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CITY OF CUPEKI INO
BUILDING DIVISION PERMIT
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CONTRACTOR INFQRMATION: '.
8R1'£TEVENS CREEK BLVD
PERNHpN02090066
i.
NSi@M1Q+A & BEN SITYY
APPLICA" Af3YAp'2002
1/ 7
ONE:
SANITARY NO. CONTROL NO.
ARCHITEC IENGINECB:
BUILDING PERMIT INTO
BLDG ELECT PLUMB MED
LICENSEDCONTRACfOR'S DECLARATION
I III .loon that l am licensed Under P,ovio,m.ofCnapmr 9(commencing
TENANT
IMPRVOEMEN'lscription
kplpf
with Scclior TI00)of Dioi,i,, 3oftl¢Boinco, and Professions Cedc. and my license is
n full forte and clfcel
i.iecn�Glnaa
1TMA LE®
Dalc�,� =� /z�7 Cnntractm
ARCI TLTS UECI.
I understand my plans sM1all be used as rttrorJs
FIN/
.
.e ti,
0,
^��`' 1 200 1
hiccnsJ Pmlcanion
OWNER BUILDER DECLARATION
1 herchy anion that 1 am emor pt from the Contractor's License Law for the
(5
®Ell
1
I I e.0 �'l $25000
following neaxna(Section 703L5. Business and Professions Gale: Any city nr county
R151�i 111111 /'�
b NG
which requires a permit to consumer, alter. improve. demolkh, or repair any Structure
{J tLD
prior to its isomfoc. also requires the applicant for such permit ,, file a Signed Statement
3 Ir dr. A4kfl
Valuation
that be is licensed pursuant the provisions of the Conumcmr's License Law (Chapter 9
(commencing with Section 710 11 nl Division 3 nl' the Business and Prn(ossionx Code) nr
t `f � •
that he is exempt therefrom and the basis for me alleged exemption. Any violation of
U Pp
Occupancy Type
Section 7031.5 by any applicant for a permit Subjects the applicant to a civil penally of
not more than rive hundred dollars ($500).
102
- PIERS
1, as owner of the property, or my employees with wages es their, axle compensation,
Required Inspections
C ns
q p
will do the worl and the structure isnm intended to offered for salc(See. 701 Business
Law diva n apply In an owner of
and Professions Code: The Constrictors Liecnm and
104
- REBAR
prupcny who builds or improves thereon, and who does such work himulfor through his
n employees. provided that such improvements art not intended or onerod for sale. If.
105
- ANCHOR BOLTS
however. the building or improvement is mold within one year of completion, the owner-
106
— SEWER & WATER
Wilder will ban the burden of proving that he did not Wild or improve for putpou of
sale.).
202
- UNDERFLOOR PLUMBING
C] 1. as owner of the property. am exclusively commcting with Hectored contrast onto
203
- UNDERFLOOR MECHANICAL
construct the project (Sec. 7044, Business and Professions Coill The Corm or'sLi-
ceireLawnoesnotapplytuanownerofpropenywhoWildaorimprovesthemon .and
204
— UNDERFLOOR FRAME
who feet mct fr aueh pmicav with a commem,P) licensed pursuant to the Cmnmcmr's
205
— UNDERFLOOR INSULATION
License Law.
I am exempt under Sec. ,B &P C for this rcx °"
301
- ROUGH PLUMBING
Ina, Date
302
— TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION
303
— ROUGH MECHANICAL
I hereby affirm under penally of Perjury one of the following declaraao..
304
- ROUGH ELECTRICAL
I have and will maintain a Ccniftcale of Consenuo self - insure for Worker's Camper-
305
- FRAM.
cation, as provided for by Section That of the labor Cafe, for the performance of the
work lot which this permit is issued.
306
— HOLDOWNS
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
307
- INSULATION
3100 of the Labor Gale, for the perfmmance of the work for which this permit is issued.
mmmna Pwey
308
— SHEETROCK
My Workers Compensation easier a ad somber am:
F.(J✓% PUlicy No
309
- EXTERIOR LATH
caniera'7'i-
TQl 1( Ci^ Of EXEMPTION FROM W0 ERS'
310
— INTERIOR LATH
COMPENSATION INSURANCE
(TM1is scnilm need nw MCnmplctediftM TCtm'n is Rannc hundred Jollan(SBxO
311
— SCRATCH COAT
mmu3
313
— ROOF NAIL
I cenily that in the performance of the work for which this permit is issued. I shall not
501
— FINAL ELECTRICAL ENERGY
employ any person in any manner m as,. become subject to the Workers Compensation
IawsofC.BfmIf..Dow
502
503
- FINAL PLUMBING ENERGY
— FINAL MECHANICAL ENERGY
Applies. n
h d
NOTICE TO APPLICANT': 11L alter making This Cenilieam of Exemption, you s nu l
become subject o the Workers Compensation provisions of the Labor Code, you must
504
— FINAL BUILDING ENERGY
forthwith comply with such provisions or this permit Staff he deemed mvoked.
505
— FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
506
—. GAS TEST
thereby anion that there isaconstruction lending agency loathe perlormancenl
0. work for which this perman issued (See 3097, Cis. C)
507
— FINAL PLUMBING
Lender's Namc
508
509
- FINAL MECHANICAL
— FINAL GRADE
Landcr's Address
1 emir, that 1 have read this tni ... n and awto that he above information is
meet. 1 agree to comply with all city and county ordinances and state laws relating,.
5
- FINAL PLANNING
buildingconsuncertain, and III aithatie refresorwovesof mice city,. enter farm the
abovicemboracd Intperty, for inspection purinus'
S 4
— FIN PUBLIC OAKS
(We) agree to save, indemnify and keep harmless me City of Cupertino against
Liabilities. judgment, costs and expenses which may in any way aceme against .,aid City
in eonuqucnce of the gramin !this permit. ��JJ
APPLICANT UNDERS N W ILL MPLY wl'I'll ALL NON POINT
Issued by:
Date
SOURCE REGULATI S.
• �� /L uL
'
Re -roofs
Type of Roof
g c n mrlme or Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamobus material
as defined by the Cupenin) Municipal Code. Chapter 9.12, and the Health and Safety
node. Scotian 255320)?
All roofs shall be inspected prior to any roofing material being installed.
p Y." X No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fulnrc building rt Sae c pi t or dcomes which
tin gby the q Amen
emitict' SairttmuminanuasJClincJbytheBayArcaAirQualityManagement
all new materials
for inspection.
District'
DYCS AN.
1 have read the huvaNnns materials "aimments under Chapter 6 95 of thc Califor-
nia Health & Safety Cak:.Sccutms15505. 25533 and 255.W. 1 understood der ifthe building
does not a'urreml, hase.ICnu it is my ties . mility m notify the occupant of the
requirements which must prig nfacemrcalearOcculs.
Signature of Applicant
Date
/2 ay
All roof coverings to be Class "B" or better
tier or aathorLC risen) Dal
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CITY OF CUPERTINO
BUILDING DIVISION P E T
0 6 �yA
BUI &@RE$TEVENS CREEK BLVD
PERMITh02090066
040D,1410A & BEN SITYY
APPLICA'"? y EA'_2002
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
�r�,h
TENANT I MPRVOEI�n scription
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
License
Date � Contractor
ARC S DELL
1 understand my plans shall be used as records
Licensed Professional
OWNER - BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
$25000
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter• improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
e9 fin n ?,7_ r��
3 3cp PC B13d tiV/a
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
five hundred dollars
pN
OCCU
Occupancy Type
not more than ($500).
102 —
PIERS
❑ 1, as owner of 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 (Sec. 7044, Business
and Professions Code: The Contractors License Law does apply to an of
103
UFER
Required Inspections '
not owner
104 -
REBAR
property who builds or improves thereon,and whodoes such work himself or through his
own employees. provided that such improvements are not intended or offered for sale. if.
105 —
ANCHOR BOLTS
however, the building or improvement is sold within one year of completion, the owner-
106 —
SEWER & WATER
builder will have the burden of proving that he did not build or improve for purpose of
sale')'
202 —
UNDERFLOOR PLUMBING
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
203 —
UNDERFLOOR MECHANICAL
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and '
204 —
UNDERFLOOR FRAME
who contracts for such projects with a cor ractor(s) licensed pursuant to the Contractor's
License Law.
205 -
UNDERFLOOR INSULATION
❑ I am exempt under Sec. , B & P C for this reason
301 —
ROUGH PLUMBING
Owner Date
302 —
303 —
TUB & OR SHOWER
ROUGH MECHANICAL
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
304 —
ROUGH ELECTRICAL
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
3 05
FRAME
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
—
work for which this permit is issued.
306 —
HOLDOWNS
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
307 —
INSULATION
3700 of the Labor Code• for the performance of the work for which this permit is issued.
My workers Compensation Insurance carrier and Policy number are:
308 —
SHEETROC K
Carrier._ 2! (/P�%�PolicyNo.: -'�
n/ 309 —
EXTERIOR LATH
�COMPENSATION W NS INSURANCE CERS'
310 —
INTERIOR LATH
(Tltisseetionneed notbecompleted if thepernilis foronehun&eddoilars(SI00)
311 —
SCRATCH COAT
or less.)
313 —
ROOF NAIL
I certify that in the performance of the work for which this permit is issued, I shall not
501 —
FINAL ELECTRICAL ENERGY
employ any person in any mannerso as to become subject to the Workers' Compensation
Laws of Califomia. Date
502 —
FINAL PLUMBING ENERGY
Applicant
503 -
FINAL MECHANICAL ENERGY
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
504 —
FINAL BUILDING ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
505 —
FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
506 —•
GAS TEST
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
507 —
508 -
FINAL PLUMBING
FINAL MECHANICAL
Lender's Address
I certify that I have read this application and state that the above information is
509 -
FINAL GRADE
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
5 —
FINAL PLANNING
above - mentioned property for inspection purposes.
j 4 —
FIN PUBLIC 0 KS
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequence of the grantin f this permit.
APPLICANT UNDERS AND WILL MPLY WITH ALL NON -POINT
Issued by:
Date
SOURCE REGULATI S.
1i
rZ °
L Re -roofs
Type of Roof
g c onrac or Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑ Yes A No
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 future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes A[ ,N.
Ihave read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505, 25533 and 25534. I understand that if doe building
does not currently have a Lena it is my res ability to notify the occupant of the
requirements which must pno 'ss c of a Certificate of Occupant
Signature of Applicant Date
/L a
All roof coverings to be Class "B" or better
ner or i0horized agent Datf
O
D CITY 07 CCUP ERTINO
Cu P> y r FIERILY APP LHCCA� H(DN FORM
APN # 42-9- t I 0 7
Date: S� D <IXT Z
Building Address: o
Fee Group
Owner's Name:
Phone #:
f AOV16cc�- & 4M- 5
(4o 8) 168
Contractor:
License #:
Contact:
�o�,, H0,-
Phone #:
(a0g) 24So`j��
A plicant/Contractor:
Fax #:
1,C) L,
C4o� 24� 03 i
Building Permit Info:
Id Ele Plumb Mech
o Description:
S
Residential: Commercial:
Sq.Ft. Floor Area:
4-
$ /Sq.Ft::
eer:
Valuation:
tTv;1JM1
a
I-Type o f o traction:
ccup y Group:
V�
BELEC1000
Quantity
Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
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
Energ
BUI LIlDIING
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-family Res
ELECTRICAL
BNUCOMME
New Comm Electric
ELECTRICAL
BNUCOMMM
New Comm Mechanical
MECHANICAL
BNUCOMMP
New Comm Plumb
PLUMBING
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