03100168 CITY OF CUPERTINO ✓ 'ay.`.q
BUILDING DIVISION PERMITCONI,RACTIOR INR'ORMATION:
BUILDING ADDRESS: _ CLAUSEN ELECTRIC PERMIT N003100168
10111 PHAR LAP DR
OWNER'S NAME: 20401 HARRY RD PERM70SUEDATE
Alk TUCKER JAMES D JR AND MARIE TE 10/23/2003
ONE: (408) 927-7322 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
iOa LICENSED CONTRACTOR'S DECLARATION
U 1 hereby affirm That I am licensed under provisions of Chapter 9(commencing IOb DESCfIptlOn
with Section 7NN])of Division S of thc Businuund Professions Codc,and my license is
in(munCr1 (� .1 200 AMP SERVEICE CHANGE
,00 L'iccna lc s 1O ,Lie.M^'
,f Dam---n`�-Com y L
eq ARCHITECT'S DEC ATION �11
{2ndcrosanJ my plans shall M vuJ a ublic mantis
?i
:0 Licensed Pn,fcssionel /
OWNER BUILDER DECLARATION 0
I hereby affirm that 1 ons exempt from the Connector's :Any c Law for the `<
p o following tumors. probit t RDI.S.Business and Rvfessions Code:Any tiny s county V
e m which reyuirns a permit m cnnnrwt,alcor,imbmw.Jcmnlish,lir.,air any nmcmm
$1000
prior u,its issuanec,also mquires the applicant for such permiuo file asigned statement
F<
that ho is lim tied forward to the previsions of fit,Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
�5$ (commencing with Section 700(1)or Division 3 of the Business and Prafessinns
NCtyle)or 32618013 . 00
at he le exempt therefrom and the buil for the alleged exemption.Any=of
Section 7831.5 by any applicant for a permit subjccu the applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred d.1box(5508).
❑Luowner of the propcny,or my employees with wgesu their sole eempewnion,
will do the work,and the structure is not inionded m oRcmd!omni(Sec.7044,Business
and Professions Code:The Contractor's Lieetue Law does not apply to an owner of Required Inspections
propeny who builds or improves Hereon,and who doessuch work himself or through hit -
own employees,provided that such improvements Moot intended orvRemd formic,It,
however,the building or improvement is sold within ane you of completion.Ne owner
builder will have the burden of proving Nan M did not build of improve for purpose of
sale.).
❑h as owner of the property,am exclusively contracting with licensed contractors to
construct Ne project(See.7044,Businev and Profcaiom Code:)The ConOmmr'a U.
cense Law doer not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a conpamor(s)licensed purer onto th,Contractor's
License Law.
❑I am exempt under Sec. ,B&PC for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
J i hereby affirm under penalty of perjury one of to following declarations:
✓ I have and will maintain a Cenifaau of Consent o rel binsum for Worker's Camper
urian,o provided for by Section 7]08 of the Islar Ctke,for me perfermana of the
work for which this permin is iawd.
❑1 have and will maintain Worker's Compensation Insurance,o requited by Section
]]00 of the labor Code,for Ne performance of the wore for which this permit is issued.
My Work✓cr^',C nml'ensutiCC limns res c 1-0'iWand Policy
05WO1h ram: ��010
Tier. 1 'r t .x,11 C -pR {PC. 1 am-
CERTIFICATEOF PTII NF 0 WORKERS'
COMPENSATION INSURANCE '
mAs section n,cd not he completed if the fetmit m fortune hundrW dolhra(SI00)
leu.)
1 certify that in the perfmtnance of th,work for which this permit is issued.1 shell not
employ any person in any manner in as to become subject o the Workcoi Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become mhjoet of the Worker's Combination previsions of the Labor Codc,you must
Z forthwith comply with such provisions at this pcomitshall be dcomed revoked.
z O CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a eanswetion lending agency for the performance of
Yd the work for which this .if H issued(See.3097,Civ.C.)
A Q Lender`s Name
z Lender's Addrom T
1 certify that I have Mail this application and sum that the above information is
S. (~
Correct.1 agree to comply with all city and county ordinances and sum laws relating to
0V building construction,and hereby anchoriterepresentatives of Nis city 10 enter upon the
W shove.mentioned property for inspection burpous.
(We)agrees no ave,indemnify and keep harmless the City of Cupertino against
r i lisbilides,judgmen0.costs and cabooses which may in any way accrue against aid City
) ,Z in consequence of the granting of this permit. (/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU I REG LATIONS.
Re-roofs
Sin rc of Apphcent/Contracom ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam tar forum building accubam nam sur handl,bavallous..wrist
as defined by dm Cupenim Municipal Code.Chapter 9.11,and the Health and Safety
,111Code.Section 15511(a)7 Yes All roofs shall be inspected prior to any roofing material being installed.
❑
WI I the applicant 0r(arum building Occupant use equipment lir devices which If a roof is installed without first obtaining an inspection,I agree to remove
in humdons air contaminants as delired by the Bay Area Air Quality Management all new materials for inspection.
District?
❑YetNo
I have mad the humnlcus materials requirements underCMpter 6.95 ofthe Calirm-
nia Health&Safety Code.Sections 25505.25533 and 15534.1 undersand that if the Wiling
does not currently haw a tenana that it is my onspti uihility on notify the occubant of the
yvi whit mustaton our w,St. coraCcniftcaleofOccuany. Signature of Applicant Date
owner bfiouhmi,edagent Date All roof coverings to be Class "B" or better
aC:]Tyo
CITYOF CUPERTINO
CUO PERMIT APPLICATION FORM
APEP-
N# i Date: I
Building Address: . O
Owner's Name: Phone #:
i 9a-7- "733 .
Contractor: License #:
Contact: Cupertino Business License#:
B ' it Info:
Bld Elect Plumb ❑ Mech ❑
Job esc ion:
1
Resid ial C-C ommercial ❑
-SqTt. FloorArea: $/Sq.Ft.:
Cost of Project: /�� Occupancy Group:
Type of Construction:
r
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL a
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> 1 M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/OfFComm/ uasi. 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
z 3 s�6�
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��X3. 3
r -
CITY OF CUPERTINO
CUPEI OF PERMIT APPLICATION FORM ,
QuantityFee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamil Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Re eat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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0p, CITY OF CUPERTINO :
aTMOF PERMIT APPLICATION FORM
CUPERTINO
uanti Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA. Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE umbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
a
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