03050023 CITY OF COPERTINO ~61 _ a.1irhs
BUILDING DIVISION PERMIT %CONrA'A"q RaM PO�R�IAW-10M..,
BUIMINGADORESS: CHAMPION PLUMBING PERMIT
NO03050023
06;E;6 RANDY T,A
OWNER'S NAME: 2059 CAMDEN AVE. #277 PERMR BS{IQDn6/2003
THEWS THOMASU�
INE: (408) 437-1507 SANITARY NO. CONTROL NO.
ARCHITECDPNGINEER: BUILDING PERMIT INFO
BLDO
O ELECT O PLUMB MECH
O O
�8ip LICENSED CONIRACTORs DECLARATION Jb Description
F 1 hereby affirm Nel 1 am limnecd unit,p visions mop of Chapter 9(co
mencing
!SI with Sa'on lBrp fl) 1io03gfN Bm� � uW Y i veH
WATER MAIN FfNALED
MDau, Convenor `��
ARCHITELTS OEO IO
'�W tltpdarsts y plan shall be used as public mcoro MAY O 8 2003
C
3 G SLicensed Professional
OWNER-BUILDER DECLARATION
iV 1 herchy affirm that I am exempt from the Contractor's License Law for[be BUILDING
K:00 following moon.(Section Nn 1.5,Business and Profession Code:Any city or county
$ which requires a permit to convect,eller.improv,demolish.or repair my swctum
FZj• prior to its issuance.also requires the applicant for men permit to fie a signed Moment
ss< Net he is licensed momenttothepvvlsionnfNm
eCotnctO'sULT.law(Chapter9 Sq.Ft. Floor Area $1y bI8tion
aa'D (commencing with Section 7000)of Division 3 or the Business and Professions Coded or
that he ts exempt Internist and the basis for has alleged emmp ion.My violation of
Section 7031.5 by arty applicant for a pewit subjects the applicant to a civil penalty of 3 1WN2Vbfn'@el0 0 Occupancy Type
nut mart Nan five hundred dollars(S5001
❑I,as owner of the Property,Omy,replay=wth werA as deb tele competts+tion.
will do the wosk.md dummunse is Out intended or offered lmaale(Sec.70th.Business 1 U b - bEwbxons
end Profusion,Cominse
Code:The Committees Licelaw data ret apply m an owner of 202 - UNDER F U R PLUMBING
property who build,or improve humans,and who does such work himself or though his
awn employee,provided this such improvements am not intended or offered for nit.If, 301 — ROUGH PLUMBING
however,the Wilding or improvement is mid within on year of completion.to Ovnce
builder will have the burden of proving that he did not Wild or improv for purport of 302 - TUB & OR SHOWER
502 - FINAL PLUMBING ENERGY
1,as Owner of l o property.am exclusively contracting with licensed contnemrs to
construct that project(Sec.70x4.Business and Pmfu"an Cade:)The C.nuactefs U. 506 — GAS TEST
count low deo not apply to an owner of property who Wilds or improv demon.and, 507 FINAL PLUMBING
who contracts for such projeon with a contractor(s)licensed pursuant to the Contractors
License Law.
❑lamuemptundesm .BkPCforehusnamn '
Owner Dae
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury on of to following decimation:
I have and will maintain aCeniOnte of Conant to Ulf-inmm for Worker's ComPem
Milan.u provided for by Section 37M of an Labe,Code,for to performance of the
work for which this permit it issued.
❑I have and will maintain Worker's Compensation Insurance,a required by Section
3700.(NC labor Cadc.far tm .rmance o(thewerk forwhich this permit i,issued.
C. WorkcfaG-. ,N{ cent andPolicynumber. /v�O� y(y •�` -0Z
Caniep G-• �`1 Polity No.: ' I 7c/l�
`'\/,p/ CERTIFI COMPENSATION
EXEMPTION WORKERS'
COMPENSATION INSURANCE
(fn(sscctim it notbccmplcted if O e permit is far..hundmdd.ltsm(5100)
nr leu)
1 certify Net in the performance of do work for which this permit v issued,I shall not
employ any Noun in any mannerm as in become subject to the Workerx Compensation
Lew.of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenineate of Exemption,you should
become subject to the Worker's Compensation provisions of the rat Wr Code,you must
�0 forthwith comply with such provision at this Permit&hall be deemed revoked. .
Z y CONMUCrION LENDINO AGENCY
'Elbembyelfirmthat Nem is a convection lending agency for de performance of
> Ne.,it for which this Permit Is issued(Sec.3097.Civ,C.)
1 0 unarm,Name
� Lcad,es Address
z
C,7 Q I certify that 1 have read this application me!state that the*how infow"lun u
{r.(✓ comxa 1 agree to comply With all city and co my oNinMce,end tote laws relating te
O U building construction,and hereby auNorim rcxnutivesofthiscityteen=uponft
W alav>mcmioned property for inepcnirm a
(Wc)agree la saw indemni ep hawleM the City of C.penino'gain"
ti Ilabllitiu.judgments,costs an hich may In any weyearoc against hid City
C)7 in consequenceofde gm ,mit.
f•� APPLICANT UNO D WILL COMPLY WITH ALL N •P Nr Issued by: Date
SOURCE RE
4 b3 Re-roofs
Signigg of ApplicautCeAusector D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupanutere nr handle hoodoo mammal
as de0ned by the Cupenino Municipal Code.Chapter 9.12.and tits Health and Safety
Code. 0Section sss3z(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Na
Will the applicant or lure building occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
mil hmardous sur conumin u as defined by th y Area Air Quality Management all new materials for inspection.
Nunn? /
❑Ycs No
Ihavreadd,lbs. .a nals mcntsundarChapterti.95ofIF.c C lifar.
nia Hamhh&SafclyC 525505, and25334.1.milound ifthe ilding
thou am cunently h est.Nat i responsibility 0 notify acv t of the
rcyuimmen hi vat metpri to. onceancenircaar, p Signature of Applicant Date -�
owner., noascot Date All roof coverings to be Class"B"or better
5MCITY OF CUPERTINO 3 C>
CITY OF PERMITAPPLICATION FORM
CUPERTINO
.� -6. Date: _ J
Buil m ` (�
Q h L
Owner's NaTT : Phone#: Y 7 7 _ ) C D 17
Contr�o� /'m � ^ 1 License#: ��7` c�7�
Pf
Contact: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: )
ResidentialCommercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: „s Occupancy G oup: ,
Type of Construction: (�
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to IM Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 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
BMITIGATC Comm. Housing Mit. Fee I BUILDING
ZI
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..= CITY OF CUPERTINO
CITY
PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BM04EWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily 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 Pblg 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 Repeat 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 HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAEUiAN A/C Units <= 10,000 efm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFD{T Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc A�� status ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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CUPEI�TINO rRPERMIT APPLICATION FORM
Quantity 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 Insection 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 Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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