03120012 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR�INF RMATION
BUI DING ADDRESS: PERMITNO03120012
�2570 SAN JUAN RD
NEWS NAME: PERMIT ISSUE DATE
VERIN HENRY J AND LILLIAN E 12 /03 /2003
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB
TRMECH
)%, LICENSED CONACTOR'S DECLARATION O O O
U Job Description
1 notchy affirm Nat I am licensed under previsions or Chanter 9 recommencing
With Section )of Division 3 order Business s d Professions code,and my littnse is
I f nImle ._d 3 UPGRADE ELECTRIC PANEL
i = Licca es ConLictra OUTLETS FOR BATHROOM
Lqq Date Cover r
<W a ATN
1 understand my pl ns hall he us dACHITESDEPMas public records FINALEO
>yU
e C� Licensed Professional
7 OWNER-BUILDER DECLARATION DEC 3 0 2003
2 a f 1 oute affirm rin I am exempt from the Cascorer's License Law for the
o O fnllawin6 reason.(Section IID1.5,Business and Pmfesxiens Cnde:Any city nr county
5 which requires a permit m construct.eImr.improve,demolish.or repair any suuctum
iy
Poor It) issuance,also requires the applicant for such permit o file a signed statement
2€p that he is licensed pursuanuo the pmvisions of the Contractor'a License U.(Chapter 9 Sq.FL Floor Area 10
2 (commencing with Section7fi0(I)of Division 3 of the Business and Professions Cedc)a,
that he is exempt therefrom and he basis for the alleged exemption.Any violad,on of
Section 7031.5 by any applicant for a permit subjects he applicant to a civil Penalty of APN Number Occupancy Type
net mere man five hundred dollars($580). 34218020 . 00
p Y YP
I,as owner of the property,or my employees with wages as their sole compensation,
will do he work,and the structure is not intended or offered for sale(Sec.7(F4,Business
and Professions Cook:into Consector's License Law does not apply to an owner of Required Inspections
property who builds or improves thenen,and who does such work himself or through his
own employees,provided that such improvements ere not intended or offered for sale.IL
however,he building or improvement is sold within one yam of completion,he owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
E)1,IN owner of the properly,am exclusively contracting with licensed contractors to
construct the project(see.70,14,Business and Professions Code:)The Cantilever's Li.
cense Law does not apply to an owner of property,who builds or improves theater,and -
who contracts for such peojecn with r contractor(s)licensed pursuant to the Contractor's
License Law.
❑ I am exempt under sec. B&P C for this reason
1307Mor Date
WORKER'S COMPENSATION DECLARATION
I hereby.Rum under Penalty of perjury one of dm following declarations:
have and will maintain a Certificate of Consent to self insure for Worker's Compen-
n,as provided for by Section 37M of he Labor Code,for the performance of the
for which this Permit is issued
bare and will maintain Worker's Compensation insurance,as required by Section
of he labor Cde,for he performance of he work for which this Permit is issued.
W kala Compensation Insurance canter and Policy number art:
'54
@0wtto Y4YAIwaVlPpblie . owloy-=p -
CERTIFI ATEOFEXEMPTI MWORKERS'
COMPENSATION INSURANCE
(Thissection need not M completed If the Permit Is Temno hundred dollars($100)
or less.)
1 ccnify 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 sulapoo to he Werkari Compensation
Law.of California.Date
Applicant
NOTICE TO APPLICANT:If.after making his Ccnir tc of Extra prion,you should
become subject to he Worker's Comp,nation previsions of the Labor Code,you must
�0 forthwith comply with such provisions or this Permit shall he deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a construction lending agency lar the Performance of
the work fur which this permit is issued(Sec.3()97,Civ,C.)
4 Q Lentler's Name ..
Lender's Addmas
U Q I ccnify that 1 have read this application and sum that the above information is
et. fes• correct.1 agree to comply with all city and county ordinances and stale laws relating to
0 building construction,and hereby Inflouor represcntatiwa of this city to enter upon the
h ahovcmemionsed dgmems.propertycosts
for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
t�—th liabilitiesenceothe gramand exprti ng;of enses Permit. may inany waynerneagainst said City
U z APPLIC uNTeUNDERSTANDStAND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOUR R UL ONS.
Re-roofs
I at plic UCor mem' Date
HA2'.ARDOU ERIALS DISCLOSURE Type of Roof
Ill he applicant or forum bat ding uccupnt store nr M1andle htvardou.matenal
as defined by the Cuperiuo Municipal Code,Chapter 9.12,and the Health and safety
it,Section 25532(.)? .�[ All roofs shall be inspected prior to an roofing material beim
❑Yes ! No
P P Y g g installed.
Will the applicant or future building occupant ata equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
emit hovardeus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑YesNu
1 have mad hat ha aNnus materials requirements under Chapter 6.95 of the Calihr.
not Health&Safety Code,Socuons 25505.25533 and 25534.1 undersand Ra if the building
dons nm c montly M1avc a tenant,ha it is my responsihiliry m notify the txaupant of he
reyuin a ton u.tbeirc nortnoreneeorkCeNfieam fOc,apancy. Signature of Applicant Dale
Ow anmorizedas,nt Date All roof coverings to be Class 'B" or better
'1
CITY OF CUPERTINO
CUCITY
TYOF NO PERMIT APPLICATION FORM
APN# 2 � r /(� � Q Date:
Building Address:
Ag,5no N �"
Owner's Name: Phone#:
Ikkiry bev
Contractor: License #:
N2 hw+ W010, `'06 .2._—
Contact: Cupertino Business License#:
kT e, AUS
Building Permit Info:
B d lect LI Plumb ❑ Mech ❑
Jo cription: /
Residential Ela ❑ LG
Sq.Ft. Floor Area: f $/Sq.Ft.:
Cost of Project: Occupancy Group
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 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 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 I Comm. Housing Mit. Fee I BUILDING
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� CITY OF CUPERTINO
CUPEI�TINO
PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWI U TI New Multi-Family Res MECHANICAL
BMNEWSF&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 RepipeOfFixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinMer/Backflo 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 Fumace 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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CITY OF CUPERTINO
c TM F PERMIT APPLICATION FORM
CUPEkTINO
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 Seb 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
MPEPJAFEE 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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