01040011 CITY OF CUPERTINO ''^ -
BUILDING DIVISION PERMIT %C0NT1tAC't�Y;TN C NATION:"
P :Rk
BUILDING ADDRESS: PERMITNO.
22384 RIVERSIDE DR WM H FRY CONSTRUCTION COM ANY 01040011
OWNER'S NAME: PERMITL55UEDATE
JAY ANDERSON 10351 SAN FERNANDO AVE 06/25/2001
SANITARY NO. CONTROL NO.
(408) 996-8173
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�Op LICENSED CONTRACTOR'S DECLARATION
�� i hereby aft that 1 am licensed under provisions of Chapter 9(commencing lob Description
n.� with Section 7000)of Division 3 oftbe Business and Pmfessiom Cade,and my license is
in full for¢end effect
License Claw Lic.0 ADDITION & REMODEL
atractor
ll ARCrHTEcrs DECLARATION ADDITION 575 SQ. FT. piIVAL
I 1 understood my plant[hall he used w public recorN e D
W Licensed Professional SEP ((yy
='G OWNER-BUILDER DECLARATION U 3 2002
<$ 1 hereby affirm that 1 am exempt from the Comractors License Law for IW
09 following meson.(Section 7031.5,Business and Pmfealm s Cade:Any city or county
e.$_ which rcquima•Permit an consumer,alcor,improve,demolish.or repair any museum
prior m Its item ea,also requites the applicant forsuch Permit m rile a signed.mtement
�< that be is licensed pursuant to the pmvisiom nftbe Contractor's Litems Law(Chepter9 Sq.FL Floor Area
C (commencing with Section 7000)of Division 3oflhe Businmand Prefewlmu Code)m
that he is exempt Ourefrom and the bases for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit Objects the applicant an a civil penalty of APN Number 6 HcpOy Type
not mom Nan five hundred dollars(SSOW.
0 1.as owner of the property,or my employer with wages as then Ole compemetion, 35602005) 00
will do the work.and the structure 1s not intended or offered for sale(Sm.7044,Business IRequired Inspections
and Professions Code:The Coruscate,Liam law does e nsa nut apply to an owner of q P
property who builds orimpmwsdwree,anti whodoes.uchwmrkM1Mwlfmmrough his 101 - FOUNDATION
now employees,provided thatsmh Improvements are not intended aspirated for cele.IL
however,the building or Improvement 1,Old within one year ofeompletion.the owner. 102 — PIERS
builder wig have the burden of proving that he did not build or Improv fm purpose of
cele.). 103 - UFER
❑1,as Owner of the property.am"elusively contracting with licensed contractors to 104 - REBAR
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Ll- 105 — ANCHOR BOLTS
cerue law does not apply an an owner of property who Wilds or Improves mentor.and,
who contracts for such projeela with a conlracmKU licensed pursuant to me Contractor. 106 - SEWER & WATER
License Law.
❑I am exempt under Sea. .B&P C for this notes 114 - PLUMBING UNDERGROUND
Owner Dem 202 - UNDERFLOOR PLUMBING
WORKER'S COMPENSATION DECLARATION 203 - UNDERFLOOR MECHANICAL
I hereby harm under Penalty of perjury,one of the fallowing declarations: 204 - UNDERFLOOR FRAME
havemd will mdnuln a CenlBesm of Consent to sell-metre mrwarkee-Compcn- 205 — UNDERFLOOR INSULATION
canon,u provided for by Section 3700 of the lather Code.fm the performance of the
work for which thispermllisissued. 301 - ROUGH PLUMBING
❑1 have and will maintain Wmkeri Compensation Immmuma,u required by Section _ 302 — TUB & OR SHOWER
37M of me later Cade.for the performance of the work for which this permit 1.IsamA 303 - ROUGH MECHANICAL
My Workeri Compensation Insurance carrier and Polley number am:
Carrier: Policy No.: 304 - ROUGH ELECTRICAL
CERTIFICATE OF EXEMPTION FROM WOR KERS' 305 - FRAME
COMPENSATION INSURANCE
MissecOm need notbecomplated trust permit is fmone Wmbed dolWs(g100) 306 - HOLDOWNS
teles.) 307 - INSULATION
I cattily that In the performance of the work for which this permit i.Issued,I.hall not 308 - SHE ETROCK
employ any person in my mmner an as to become subject to the Warktn'Compensation
Laws of Califomle.Dam 309 - EXTERIOR LATH
Applicant 310 - INTERIOR LATH
NOTICE TO APPLICANT:If.alcor making this Cerdficam of Exemption,you should
Wcome tubjev or the Worker's Compensation provisions of that Labor Code,you mum 311 - SCRATCH COAT
'j. furmwlth comply with such provision or this Permit Aall W deemed revoked.
zO 313 - ROOF NAIL
z;� CONSfRUCnONLf+N01NGAGENCY 315 - EXT SHEAR
i—t I her by which thi our titerebsued(Sect3D97,lending Ch,ageneyfor the performance of
W' cI the der'sNrwhlchthis pemtitlslnnee(Scc,31YJ7,Civ.C.) 316 - INT SHEAR
u7Q Leader's Name 402 - TEMPORARY POWER
z Larder,Aaem,. .
UO l certify that l have mad this application and tum mm the state uromariun). 404 - ELECTRIC METER :RELEASE
O
construction,
l agree to comply with all city and county uNinances and stem law mlatrng In 1 - FINAL ELECTRICAL ENERGY
Wilding consction,and hereby authority mpresenmiwa of this city m enter upon me
W above-mentioned pmpeny for inspection purposed 0 A I— FI L PLUMB NG ENERGY
L4
(We)arms to save,Indemnify and keep hvmlm the City of Cupertino against 3 FI AL ENERGY
v,acn nabiliticsjudgmenu,com mdeapertseswhlch msyin anyway amrotagainarsaid City
U Inconsequence of the granting of this permit. 5
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by., NG ENE B2,Y
SOURCE REGULATIONS.
Re-roofs 506 AS TEST
Signewrc of ApPIk HAZARDOUS MATERIALS DISCLOSURE Dam Type of Ro6107 - FINAL PLUMBING
Will me applicant or forum Wilding occuWnt mom or handle hvardom material 508 - FINAL MECHANICAL
Or dcOned by the Cumnloo Municipal Cade,Chapter 9,12,and site Health and Safety
Cade,Section 25532(.)7 All roofs sAR&Iosp�a OIC[ l6f3n material being installed.
r]Y. ONO
Will the applicant Or future building Occupant use equipment or devices which If a roof is Ilea ,-BUILDING
[ AYI jpsp@Ghon,I agree to remove
I ha'rardnw air contaminants w defined by the Bay Arta Air Quality Management all new ma s for t •gUI LDING
Gimlet? bbb —
[]YC. Chit, 602 - ROOF PLYWOOD NAIL
I hew mad the hwmmaus materiels mqunements under Chapter 6.95 of the Califor. 703 — MISCELLANEOUS
nit Healer&SafetyCode,Smfiaes25505,25533aru125534.lunarsmndmmlfthe Wilding
does not cumendy hew a tenant that II is my mspou0dlity to nudl'y the accupant M the
requirements which mot be met prior to issuance of a Certificate of Occupancy. Signature Of Applicant Date
Owner orsuthori'red agent Dow I All roof coverings to be Class nB„or better
FY OF
CrBUIU
BUILDING DIIVISSIIONVO1PERMIIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22384 RIVERSIDE DR WM H FRY CONSTRUCTION COIIPANY01040011
OWNER'S NAME: APPLICATION SUB DATE
JAY ANDERSON 10351 SAN FERNANDO AVE 04/04/2001
,. PHONE: SANITARY NO. CONTROL N0.
(408) 996-8173
FI O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
,2 u- BLDG ELECT PLUMB MECH
y<se I___1I_
_I J I__.I �I
Z t y= LICENSED CONTRACTOR'S DECLARATION Job Description
O z= m
C 1 hereby offrm at 1 am licensed under provisions of Chapter (commencing P
I-_1-se with Section 7")ofDivision 3ofthe Business and ProfecoonsCocie,andany license ADDITION & RPRODEL%y
a is in full force and effect.
R..sr LiccmClas Lloa ADDITION 575 S/Q.F`T. "
X0,,i` Date Contractor
of is. ARCHITECT'S DECLARATION 2002
C-O 1 understand my plans shall be used as public records }
nr
lea6n d O O Licensed Professional
o� OWNER-BUILDER DECLARATION UI
vi= I greasy affirm that 1 bed exempt ream the Contractor's Code:Liana law for the B LDING
t= a fallowinguires a(Section pIALS,Business and ve.d moll h.oAny city structure or x o which requires e. o to rconstruct. he p demolish.zh repair any l ocean
i ll t issuance. 1 9 thef chps L til signed t Taman - $ 5500-",
4
(c.tl,, FII. apt tint p t:t nl c t t r.r- r ons e 9 Sy Ft. 111..1 Area y - a nation
or
he is eempttheefroma)d a bas slot the kiedisand hm.AnonsCWq '•� '. i " '.t :-�.�._•.,.: a,J,4;
or that he is exempt any applicant
p li and the bash forme ctsthe ckemant to Any l Pennon
- of notSection 403 L5 iv any a permit subjects the applicant m u civil Penalty s.,
or not more matt rive hundred dollars fssoo), umber I. Occupancy Type
[3 1.ns owner of the property,or my employees with wages as their.sole compensation.
will do the w«&.'and the swcmm is not imandee or offered for sale rsce:70,14, Required Inspections
'Business fid Professions CThe Connector's nnecr's License Law does not apply man 102 - PIERS
owner of prupeny Who builds or improves thereon,and who docs such work himself
or through his own employees,provided that such improvements are not intended or ---10 3 - UFER ... .. __t
------
completion.
fon Ffor IL owner
harder
thebuilding av [ or urden f Prov is old he did not yea:or'-- 10 4 - REBAR '
compinion,me.wncrbuildcr will have the burden of proving that he did not Build or
improver«wrporeoramal. 105 - ANCHOR_ BOLTS
-_.. e.. rt . . ._ .. ._,.
--
Lacocaner orrhe propeny0411.Dcws.mul ntmcunmr,Cfan:ed Contatarab 106 SEWER _& WATER I ..,'___., .. __....__.
Lonna the project(Sec. to an Business and property
who
CWe:)The Contractor's
Li«osr Law d«�not apply m an owner(if pr:+prrtY woo halloo or improve.thereon. 2 02 - UNDERFLOOR PLUMBING .'
.and who contracts for such pmjech with a.conuactogs)licensed pursuant to the
Cerise Law. 203 UNDERFLOOR MECHANICAL- — -
❑lamer unJcrSec. ,B&PCformismoson 204 - UNDERFLOOR'iFRAME l`
�.•� �0� 205 - UNDERFLOOR INSULATION
woRKER's coMDECLARAnoN 301 - ROUGH PLUMBING
_:• Ihe.egy arfm,amp penmty,or pgi6rr on,eorJnq rouowing drmame.ns: 302 - TUB & OR SHOWER
Cl l have and will malnam'.Cenifcaro or Con.ent'to.elf-mome foe Worker's 3 03 - ROUGH MECHANICAL
Compcnsainn. as ....idea far by Section 3]00 of the Labor Code. for the
p nm a.time'w.rgmr thichthi,pshoutiaisow; 304 - ROUGH ELECTRICAL
❑1 have boil willimbinuin Workers Compensation Insurance.as required by Section 3 05 - FRAME
v
37M of the labor Code,for the perfermmate 6f me worts for which do,permit is
issied.My workers Comprnaaaon msum«eear.and Policy number err: 306 - HOLDOWNS
- N
policy No.. 307INSULATION
'•.`.':( � �� _.
„ CERTIFICATION OF EXEMPTION FROM WORKERS'S 1. 3 0'B 1- SHEETkOCK
°i COMPCNSATIONINSURANCE "
_..._..... 309-: :=:';EXTERIOR--liATH.._.
(Ths
I(gl�le`mnlonoeed not be,committed if the permit .for one hundred dollars 310 - INTERIOR LATH '
Ir rtr mat in e nn nr which -3-1'1-•- *SCRATCH ,COAT" _
Y P . poemit is sued.I
shin hot employ,any pc- 1 any-man as to arimna object u+the workers 313 - ROOF NAI LI• kt ' '
Applicant.
setws cdcllr lu.Dole "• .
pmpe _ nonta 50-1 - F-INAL ELECTRICAL ENERGY
"._ .. . ._ ids
OTICE
ANT.If.
Ncome'oOAP ax
Workers Compensation
this Crnifnm of Labor Code,n. you
502 - FINAL PLUMBING ENERGY
becomes comply
the such pr Cions or tion permit shall thelaborCWe,you mon
O ZO m,rnwilheornplrwin,5arnproaisinn.,.rmmprrndtshangreammre.aee, 503 FINAL MECHANICAL ENERGY. . .. .. .. .
F..^ CONSTRUCTION LEND,fNGAGENCY 504 - FINAL BUILDING ENERGY,
I hrr w'dirm that there is a construction lending agency for the ferhar soce
�.� oftheworkfirwhichhis remnaisissued(Sec.309].Civ.C.1 . t' 505 - FINAL ELECTRICAL _
0..Q Lenders Name .. '- _- � -
ende'rsAddresa• - - 506 GAS TEST
_ U'O Icertifythea1haverm.cthisapplicaionandseammattheaboveinromwtionis 507 - FINAL PLUMBING
oorravl agree tv rosoply.with all city and countyordinancesand state laws miming 508 - F I NAL MECHANICAL
..0 U m buildingessomerioa and hereby ummi tap sesnm,ues onhischy mama.upon
p .W he rivals,mentioned phipeny for insperfma patpo«a 509 - FINAL GRADE
t.., 0. IWel agree to save,indemnify and keep lmbmlcssme City of Cupenino against -
-m I ab I I ad .at, von.,a rape :.which may m any way accrur aga'nsI said 510 F I NAL PLANNING
USZ City in of scqunnc of thr gr + i his prrmiL'„
y Ci, I A U on.l. V LL O!APLY WITH L ,1. �14 - NA C WORKS j�
- � soc):e, «s 6 '�0� Issued y: Are EG---�-
Signature ofApplicaMCommustor - a Re-roofs
HAZARDOUS MIALS DISCLOSURE '
t WA R
Will me ap,li< rf future building oscupm store or handle haraNus numrul 'Type of Roof - - - - - -- -
as darn d by th Cupertino p no c l Codc Chapter 9.12.amt m Health and Safety -
Ct J S a n 25532(] t I I> r
❑Y. n `. All roofs shall be inspected prior,to.any.roofing material being installed.-.
jwmthe applicant orfuture building occupant pseegolpmentordevices which If a roof is installed-without first obtaining an inspection;I'agree.to remove
emit hamadous at,rcordearli ddined by the Bay Area Air Quality Management
District^ all new materials for inspection., Applicant understands and,will comply with.. _
.oyr: No all non-point source regulations.
d have read.the haramous materials tequindi under Chapter 6.95 of the
California Health dr Safay CWe.Sessions 25505.25533 and 25534.I understand that
-'Ifthc bui!Iimd«s not svrrcmly na n thecitis my rczponobill
i itytooti Ythe -" - -- - - _
'occupant t c he'If menti wglcyryd< et pont m issuance o Cenifm (Oto. . ^.... // _ .. _
IVNS/ 2,j U( Signature of Applicant _ Date
owner..aid mdi ed agent Da All roof coverings to be Class "B" or better
-OFFICE ..