permit subJau the applicant to a civil penalty of
not mom than five hundred dollars (SSW).
❑ I,esowmofrhepmpmy,amyemploymwlNwaguude mlecompemdm.
Required Inspections '
will do the wort and the&=turn is nolimended coffered faraaa(Sm. 70u, Business
and Pmfesslons Code: Tire Conuacmr's Liam Law does not apply us an owner of
q P
himWfa Wough his
suNamn,anCwhodasauchwok
oweenywhobuilds i edimparmini
provided such improvemanuarc moRaed for uta
v -
however. the W, r-
pr rm year
milder the building or Improvementismid withinone year ofmprovefn,Neowes'-
builder will have du burden of proving that be did ml build a improve fa purpose of
tars1,
❑ 1, as ower of the property, sec exclusively conlru.9ng with licensed mnvanmrs to
3
constructLned ro Code) Them Li.
project (Sec. 7046, Busiowner
and Profieproperty
thenwn,
came law cora not apply m an owner orproperty who builds or impresses therein, ren!,
d of who
who contracts for such pmjcns with a contranor(s) (lamed porton in the ConumuM1
D
law.
❑lam eaemDt under Sm. ,B&PCfor this mason
[I Im
er Dau
WORKER'S COMPENSATION DECLARATION
I hemby &Inure under penalty of perjury ors of six following daWatiots:
❑ 1 ham and will maintain aCenificau of Comenl to self-iuurc far Wark esCompcn.
sation, as provided for by Section 3700 of the labor Code, for the performance of the,
work for which this permit is leaned.
❑ I bas and will maintain Worker's Compensation Insurance. an required by Section
,
3700 of the Labor Code, for Ne performance of Ne work for which this permit is Issued
My Worker's Compensation Insurance ams and Policy number arc:
carver: /QA( R?&&I t Policy No.; mwL liop
CERT MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Wcompleted Bite, permit isforomhundrcd dollars (SIM)
or au)
1 certify that in Ne performance of the work for which Nis permit is Issued. I Nall ran
employ any .an litany ..no, se as in bttVme mlfjeel in be Workeri Campcmdon
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: If, after making Nu Certireatc of Exemption. you Mould
become subject to the WorkeM1 Compensation provisions of Nc labor Code, you must
forthwith comply with such provisions or Nis permit that be dcemed mrokee.
CONSMUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for that performance of
the wurk for which Na permit is issued (Sec. 3097. Civ. C.)
'
Lender's Name
,
Lender's Addrcea
1 cenffy that 1 have mad this application and some that the above information I,
cornea. 1 agree to comply with all city and county ordinances and sum laws relating an
building construction. and hereby suthodm rcpresematives of this city to enter upon the
shove -mentioned property for Impaction purposes.
(We) agree to an. indemnify and lap harmless the City of Cupertino again'
liabilities, Ineffectual, costs and expenses which may in my my acne against said City
In consequence or the granting of this permit.
APPLIC NDERSTANDS AN WILL COMPLY WITH ALL NON -POINT
I
Issued by: Date Q,/
SOU UL HE
Re -roofs
Type of Roof
/D� OS
Signre of ApplleanfiCmuractorData
su
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant tar roars buildin aaupmtstom erhendle haurdom material
u dermad by the Cupomr. Munici rids. Chapter 9.12. and the Health and Safety
section us3z(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicml or uwrc building occupant use equipment or devices which
call Wisockma air conuminanu an dc0ned by the Bay Area Air Quality Management
all new materials for inspection.
'a tell , 1
❑Yes �y
I have read the hassrdous materials rcquircmcnu underCWpser A95ofthe Califor.
nice Health&Safay Cade, Emblem 25505,25533 and 25534.1 undersand thatiflhe Wilding
tau not cu ave a tams thin It is meprinal1111Ity w entry IM occupml of Nc
regaire MCI pin riIaCertficateofOcmpag..
Signature of Applicant Date
��L M —�m�
All roof coverings to be Class "B" or better
o nes or mNririmd agent a
CITY OF CUPERTINO
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41"AA yk'`�j
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BUILDING DIVISION PE
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Fa�As'S
BUILDING ADDRESS:
[077n PRINITINIRTTLAR AV
OWENS CORNING
PERMIT NO.05100084
OWNER'S NAME:
FERMITISSUEDATE
JOSEPH YOUNG
3037 INDEPENDENCE
ONE:
SANITARY NO. CONTROL NO.
925)245-5238
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
rr�lltaawee�aa,,,�aaaTTTnnt�```,,,Q(anrPa�
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I hereby that I em licensed under of Chafer 9 (ammense
haptenand
of rDivision
Proems mnonamcul
Sof mesad
0) of Professions Is
with Section 70110) And
LC
I. full force and Affect. 2
`Yee
BATHROOM REMODEL
• -1
LlceOdo�Cl�`�� Llc. N
Date/Cuntrecur Ta/'T S
ARCHITECTS DEcLA A ON
-
I understand my plan. shall he used As public records
-
MAR
a p
1006
Licensed
OWNER -BUILDER DECLARATION
nio
hereby License Law for the
I hereby
(Sect Inn 11. =crepe from the CeMOAS
BUILDING`
U
I L
as�`
®�
Ce
nn. Calc: My city or [aunty
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fallowing meson Permian 703 1.5, Business and
J-/
improve, de
which rcyuire a Permit m construct. eller, impmm, dcmulkM1. or repots any nrucwm$25000
prior An am issuance, also regains the eppliant for such permit to file.signed statement
Ft. Floor Area
Valuation
that he Is licensed purmanuo the provisions of thc Contractors License Law (Charter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Profession Code) or
that M Is euMpt therefrom end the basis for the alleged exemption. Any vm educt of
0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more man fim hundred dela. ($500).
❑ 1, a owner of the properly, or my employees wish wages As their sole compensation,
Required Inspections '
will do due work. end the structure is An[ imendcd or Altered fmsafc(Sm. 7014, Business
and Professions Code: The Contractors License Lew does not apply to an owner of
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gmpenywho build, or improve timme .and whodeeasuch work himself er through his
awn employee, provided Not ouch improvements ere not I.uMed ore@red rural.. If,
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however, the building or improvement is sold within one your of completion. the owner,
builder will have doe burden of proving that he did not build a Improve for purpose of
sale.).
❑ 1. a Owner of the properly. em =elusively enameling with licensed contractors, m
comm cl the pmjea (Sec. 7044, Business and Professions Code:) The Coa moo's Li.
tendo Law docs not apply to an owner of properly who builds or Improve thereon, and,
who contracts for such prejecu with a contractor(s) licensed pursuam m the Contrumrs
LicenseLaw.
pl on. oaempt under Sec ,B&PC for this scion
Owner Date
,
W ORKEWS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations,
❑ 1 have and will reainuia a Cenifiate of Consent to self-ieum for Wa1cc`1Compere
gotten. As provided for by Section 3700 of she Labor Code. for the performance of the
work for which this Permit is Issued.
❑ I haw and will maintain Workers Compensation Insurance, As required by Section
3700 of the lsba Code. for the performance of the ware for which this permit is issued
My Workers Compensation Insurance carrier and Policy number am:
Cartier. 0,d Revubh[ potty No.: mWL 16)fr
CERTIF�OFEXEMP 1ONFROM WORKERS
COMPENSATION INSURANCE
(Tho section need noun[ completed Irthe Permit s Insane hundred dollars; (SIM)
or 1=s)
1 cenify that in the performance of the work for Which this permit is issued, l shall not
employ any peon In any manner an As to became subjecuo me Workers' CAmpendation
Laws Of California. Dau
Applicant
NOTICE TO APPLICANT: If. After making Otis Conificau of Exemption, you should
become subject m the Worker's Compensation provisions of the Ichor CMe, you must
' forthwith comply with such provisions Or this permit hall be, deemed mmked.
1
CONSTRUCTION LENDING AGENCY
I herehy affirm that there is a construction lending ageaY for the Performance of
' the work for which dtia permit is issued (Sec. W. Civ. C.)
'
I mdoea Name
.
Lenders Addrea,
I enlfy than 1 have read this application and sum that the above Information A
4 correct. I agree m comply with all city and county oNinences and sure laws mating An
building construction, and hemby mummire mpresematims or this city to enter upon the
above-mentioned property for inspeaton purposes
(We) Agree to Am, indemnify and keep harmless the City of Cupcnino against
j liabilities,judgments, costs and expense which may in any way accrue againsead City
k
in consequence or the granting Of this permit.
APPLIC&4g,[INDERSTANDS_ANP WILL COMPLY WI TN ALL NON -POINT
Issued by: Date /Q,/
SOU — UL NS.' 'q�
/D OS
Re -roofs J
Signature of ApplianVContncmr ' Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will be applicant dor future builain uccupenetore Orhandlc hmudrus material
m defined by the Cupe tine, Municip ode. Charm, 9.12, and tM Health and Safety
Crum, Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Ye o
If a roof is installed without first obtaining an inspection, I agree to remove
wills applicant ma umm browing «mupant ado rgmpmrnA or aroma: which
emh W Ard...A ole conmmimma As defined by the Bay Arca Air Quality Management
all new materials for inspection.
Disuics7 . r
❑Yea �dlst_
I ham mad the hamrdous material$ requirement, under Chopmr6.95of the Califon
nia Hcalm&SofetyCode, Sections 25505.25533 and 25534.1 understood thmifmc Wilding
does not cu am a tonant. oat it ism responsibility m notify me..Psnt O( the
require cram met pri u enCenillauofOccupancy.
x
Signature of Applicant Date
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—�au
All roof coverings to be Class "B" or better
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CITY of
CUPERTINO
0 CITY OF CUPERTINqb
PERMIT APPLICATION FORM
b 5/O�vB�
APN # a� � �_/
Date:
Building Address: Mailing Address (i different from building address):
7 O /Gn i.vsv/ /�YL
Owner's Name:
Phone #:
YOvo o
yob 9 92 - oia0
Contractor:
OtwevlJ A1eA efTJ
License #:
67 _7-8- yo 23
Contact: Phone: koe
CAOL rlt e i977 -a 1-d Fax: G fo - ;91gP6
Cupertino Business License#:
A Y a 3
Building Permit Info:
/ —/
BldgEl Elect 2 Plumb l� Mech Z
Job Description:
Residential ❑ QiilruoM Rolrw Commercial ❑
Sq.Ft. Floor Area: AWL
q.Ft.: y -L-
LCost
Costof Project: _
Occupancy Group:
Boiler > 1.75M Btu
MECHANICAL
Type of Construction:
Please check this box if the project is a
49 010 cy
second -story addition: ❑
Ind/Off/Comm/Quasi
BUILDING
ro'ect Size: Standard rrl� Large ❑ Major ❑
Con. Tax for BQ Zone
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBOILERI
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler > 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 500K to 1M Btu
MECHANICAL
BBOILER4
Boiler > 1M to 1.75 M Btu
MECHANICAL
BBOH ER5
Boiler > 1.75M Btu
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
BUILDING
BELEC1000
Elec 600V <= 1000A
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
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