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31380APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN BUILDING DIVISION APPLICATION/PERMIT ❑ Consultant Fees Paid by Applicant (Initial) 1 bandy affum that 1 am licensed under Provisions of Chapter 9 (cmmnencing 042 with Section 7")of Division 3ofine Business and Pmfession. Code, and my license is i n loll farce and effect. k�. U {IUr License Class Lie. It N 6 a Date Contractor A RCHIT'ECTS DECLARATION p r' K I understand my plans shall he used as public mcoms Z� qLicensed Professional ...�OWNER-BUILDER DECLARATION 1 hereby affirm that 1 ma exempt from the Conoco is License Law for the �6U following rearan.(Section 7031.5. Husiness and Professions Code: Any city or county UE" which requires a permit to construct, alter, improve, demolish, or repair tiny structure' m �� prior m in issuance. elsn acquires the uppliam,mrsucb permit to file a signed statement 04�that, he is licensed Emission. the Provrsmos or the Conhuctors Licanse Law(Chapter 9 CG7OC (commencing with Section 7000) of Di vision 3 of the Business and Professions Calmar q K that he ix exempt therefrom and the basis for the alleged exemption. Any violation of YXl a• Section 7031,5 by any applicant far, a peach subjects the applicant to a civil penalty of Z }not mom than five hundred dollars ($510). 0 O 1, as owner .1 the propcay, or any employees with wages as their sole nrmpirma.m F will do the work. srtad the structure is not intended or attract for .1,(See . 70,14. Business 4 a and Professions Code: The Contractors License Law does not apply to an owner of propeny who builds or improves Ihemon, and who docs such work Torso or through his own employees, provided that such Improvements arc not intended or offered for sale. If however, the building or improvement is sold within one year ofcompletion, the owner -builder will have the burden of proving thai he did not no Id or improve for par - Panic of sole J. ❑ L an curter of the pmperty, am exclusively contracting with licensed contactors to construct the project (Sec, 70kt4, Business and Pmfessi(.ns CoJe:) The Contac or's Li- censeLowdoesnotapplyloanownerofpropertywhobuildsorimprovesthereon,and Q'ry who contracts for such Projects with a contacutgs) licensed pursuunt to the Contactors License Law. 1 am exempt under Sec. , B & P C for this reason D if BEER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: .C] I have and will maintain a Certificate ofConsentto self-insumfor WorkersCompen- sation, os provided for by Section 3700 or the Labor Code, for the performance of the work far which this permit is issued. I have and will maintain Workers Compensation Insurance, in required by Section 37011 of the labor Code, for the Performance of the work for which this Permit is issued. My Worker's Compensmion Insurance carrier and Policy Carrier. Policy No.: LC CERTIFICATE OF EXEMPT ION FROM WORKERS' COMPENSATION INSURANCE (Thissectinn need nm be completed ifthe permit is forooe hundmlJollaa (S 100) or less,) certify that in the my man n r of the work for which th o permit is issued, ]shall not employ any person is any manner so as to become subject m the Workeri Compcn- O z Applicant Laws of Colifomia, hate 77 O NOT( E you r1. FN -t NOTICE TObj AP. the Worker's Compenser ation this Provisions of of E.empaod,youshould st a beeome subject m the Workds Compensation provisions of the Inbar Cade, you must {1a forthwith comply with such Pmvieinrtr or this pennit.rhall be deemed revoked. CONSTRUCTION LENDING AGENCY U 0 I herebywhich his that is mal (See 3 n lending agency for the pedormance of � tr the work for which this Permit la issued (See. 909]. Co, CJ Q U Leader. Name Linda's Ammas I certify that 1 have read this applicminn and state that the ahnvu if(.....ma is f' to cortect.l agree ar comply with all city and county oNinanees end saw laws relating to QTY, :.) building construction, and hereby authorize representatives of this city to enter upon are above-mentioned property for inspection purposes, (We) agree to save, indemnify and keep minim. the City of Cupertino against liabilities,judgments, costs and expenses which may in any way accrue against said City in onsequence of the Banti ng of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT HAZARDOUS MATERIALS DISCLOSURE Will the applicant or fawn building marmnLaore or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code. Section 25532nd? ❑Yes E] No 1 Will the applicant or future building occupant use equipment or devices which imit hazardous air omournmants ns defined by the Bay Arm Air Quality Management District? E] yes FNo 1 have read the hazardous materials requiremenu under Chapter 6.95 of the Cali- fornia Health & Safety Com. Sections 8505, 25533 and 25534. 1 understand awn if Ne building does not currently have o tenant. that it is my responsibility, to notify the oecolm t of the requimmemx which must he met prior to issuance of a Cenilicate alOccupancy. Owner or authorized agent Date ELECTRIC PERMIT FEE PERMIT ISSUANCE APPLIANCES - RESIDENTIAL. PANELS UPTO 200 AMPS SIGNS ELECPRICAL SPECIAL CIRCUIT/MISC. 'TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES NEW RESIDEb TIAL HLECTR SQ Er. PLUMBING PERMIT PERMIT ISSUANCE ALTER - DRAIN & VENT- WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS- FLOOR. ROOF, AREA, GOND. FIXTURES - PER TRAP GAS - EA. SYSTEM -1 INC.4 OUTLETS GAS - EA. SYSTEM OVER 4 (EA) GREASOINDUSTRI. WASTE INTERCEPCIR GRIVASETRAP SEWER -SANITARY -STORM EA. 200 FT WATER HEATERF/V0'TtL{y1 n WATER SYSTEM/TREATING NEW RESIDENTIAL. PLMB. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CEM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD(W/UUCP) HEATING UNIT (TO 100,00i) BTU) HEATING UNIT (OVER ITIT"BTU) VENTILATION FAN (SINGLE RESID) BOILER -COMP (3HP OR 100,0X10 BTU) BOILER - COMP (OVER 10(1,(00 BTU) AIR CONDITIONER NEW RESIDENTIAL. MECH. SQ. FT. OFFICE FEE X BUILDING PERMIT INFO a� ,Lor roa ore JOB DESCRIPTION RESIDENTIAL• ❑SFDWL D KITCHEN REMODEL ❑ADDITION El PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL ' MODIFICATION ❑INTERIOR F1 CHIMNEY REPAIR IMPROVEMENT HOUSING MITIGATION FEE ❑ BATH REMODEUREPAIH EMOLIT N DOTTER !//g 'ass -o", as COMMERCIAL: ❑NEWBLDGIADDITION ❑D OLITION []TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER C' BUILDING DIVISION FP.FS PLANCHECK FEE ENERGY FEB GRADING FEB SOILS FEE PAID Date Receipt0 BUILDING FEE "a— SEISMIC FEE I g ELL'CfRIC FEE PLUMBING FEE MECHANICAL FEE CONST RUM ION TAX HOUSING MITIGATION FEE 10145• U L n 17s' -- PAID 7 PAID Date Receild TOTAL.: 0 1. 0 10/30/1996 12:41 9168981599 i y i o $ • V 4 A s o< 1 y < O yj i jj °u W asdo . l IP r ! P.F REILLY, INC. PAGE 04 10/30/1996 12:41 9168981599 P.F REILLY, INC. "10i30:38 11:09 04087773331 CITY COPERTTNO 10100 TORRE AVENUE • CUPERTTNO. CA 91016 (406) 777-3219 NAME LOCAT ACCOUNTq CITY OF CUPERTINO BUSINESS LICENSE APPLICATION PAGE 02 0002iooz r / f • •r o,i _.a_ J MAILING ADDRESS IF 13UW ENT THAN ABOVE HOME BUSM1189 APPLIC.lN�CTf _S MUST COMPLETE BOTH SIDES OF THIS APPLICATION. Z O G'f''9 NATURE OF BUSINESS ' 1 a2a� HOURS OF OPERATION 7��1 IF NATURE OF BUSINESS IS AN APARTMENT. PLEfo STATE NUMBE1t OF UMTS SQUARE FOOTAGE OF YOUR BUILDING SPACE IN CUPERTINO (NON= 80M8 BUSINESS ONLY) LEGAL STATUS OF BUSINESS ✓ CORPORATION ��AF.TNSRSHlP SOLE PROPRIETOR START DATE OF BUSINESS IN CUPERTINO 4 7 -M -L ARE YOU PURCHASING AN EXISTING, BUSINESSS7• YE8 _✓ NO STATEEMPLOYERMENTIFICAT10NNIM8ER q&-7f?L—? FEDERAL EMPLOYER IDENTIFICATION NUMB ER�pg=r%22 &I iI ?0 STATE BOARD OF EQUALIZATION TAX NUMBER OWNER/OPPICER SOCIAL SECURITY NU6 SER %" •� fdd' PHONE t��,) ME X40 OWNERlOF1SCER N SOCIAL SECURITY NUMBER•_ LyLS 5 5,LPHONE IF/G) LJ'lre9/ STREET CrrY/9TATElZlP OWNEWOFFICERNAME SOCIAL SECURITY NUMBBR. - _ PHONE(' STREET ADDRESS CTTY/STATEIZIP TTo THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TWE AND CORRECT. 4&&-t:5cc_ 0'30 1F, 1 �XMMANTIS SIGNATURE DATE •FOR OFFICE US&ONLY ZONING APPROVAL DATE APPROVED DATE PROCESSED RECEIPT AMOUNT INITIALS 10/30/1996 STATE COMpBNSATION INSURANCE GUND 12:41 9168981599 P.F REILLY, INC. PAGE 05 IMPORTANT - THIS IS NOT A BILL. SEND NO MONEY UNLESS STATSME14T IS ENCLOSED. HOME OFFICE SAN FRANCISCO WORKERS' COMPENSATION ENDORSEMENT CERTIFICATE IN CONSIDERATION OF THE PAYMENT DP THE TOTAL DEPOSIT PREMIUM AND PULL PREMIUM TO BE COMPUTED AS PROVIDED IN THE CONTINUOUS WORKERS' COMPENSATION POLICY INDICATED HEREON, IT IS AGREED THAT SUBJECT TO THE PROVISIONS OF SUCH POLICY AND ENDORSEMENTS THERETO, THE EMPLOYER INDICATED HEREON 15 HEREBY NAMED AS ADDITIONAL GROUP INSURED EMPLOYER. ::01 A.M., PACIFIC STANDARD TIME -01-96 TO 1-01-97 AND SHALL TOMATICALLY RENEW EACH 1-01 'TIL CANCELLED P. F. REILLY AND COMPANY, INC. 3028 ESPLANADE STE F DECLARATIONS CONTINUOUS POLICY 229-9.6 ISSUED TO WESTERN REGIONAL MASTER BUILDERS ASSOCIATION . UNIT 13751 DEPOSIT PREMIUM $836.00 CHICO, CALIF 95973 MINIMUM PREMIUM $520.00 PREMIUM ADJUSTMENT,PERIOD MONTHLY REP 02 R NJ NAME OF EMPLOYER- P. F. REILLY AND COMPANY, INC. (A CORPORATION) 1. WORKERS' COMPENSATION INSURANCE - PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA. 2. EMPLOYER'S LIABILITY INSURANCE - PART TWO OF THIS POLICY APPLIES TO LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS, • $1,000,000 CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE IO 1-01-97 INTERIM BASE BILLING RATE RATE* BUILDING CONSTRUCTION -SEE EXTENSION SCHEDULE FORM 10500 5201 CONCRETE OR CEMENT WORK --POURING OR FINISHING OF CONCRETE SIDEWALKS SPLIT RATES APPLY 1-01-96 TO 7-19-96 12.40 8.43 7-19-96 TO 1-01-97 14.96 10.17 5201 CONCRETE OR CEMENT WORK --POURING OR FINISHING OF CONCRETE FLOOR SLABS SPLIT RATES APPLY 1-01-96 TO 7-19-96 12.40 8.43 7-19-96 TO 1-01-97 14.96 10.17 5205 CONCRETE OR CEMENT WORK --POURING OR FINISHING OF CONCRETE SIDEWALKS SPLIT RATES APPLY 1-01-96 TO 7-19-96 10.60 7.21 7-19-96 TO 1-01-97 .8.67 5.90 5205 CONCRETE OR CEMENT WORK --POURING OR • ON THE EFFECTIVE DATE SHOWN ABOVE, THE COVERAGE PROVIDED BY THIS ENDORSEMENT CERTIFICATE REPLACES ALL PRIOR COVERAGE. INTERSIGNED AND ISSUED AT SAN FRANCISCO DECEMBER 18. 1995 PnT.Try vnnx r