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CITY OF CUPF.RTINO I
*nom ' few.
CONTRACTOR INFORMATION:`
BUILDING DIVISION PERMIT
I
BUIL17I83'9sRRCBIN1DELL WY I j I
HUMRICH CONSTRUCTION
PERMIFN(02060022
NTA' PSON CARL D AND IMOBLEY=ILA
S02995 WOODSIDE RD #232
APPucnTl to0gy2002
PHONE:
i
I III
6 5 0 3 6 9- 0 9 9 9
1
SANITARY NO. CONTROL NO,
'ARCHII EC (ENGINEER;
BUILDING PERMIT INFO
I
BLDG ELECT PLUMB MECII
o 0 0 0
ID CON'nsed FACTOR �•
LICENSED DECons
i w r
that under provisions of
n000)omlhml,mttheBunr
SINGLE STORY �9FINALE®
��
ioON
nalPiom,snrChapter.dalmmmenciis
with RcClirn ilxxp of Division Sal NC Busi�nejs antl Prn(essans Gule. and yli[ense
inful1.1 aJ cffct. 7
a''_
is
Li.ensc h 1:i..N_
Ca Our
MAR 2 4 2004
1 unJcrsunJ my PIanRs shall M uJ as Public cc Ns
BUILDING
LiccnreJ Pmlcssional
OWNER -BUILDER III
1 hereby acorns that 1 am exempt from the CnracuoYs License Lufor the
Surapt m .
$170000
following rearm. (Section 703 15. Business and Professions Calc: Any city �cuumy
or,
which retlnlcs a Permit Ir construct, alter. Improve, demolish, or repair anysimemm
prior to its issuance, also requires the applicant for such permit fit file a signed statement
that he is Jimmied pursuant to the Provisions of the Contractor's Licrove Law (Chapter 9
��.�'.t. f}'m1��I(�[0
Valuation
'fcummencing with Section IIXll) of Division t of the Business and Professions Cale) or
'that
t
I
k is exempt therefrom and Ne basis for One alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty OfPN-N
Occupancy
P Y Type
not more Nan five hundred dollars ($500). 1
10 2 - PIERS
D I, a owner of the property, or my employees with wages as their sole cnmpense0nd,
will do she work. and doe strumum is not intended or offered for sale(Sa'.OM. Business
and Profcions Code: The Commerora License Law d6es not apply m an owner of
., -UPER
104 - REBAR Required Inspections
pm,rny who builds orimproves thereon. and whodocs such work himself or thmugh his
own employee, provided that such improvements are not intended Or offered for Safe. If,
105 - ANCHOR BOLTS
however One building or improvement is sold within one year of completion, the owner -
have
106 SEWER & WATER -
.builder will the burden of prnving that he did not IJ r improve for puipnse of
Isale.). 11
_
i 202 UNDERFLOOR
Dl, a owner of the progeny, am exclusively contracting with licensed contacmrsm
,PLUMBING
203 - UNDERFLOOR MECHANICAL
construct the protect (Sea 7044, Business and Professions Code:) The Cmur¢chrs Li -
sense Law does not apply toanowner ofproperty who Nuldsorimproves themon.and
204 - UNDERFLOOR FRAME
who contacts for such projects with a mnBacmr(s) licensed pursuant to the Contractor's
License Law.l
205 - UNDERFLOOR (INSULATION
❑lam exempt ander ser. B&PGfalAlarcason
I301. - ROUGH PLUMBING
mer Date 1.1
302 - TUB & OR SHOWER
WORKER'S COMPENSATION DEC[IASIATION�
l hereby antrm under penalty of perjury one of the following draleraunns:
303 - ROUGH MECHANICAL
I I If
304 - ROUGH EI;ECTRICAL
D 1 have and will maintain a Cemificete of Crnsem m self -insert for Worker's Compen-
sation, a provided for by Section 3700 of the Labor Code, for the pedbrmanlie of the
3 05 - FRAME
work far which thisproomi1isned.
306 - HOLDOWND
iON
1 have and win maintain Workers Compensation Insurance, as required by';Section
3900 of Rc Iallo Codc. for Nc pcOur anSoce of the work for which this Permit i9 issued
3 07 - INSULAT'
My Worker' ompenatuopinsuan�tt/�capo, and Policy mink, are I11
ter a Policy NI. �'
308 - SHEETROCK
309 - EXTERIOR LATH
CERTIFICATE OF PPIONFR 0 KERS' 1
COMPEN ATION INSURANCE(
310 - INTERIOR LATH
(This section need not he completed if the permit is�fnrine hundred dod.i,(.I I od)
311 - SCRATCH COAT
313 ROOF NAIL I
Ices.)
1 crnify that in the perfntmancc of the work for which this permit is issucJ.1 shall not
employ any Person in any manner w m to kmme suhjccun the Workers' Crmpensmiun
5 01 - FINAL ELEC I P I CAL ENERGY
Lawsof Calfforda.Dme "
Applicant II
502 - FINAL PLUMBIING ENERGY
50_: - FINAL MECHANICAL ENERGY
NOTICE TOAPPLICANT: 1Lafscrmaking this Ceirlicutc of Exemption, yn4 should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this arm, shall k'dern cd mvokfe.
I
I SO4 - FINAL BUILDING ENERGY
505 - FINAL ELECTRICAL
CONSTRUCTIONLENDINGng agent I
hereby Oat them isacnaSec.3N7,nCis. agency tiro the performance of
506 - GAS TEST
Which
the work for which this permit is issued (Sec. 3(191, Civ. CJ. I
Lender's Name
507 - FINAL PLUMBING
508 - FINAL MECHANICAL
Lender's Address
1 certify Nat I have read this application and soon, that the above information is
509 - r T NAL GRADE' l
correct. I agree to comply with all city ad .,only ordinances and slate laws relating m
building construction, and hereby authorim repmsenutives of Chi: chym emri uqm the
, r
_ _. FINAL PLANNING
1
ah,ve-mentioned property for inspection purposes. til
[ n t:
RK$
(We)agree to save, indemnify and keep harmless the City of Cupenua against
-1' .IN
liabilitics,judgmenu. ensu andexprn whi may in any way a¢roc against sail City
in conscittu kgranting of di mi
t
�
APPLICANT DERSTANDS D ILL MPLY WI'1'll ALL NON POINT
Issued by: Date
SOURCER IATIONS
t 1 V V
Re -roofs
Type of Roof
a6o ApplicanUCo sem De
IIA RDOUS MATERIALS DISCLOSURE I'
will the appli I or future building Occupied stort orhandle hazardous
ma¢nal
as dcrined by the C mint) Municipal Cute, Chapter 9.12, and the Health and
Safety
e.Sectinn 25532(alI
Dves No
All roofs shall be inspected circ to an roofing
P P y
material beim installed.
g g
°
l
If a roof is installed without first obtaini
g an inspection, I agree to remove
Will thea ream a future build o .r
Pp 6 '< Dam use .impotent nr Jcvft
s which
emit hazardous air ronuminants as Jerred by the IsArca Air Quality Man
grmcnt
all new materials for inspection.
Dimdm
❑ Y. �Nn ,
Ihavc Ne haaNlmsma saymmmc kr Chap¢r 6.95ufth
Califor-
.
nisHcalth cty Ctvlc.seema ,25533an 534,'Imbaua and facto
hot coal,
does rale dyhaveartna mym nalbllo,,, ism the"r.'s
uof die
Signature of Applicant
All roof coverings to
require a whichmos a iaaa erI CeN'fies.aa.apanr
� �
�
Date
be Class "B" or better
Or ,ramhoriacd m Dari
CITY OF CUPERTINO
BUILDING DIVISION pE T
` , R1 NFOR IONik
,
a:GONT_ItACT
BuILTpgg03RIR�BINDELL WY
t I
HUMRICH
CONSTRUCTION
PERMITNT2060022
N RSON CARL D ANDIMOBLEY-LATAS02995
WOODSIDE RD #232
I
APPLICATI"lft yF 002
HONE:
II
'(650)369-0999
SANITARY NO. CONTROL NO:
ARCHITECGENGINEER:
I
l
t
BUILDING PERMIT INFO
I
j
BO ELECT PLO
MECH
O
LICENSED CONTRACTOR'S DECLARATION
I hereby alripn that I am licensed under provisions of Chapter 9 (commencing
SINGLE
n
STORY
3 with Saction7000)ofDivision3OrgnBusi_neysAnd PmfejsionsCade,and mylifcnais
,
in full f rad effect .JT'
R License Lic.A
_ Con
y ARCHREC . A ION .
I undersand my plans Shall W used as public records l ��
I
Liccmctl Prufcuional
OWNER-exempt R
. do, CoATIDN
g I hereby Affirm Nal I em exempt from IW Conyyaactora License law for rhe
following rtuon, (Section 7031.5, Business and Professibns Code: Any city 6 county
I
$170000
$17 0 0 0 0
•. which rtquim, A permit to common, alter, improve, demolish, nr repair any A ctum
$ poor m is issuance, also requirra the applicant forsuch permit Bic a signed statement
that he is licensed pursuant m tie pmvisrons of WC Comrusor's Liana Law (Chapter 9
6
Valuation
6 (amrmucing with Scelon 7")of Division 3 of the Businessand Professions Cola).,
'
. Rte he H exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any Applicant for a permit subjects Ne applicant no A civil penalty, of
not moa Nan five hundred dollbs($500). 1
N-N
Occupancy Type
P
C] u owner of We pmpeny, or my employes with wag es u Weir sole compemation,
102
—
PIERS
will do Rte work, and the Mention, is not intended or offered for We (Sm. 7(Na, BuslnaM
And Pmulou feCode: The Connectors Lima. raw docs nor Apply M en owner or
104
—MR
- RE.BAR Required Inspections
property who builcis or improves thereon, and who does such work himself or through his
own employes, provided that sock, impetwoune ase not intended or offered for sale. If,
105
— ANCHOR BOLTS
however, the Wilding or improvement is sold within one War of completion. We owner,
builder will have We burden or Proving than he did not Wild or improve for purpose of
106
— SEWER & WATER
"l`')'
202
- UNDERFLOOR PLUMBING
co Out be, project
Bf dbe prorarty. am udos, andely eongactins Code:) The dodracibnto
common Rte Business, and The Cono
not (Sec.
ills
203
- UNDERFLOOR MECHANICAL
es 0 An rty who or:)
man. rad
can= Tawdaenoupplr to An with
aofpmperrywcensmds...nt owe Counselor's
who contracts for such projects wiW acongecmr(q licensftlpunuant the Conlrenori'
204
- UNDERFLOOR FRAME
Licerue Taw.
205
— UNDERFLOOR NSULATION
❑lam exempt underSa. ,BesPCror Use mason
301
— ROUGH PLUMBING
,net I Data IO
Df
WORKER'S COMPENdury
302
- TUB & OR SHOWER
1 hereby aRtm under penalty of perjury one of the following declantio �
on tbA wong
303
i
- ROUGH MECHANICAL
'❑1WveandwillmainuinaCcrofrauofCanamto.1Idurt for Workers Compcn-
304
— ROUGH ELECTRICAL /
sation, u provided for by Section 3700 of the labor Code. for We pertomana of
work for which this permit irissued.
3 05
306
— FRAME/
— HOLDOWNS
rke
❑ 1 have and will maintain Wors Compensation Insunna, u mpied by Section
37110 of We labor Code, for We performance of IMwork for which Nis permii i� Issued.
My Worker coupon Ad Ins uranccA ti
cciner end Policy nu,her e:
; 3 0 7
308
/
- INSULATION
- SHEETROCK �lX
'
el. 'G PoligN't l' '�
CERnFICATEOF Pr10NFR O KERS' "
309
- EXTERIOR LATH
COMPEN ATION INSURANCE
I 310
- INTERIOR LA H
is action rued not he completed KIM permit is frronc hundred doll (SIM)
311
- SCRATCH COA�P
toles.)
31
- ROOF NAIL
that in in any manner A the work for which Wis perm iti5 irssad.l Snellnor
employ
employ Any penin in any manner An u a become subject to the Workers Compensation
501
- FINAL ELECT ICAL ENERGY
Laws of Calif9mie. Dam
Applicant � I
502
- FINAL PLUMBING ENERGY
NOTICE TO APPLICANT,If. after making Wis Certificate of Exemption, you should
50--1
- FINAL MECHANICAL ENERGY
became subject to We Worker'S Compensation provisions of We Labor Cmlc, you mug
rortbwim eomply with such prnvisiom$a this .it shag W deemed revoked.,
504
— FINAL BUILDING ENERGY
CONSTRUCTION LENDING AG ENCY
50E�
- FINAL ELECTRICAL
I Wmhy.M. this Wert iso conswcninn leadingaScncy or We lerrosmanee of
506
- G:>',$ TEST
the work for which thrs permit is issued (See. 3097, Civ CJ
Lender's Name
507
506
— , NAL PL'iMBING
- "I NAL MECHANICAL
-
lendera Address
1 anify, that 1 have mad WH appiie3 ion and suis thg the aW a informuion is
coney 1 agree to comply with all city and county ordinances And $rate laws relating to
50r,
— ' I NAL GRADE
Wilding construction, and hereby auNnnaa represcromives of this city to enter upon the
5--
INAL PLANNING
'
a Ww-roun ioned property for inspection purposes. : '
(We) Agree m save, indemnify and keep hamnleas We City of CPPerood against
IN RK$
and espe whi they in any way eccmc Agues aid City
inconsequence egranning
'a con do
�
\.
of mi.
APPLICANT DERSTANDS D ILL MPLY WITH ALL NONiP01NT
Issued by:
(� Date
SOURCER ATIONS
\I4
/
Re-roofs
Type Of Roof
mm o ApplicanJCa aao pa
f RDOUS MATERIALS DISCLOSURE
Wattled eppli Iorfumrn building occupant stere or handle lb a ous material
As defined by ft qPerfino Municipal Code, Chapter 9.12, and the Health And Safety
Ide.sectinn 25532(x)7 i
❑YcS No
All roofs shall be inspected prior to any
roofing material being installed.
Will the applicant or future Wilding occupant vis equipment or devic s which
If a roof is installed
without first ob[aini�i
an inspection, I agree to remove
g P g
emit haurdous air conuminana u defined by the Bay Area Air Quality m-kgcmenl
District?
all new materials for inspection.
'
�
❑Yes SPI No r
a
I have Weha. rnuama smquircme der Chapnr6.95 or dbCalifor-
mrACaturcamnf��
I
i
niaNealW my Celc,Sectima ,255JJsa Sldtlundcrgand Wmif the Wilding
dura nm a Ily ham a tens my re mobility w notify IM em.papl of the
require whichmn a issa
.,SignatureofApplicant
All roof coverings to
ry.�y.
Date _
be Class "B" or better
C./�
eroraOWn�rircd rat Dam
CITY OF CUPERTINO � — � 7�� � n` � f -74 r
BUILDING DIVISION Pg+',R ,JT
BUIL171801�k@pRifZ0BINDELL WY HUMRICH CONSTRUCTION PERm"Nc02060022
Owt49AWSON CARL_ D AND MOBLEY-LA 502995 WOODSIDE RD #232 APPLICATI"1.{$(9V2002
PHONE:(650M9-099.9 SANITARY NO. II CONTROL N0:
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
o p LICENSED CONTRACTOR'S DECLARATION
C U K 1 hereby afrirm that I am licensed under provisions of Chapter 9 (core cncing
<zr�ii with Section 7000) of Division3ortheSasl`cjsandPmrelsinasCode.andmy1i enscis
h in Cull f nd effect
ig z ticcnsc Lic. p
OZ — pc Contntra I
a� Iy ARCHrTEgAIZATION
a a I 1 understand my plans shall be used as public records
xaaU
LU 3 k ,Licensed Professional I
F- O OWNER -BUILDER Dft ARATIDN
h
a a 1 hereby alrirm that I am exempt from the Com6cioes Liccrsc [aw•Ifor the
Q o following reason. (Section 70313. Business and Professibns Code: Any city o county
X
�% which requires a permit to coustmct. alter. improve. demolisk or repair any structure
ul z y prior to its issuance, also requires the applicant for such permit to file asignrd statement
m a that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Fp (commencing with Section75X10)ofDivision3oftheBusiimessandProfessionsCode)or
elr'ty $ than he is exempt therefrom and the basis for the alleged exemption. Any vidlltion of
Section 703L.5 by any applicant Cora permit subjects the ('applicant to a civil penally of
AOL more than rive hundred dollars (5500).
❑ I. as owner or the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Contmceors license Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
awn employees, provided that such improvements are not intended or offered for sale if.
however• the building or improvement (s sold within one year of completion, the owner -
builder will have tha burden of proving that he did not build or improve for purpose of
❑ 1, as owner of the property am exclusively contracting with licensed contractors to
construct the project (Sec. 7044• Business and Proressiogs Code.) The Centric kor & Li-
cense Law does not apply to an owner of property who builds or improves the)eon, and
who contracts forsuch projects with a conn or(s) licenskd pursuant to the Contractor's
License Law,
❑ I am exempt under Sec. I B & PC for ddf reason
Owner I Date
WORKER'S COMPENSATION D13CISARAI70N�
t
Ihereby aQumunder penalty orperjury one of followingdeclaratio
I❑ Ihave and will maintain ACertificatcefCoosenttoself-iravtefor WorkersCompen-
sation, as provided rot by Section 3700 of the Labor Cage, for the performance of the
work for which this permit Is issued. ,
❑ 1 have and will maimain Warker's Compensation Instirance, as requited by Section
3700 of dte Labo[Code, for the performance of the work forwhich this permlt,l Issued.
My Worker Tompensatjaft Insurance carrier rind Policy nuttiber ate: .
�r { CERTIFICATE OF F_7,9MPTION FROM -WORKERS' '
COMPFN ATIONINSURANCEi
(Missection need not becompleted fftheparmitisfor one hundred doli, (5100)
or Mss.) ,
I certify that in the performence of the work for whlrh this permit u issued, 1 shall not
employ any person in any manner so as to become subject to the workers Compensation
Laws of California. Date
Applicant ' I
NOTICE TO APPLICANT. If. after making this Certificate of Exemption, yaq should
became subject to the Worker's Compensation provisions or the tabor Code, ypu mast
O Z forthwith comply with such provisions or this permit shall be deemed revoked.,
7q O CONSTRUCTION LENDING AGENCY
�-r I hereby affirm that them is a eonswetlon lending agency for the performance of
C4 > the work for which this permit is lumucd (Sec. 3097, Civ, C.)
WWA Lender's Name
0 z Letrdcr's Address
U I certify that I have read this application and state that the above information is
w t--+ correct. I agree to comply with all city and county ordinances and state laws relating to
Q V building construction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property rot inspection purposes • '
" (We) agree to save, indcmmfy and keep harmless the City of Cupertind against
:•r fa/] liabilities,judgmems,cesmandexpens whiomayinarVwayaccrueagainstiaidCity
C.) 7 A PLIC uencc c granting of th" rmjl!
R APPLICANT DERSTANOS D/y(1LL MPLY WITH ALL NON POINT
SOURCE LATIONS,
�$rrilureofApplicantlCo actor'/ ' - — ' DasC
HA RDOUS MATERIALS DISC1.0$URE Ila
Will the applic, tarfuture
buildingottupanestore orhandle hazardous aterial
as defined by the Perrino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? % ;
❑Yes No
r
Will the applicant or future building occupant use equipmentor devi which
emit hazardous air contaminants as dcrincd byrbe. Bay ArcaAlr Quality Man gement
District?
❑Yes \o
Ihavc dthehazardousma sregvircma dcrChaprcr6.95ord1cCalifor-
niaHealtit etyCode.Scctions ,25533an 5534,iurldersLandL1W
docs not c t!y have a to my r onstbility to notify the a
reouire n whichmustbc a Issu a Ora CenificateofOccaa
�Si
Date
of the
!y
SINGLE STORY WhR�ffWn
' I �
I
$170000
102 --
Issued by: Date
Re -roofs C7t
Type of Roof r
All roofs shall be inspected prior to any oofing material being installed.
If a roof is installed without first obtaini?g an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
All roof coverings i
Date
be Class +Br' or better
104 -
REBAR Required Inspections
105 -
ANCHOR BOLTS
106 -
SEWER & WATER
202 -
UNDERFLOOR PLUMBING
203 -
UNDERFLOOR MECHANICAL
204 -
UNDERFLOOR FRAME '
205 -
UNDERFLOOR NSULATION
301 -
ROUGH PLUMBENG
302 -
TUB & OR SHOWER
303 -
ROUGH MECHANICAL
309
ROUGH ELECTRICAL
305 -
FRAME
306 -
HOLDOWNS
307 -
INSULATION
y
306 -
309 -
SHEETROCK
EXTERIOR LA H
310 -
INTERIOR LA H
311 -
SCRATCH COA
313 -
ROOF NAIL
501 -
FINAL ELECTRICAL ENERGY
502 -
FINAL PLUMBING ENERGY
50- -
FINAL MECHANICAL ENERGY
504 -
FINAL BUILDING ENERGY
501-'. -
FINAL ELECTRICAL
506 -
0-':S TEST
5^- -
:FINAL PL'IMBING
50. -
-_[NAL MECHANICAL
5 0 , -
= INAL GRADE
"
"INA.L PLANNING
n-
I
:'INS+ PTML_1Qft_0RKS 11
Issued by: Date
Re -roofs C7t
Type of Roof r
All roofs shall be inspected prior to any oofing material being installed.
If a roof is installed without first obtaini?g an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
All roof coverings i
Date
be Class +Br' or better
CITY of
CUPEkTJNO
'TY OF CUPERTINO
PERMIT APPLICATION FORM
"PN# Q� � �
Date
s;
Building Xddre (As c Q -6—n&
Owners Name: Phone #:
o- 0
- 7
Contractor: License #:
Contact: Phone #:
Applicant/Contraptor: Fax #:.
g Permit Info: 1. ,-
1 E1e lamb,Mech
ob'Description:
Residential: i,vtc `- ' Commercial:
Sq -Ft. Floor Area:
$/Sq.Ft.:
Architect/En er.
-� e &m
Valuation:
'
-c-).
Type of Construction:
Occupancy Gr
QuantityFee ID
Fee Description
Fee Group
APTFEE
EACH STORY OVER.3
HOTELFEE
EACH STORY OVER 3
OFFICEFEE
EACH STORY OVER 3
13APPLOTHER
Other Appliances
MECHANICAL
BCONSTAX
Construction Tax
BUILDING
BCONSTAX
Ind/Off/Comm/Quasi
BUILDING
BCONSTAXDP
Con. Tax for B Zone
BUILDING
BCONSTAXH
Hotel and Motel
BUILDING
BCONSTAXR
Constax ResifMobile
BUILDING
BELEC1000
Elec 600V 1000A
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
BELE 200
Elec Svcs 600V <- 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUILDING
BMITIGATR
Res. Housing,Mit Fee
BUILDING
BMNEWMULTI
New Multi -Family Res
MECHANICAL
BNEWMULTI
New Multi-fainil Res
ELECTRICAL
1 of 3
0z
z�
L:d 7
�z
UC
� L
a
U `Z
r
CITY OF CUPERTINO
f_�c
`iT i'� CrO7t t)�MA1.14
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
HUMRICH CONSTRUCTION
PERMIT"03050159
WY
_7898—F-ORINDRIJ,
OWNER'S NAME:
2995 WOODSIDE RD #232-
PER""f's"ITgn0/2003
LAWSON CARL D AND MOBLEY- WS
PHONE:
(6 5 0) 3 6 9- 0 999
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER;
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
13
1 hereby affirm that I ant licensecL nder previsions or Chapter 9 (commencing
with Se i 7000) ofDivislon3❑rdraBu indssiandProfessions de an license
irfall rceandef, -�
Da _ ) -ee clo G��
REVISION --IN HOUSE USE ONLY
NO NEW PERMIT ISSUE, ORIG. #02060022
ARCHITECTS D TION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractars License Law for the
following person- (Section 70315, Business and Profrssinns Code; Any city or county
which requires a permit W construct, alter, improve, demolish, or repair any struemm
prior to its issuance, also requires the applicant forsuch permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) ofDivision 3 ofthe Business and Professions Code) of
,+, Q
that he is exempt thercrrom and the basis for the alleged exemption. Any violation of
y�
APN Number
Occupancy Type
Sccdon 7031.5 by any applicant for a permit subjecra the applicant to a civil penalty of
nbI more than five hundred dollars ($506).
36219026.00
❑ I, as owner of the property, or my employees with wages as (heir sole compensation,
Inspections
Will do the work. and the srnucium is not intended or offered for sale (Sec. 704A. Business
and Professions Code: The CfmlractOfs License Law does not apply to an owner o!J-01
_ F,OUNDAtljTed
property who builds or improves thereon, and who does such work himselror through hisvN
own employees. provided tbatsuch improvements Are not intended or offered for We. If,
102 — PIERS
however, the building or improvement is sold within one year of completion, the owner•
103 - UFER
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
104 - REBAR
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
10 5 - ANCHOR BOLTS
construct the project (Sec. 7044, Business and Professions Cade:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
106 - SEWER & WATER
whocontmctsfor such projects with acontrector(s) licensed pursuant totheContractor's
License law,
202 - 'UNDERFLOOR PLUMBING
C] I am exempt under Sec. B & P C for this reason
203 - UNDERFLOOR MECHANICAL
owner Date
204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one or the following declarations:
3O1 — ROUGH PLUMBING
ClhaveandwillmaintainaCertificatcofConsenttoself-insuseforWorker'sCarnpen-
sation, as provided for by Section 3706 of the labor Code, for the performance of the
302 - TUB & OR SHOWER
work for which this permit is issued.
303 - ROUGH MECHANICAL
Q I have andLtain Worker's Compensation insurance, as required by Section
3700 of dee Lafor the pctformancE� work for which this permit is issued.
MyIY❑rker'rion Policy ram:
304 - ROUGH ELECTRICAL
nsurance carrier um
Cartie Polity N0.� T�
305 - FRAME
. i
306 - HOEDOWNS
ERT[FI ATE Or FXFMPT1ON FROM COMPENSATION INSURANCE WORKERS'
307 - INSULATION
(Mis section need net be completed ifthe Permit is for one hundred dollars ($100)
308 - SHEETROCK
orless.)
309 - EXTERIOR LATH
I certify that in Ithe performance of the work for which this permit is issued, I shall not
310 - INTERIOR LATH
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
311 - SCRATCH COAT
Applicant
313 - ROOF NAIL
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workcr's Compensation provisions of the LabnrCode, you must
5 O Z - FINAL ELECTRICAL ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
502 - FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affitro that there it a construction lending agency for [he performance of
503 - FINAL MECHANICAL ENER
the work for which this permit is issued (Sea 3097, civ. C.)
504 - FINAL BUILDING ENER
Lender's Namc
LenderlAddress
505 -- FINAL ELECTRICAL
1 certify that I have read this appiication and state that the above 16Cormadun is
506 - GAS TEST
corccL I agree ED comply with all city and county ordinances and state laws relating to
bonding construction, and hereby suthorirc representatives oCthis city to enter upon the
FINAL PLUMBING
above-mentioned property for inspection purposes
O g F I L
(We) agree m save, indemnify and keep harmless the City of Cupertino against
Iiabilitiea, judgments, costs and expenses which may in any way accrue against said City
in consequence oC the Ming eC this permit.
APPLICA �1I�g STAN AND WILL COMPLY WITH A NON -POINT
I A
Issued by: 5 NG Date
SO RCE E Ufl dNS.
'.------- .
_
Re -roofs
Type of Roof
Sratur of fplicant/Con❑actor Date
HAZARDOUS MATERIALS DISCLOSURE
r 1 the applicant or future building occupantatare orhandle ha7m-dous material
as defined by the Cupertino Municial Code, Chapter 9.12, and dee Health and Safety
Cads, Section 25532(a)Y
All roofs shall be inspected prior to any roofing material being installed.
E] Ycs ❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant r mtare wilding acrupan( use equipment or devices which
emit ha7_ardovs air ccataminants defined by die Bay Area Air Quality Management
all new materials for inspection.
District?
[] Yes No
Ihave rcadtheIdeas ma 'alsrequirements under Chapter 6.95❑ftheCalifur•
nfaHcalth&S t Cod ,Section 5505.25533 and 25534.1understand that ifthe building
d ntl ha a ten that it is my responsibility m nod fy the occupant of the
dsw
require ich sthe et prior to issuance ofaCenificatc Oceopaney.
Signature of Applicant Date
All roof coverings to be Class "B" or better
• -
owner u uthorixed agent Date
CM OF
CUPEkTINO
V11,Y OF CUPERTINO
( #- ig 2-,p �� 2 -
PERMIT APPLICATION FORM O-3 0 ,�� 45 7*
APN # a2 r _ c) Z
Date:
Building Address. ..-1 g 9 S � � UJA"I
Owner's Namo�,C&,a-` 5 Lovj S a
Phone #: -72-5 — 19 ( D
Contractor- �r + lJ M� L� S,-
License M ! q C B 3 O
�7- I
Contact b UP m ( LA -K[27-5
Cupertino Business License#:
�kuilding P it Info: 0 2-d 6 6 0 27
Elect ❑ Plumb ❑ Mech ❑
Job Description: _ �j �
Residential ❑ ommi cial
Sq.Ft. Floor Area: /
$ISq.Ft.:
Cost of Project:Occupancy
/e�
Group:
/I ^
Type of Constructs
Z�
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 1M Btu
MECHANICAL
BBOILER4
Boiler > IM 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
13MITIGATC
Comm. Housing Mit. Fee
BUILDING
1 of 3
CITY�DF
CUPEVINO
Ci ff OF UTERTINO
PERMIT APPLICATION FORM
Quantity Fee ID
Fee Description
Fee Group
BMITIGATR
Res. Housing Mit Fee
BUILDING
BMNEV8fnTI
New Multi-Farnily Res
MECHANICAL
BMNEWSF&2F
New Sf&2F Res Bldgs
MECHANICAL
BNEWMULTI
Multifamily Res
ELECTRICAL
BNUCOMME
New Comm Electric
ELECTRICAL
BNUCON%UI l
New Comm Mechanical
MECHANICAL
BNUCOMMP
New Comm Plumb
PLUMBING
BNUMULTI
New Multifamily Res
PLUMBING
BNUSFD
New Single Family Res
BUILDING
BOVERTME
. Inspection Overtime
BUILDING
13PBACKFLOW
Atmospheric Vacuum
PLUMBING
BPCESSPOOL
Cess ool
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
BPFIXTURE
Pblg Fixture
PLUMBING
BPGAS
Gas Piping System Fee
PLUMBING
13PINTERCEP
Ind Waste Interceptor
PLUMBING
BPLANCHK
Plan Check Fee
BUILDING
13PLANCKADD
Plan Check Add Multi
BUILDING
13PLANCKREP
Plan Check Repeat Fee
BUILDING
BPREPIPE
Re i e Of Fixtures
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
13PSEWER
Sewers
PLUMBING
13PSPRINK
Lawn 5 rinkler/Backflo
PLUMBING
13PSTORM
Storm/Rain Water
PLUMBING
BPTRAP
Kitchen Trap
PLUMBING
BPVENT
Alt of Drain & Vent
PLUMBING
BPWATER
Install/Alter Water Pie
PLUMBING
13PVIHEATER
Water Heater/Vent
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
13REINSPECT
Reinspection Fee
BUILDING
BR.EMACOVER
A/C Unit > 10,000 cfm
MECHANICAL
BREMAIlZHAN
A/C Units <=10,000 cfin
MECHANICAL
BREMAPPLI
Appliance Install
MECHANICAL
BREMBUSWAY
Remodel Busways
ELECTRICAL
BREMFIXT
Lighting Fixtures
ELECTRICAL
BREMFURN
Relocation of Furnace
MECHANICAL
BREMFURNOV
Relo Fumace > l OK btu
MECHANICAL
BREMHEAT
Heater Installation
MECHANICAL
BREMINHOOD
Installation of Hood
MECHANICAL
BREMMISC
Misc Apparatus
ELECTRICAL
BREMNRAPP
Rem Non -Res Appliance
ELECTRICAL
13REMPOLE
Pole/Platform Fixture
ELECTRICAL
2 of 3
l4 .
carr of
CUPEkTINO
"ITY OF CUPERTINC
PERMIT APPLICATION FORM
Quantity Fee ID
Fee Description
Fee Group
BREMRECEPT
Rc tl, Switch & Outlets
ELECTRICAL
BREMRELOCA
Relocation of Hood
MECHANICAL
BREMREPALT
Repair/Alter Heating
MECHANICAL
13REMRESAPP
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
BSPECUL
Special Jnspection
BUILDING
BSwivl
Swimming Pool
BUILDING
BTEMP
Temporary Power
ELECTRICAL
BTEMPPERM
Temporary BIdg 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
Numbing Permit Issuance
PLUMBING
PPLBG
Plumbing Fee sq foot
PLUMBING
ZADDCHG
Address Change
BUILDING
BMISCELL
Building Mise Fees
BUILDING
3 of 3
CITY OF CTJJ'EIZTINO
u t
BUILDING DIVISION PERK
w qte�ti§�ryTT��n
n � ���IRIJ C 'R A iN
nr,.?S 3 .5
BUILDING ADDRESS:
HUMRICH CONSTRUCTION
PE"""04010065
OWNER'S NAME;
t
PERMITISSUEDATE
CARL LAWSON
T-) 4935
njL412no
PHONE:
SANITARY NO, CONTROL NO.
650 369-0999
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
'
Job DeSCrlpLiOn
I hereby afrixm that I am licensed under provisions of Chapter 9 (commencing
with Sec lion 7000) of Division 3 of the Business and Profession Code, and my license is
full Corte and effect
License
REVISION --IN HOUSE USE ONLY
Crass L}c.
Lip
Date Contractor
NO NEW PERMIT ISSUED/ORIG. #02060022
ARCH172CrS DECLARATION
-
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt fmm the Contractor's License Law for the
following reRson. (Section 70315, Business and Professions Code; Any city of county
which mqutics a permit to conswcx, allen improve, dcmollsh, or repairany Aruclum
prior to its issuance, also requires the applicant rot such permit to file a signed staxcmcnt
Thal he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft, Floor Area - Valuati Dd$107
(com mencing with Section 7000) of Division 3 of the Business and Proressions Cc -del or
Y
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
p y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than rive hundred dollars ($500).
36219026.00
0 I, as owner of the property, or my employees with wages as their We cam pensadon,
Required Inspections
will do the work, and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Contractor's License. Law dors not apply to an owner Of
property who builds or improves lhercon, and who does such work himself arthrough his
ownemployccs, provided Ihatsueh improvcmcnLSUC notintended orotrered forynle.If.
however, the building or Improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale,.).
1, as Owner of the property, am cxc:usivdy contracting with licensed contractors to
corsuucl the project (Sec. 7044, Businrss and Profusions Code:) The Contractor's Li.
cense Law docs not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the ConvaclOr•s
License Law,
-
tI am exempt unt/deren_Sm 0 B & P C for this reason
D
r
WORK RS COMPENS [ N DSCLARA O�/
1 hereby affirm under penally of perjury one of the following declarations: -
F1 Ihave Ind will maintain aCerilficateofCoxtsenttoself-insure for Worker'sCompen.
salion, as provided for by Section 3700 of the Labor Code, for the performance of the
work rot which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work forwhich this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,
(This section need not be complexed Jibe permit is for One hundred dollars ($100)
or less.)
I ccrtiry that In the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become sub}cct to the Workers' Compensation
-
Laws of California. Date
,
Applicant
!
- I
NOTICE TO APPLICANT: (f, after making this Certificate of Fam rnpdon, you show}d
become subject [o the Worker's Compensation provisions of the Labor Code, you must
jr
forthwith comply with Such provisions or this permit shall be deemed revoked,
CONSTRUCTION LENDING AGENCY
I hereby afErm that there is a construction ]ending agency farthe perIonmanr of
..
the work for which this permit is issued (Sec. 3697, Civ. C.)
Lender's Name
Lender's Address
1 cerlify that 1 have read this applicxtinn and stale that the above infotmation is
'
correct I agree to comply with all city and county ordinances and stale laws relating to
'
building construction, and hereby auihorire representatives of this City to enter upon the
,
shove-mentiuned properly for inspection purpose&
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
,
r
}iabifities, judgmanrs, cosLc and rxpcnses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONALU-
Re-roofs
Type of Roof
igndurc afApplicZJhVCcntractcr t Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building Occupantslo(e or handle hazardous maluial
as defined by the Cupertino Municipal Codc. Chapter 9.12, and the Heatlh and Sarety
cadc,Section zss32(a)7
[a Yrs [XNO
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or rulum building occupant use equipment or devices which
emit hulvdaus air cohlamiosnLi as dcf red by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes
1 have read the havardous materials rcquircmenu under Chapter 6.95 of the Cali for-
' nit Health & Safety Codc, Sections 25565,25533 and 7-5534.1 understand that if the building
docs not eurrenlly have a tenant, that i(is my msponsihilily to notify the lxtuparrt of the
_
requiremenLcwhich rnt mapnO tuissv. txaI Certifieateoroeeupancy.
Signature of Applicant Date
/1 .4, o ¢-
All roof coverings to be Class 'B" or better
-.cd
Owneroraulhor'agent D,te
�CC�'-
CITY OF
CUPEkTINO
CITY OF CUPERTING
PERMIT APPLICATION FORM
-- 0 2- r9 ((,, -, -;' ;t)
a�,,I"0,��
APN # o
5&;2 ! tel - af
Date:
1..'14,04 --
Building Address: 76'70(-Z4Mk1.,b
9 \1\1A --J_
Owner's Name:
Phon
�'GiG•j ezc_Jso r7
/C4-0,9 ) 1 SS -tea 7 ¢
Contractor;
License M
�l.lrnhie�
Boiler <= 100,000 Btu
Contact: ShLr U&M6,e-v-
Cupertino Business License#:
Cq-o�j 5a_—Boa7
MECHANICAL
Building Permit Info:
Bldg Elect ❑ Plumb El Mech
Job Description:
�5C&24172
Residential 4
Sq.Ft. Floor Area:
S/Sq.Ft.:
Cost of Project:
Occupancy Gro p:
MECHANICAL
BCONSTAX
Type of Construction:
BUILDING
J
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
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 > 1M to 1.75 M Btu
MECHANICAL
BBOILER5
Boiler> 1.75M Btu
MECHANICAL
BCONSTAX
Construction Tax
BUILDING
BCONSTAX
Ind/Off/Comm/Quasi
BUILD
BCONSTAX13Q
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
2 of3�
Aa6l
CITY OF
CUPER.TIN0
CITY OF CUPERTINC
PERMIT APPLICATION FORM
Quantity Fee 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
Multifamily Res
ELECTRICAL
BNUCOMME
New Comm Electric
ELECTRICAL
BNUCOI DAM
New Comm Mechanical
MECHANICAL
BNUCOMMP
New Comm Plumb
PLUMBING
BNUMULTI
New Multifamily Res
PLUMBING
BOVERTWE
Inspection Overtime
BUILDING
BPBACKFLOW
Atmospheric Vacuum
PLUMBING
BPCESSPOOL
Cesspool'
PLUMBING
BPERMFEE
Bldg Permit Fees
BUILDING
MIXTURE
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 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
BREMA]RHAN
A/C Units <= 10,000 cfrn
MECHANICAL
BREMAPPLI
Appliance Install
MECHANICAL
BREMBUS WAY
Remodel Busways
ELECTRICAL
BREMFTXT
Lighting Fixtures
ELECTRICAL
BREMFURN
Relocation of Furnace
MECHANICAL
BREMFURNOV
Relo Furnace > 1 OK btu
MECHANICAL
BREMHEAT
Heater Installation
MECHANICAL
BREMINHOOD
Installation of Hood
MECHANICAL
BREMMISC
Misc A aratus
ELECTRICAL
BRENC RAPP
Rem Non -Res Appliance
ELECTRICAL
BREMPOLE
Pole/Platform Fixture
ELECTRICAL
BREMPOWER
Power Device/Apparatus
ELECTRICAL
2of3