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CI nut DI G DIIVIISIONNOPERMIT
CONTRACTOR INFORMATION:
-
BUILDINGADDRESS:
PERMIT NO.
19030,STEVENS CREEK BLVD
AEMER NORMAN & ASSOC.
02040122
OWNER'SNAME:_.
_
APPLICATION SUB DATE.
OBINSON III, CO.
5393 PACHECO BLVD
04/22/2002
PHONE:
SANITARY NO. CONTROL NO.
(925)671-9200
Z ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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,
BLDG ELECT PLUMB MECH
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1-7 CJ L_7 I__.1
LICENSED CONTRACTOR S DECLARATION
`I byaffirm that 1 a I enseJ nJ pr visions rCtb6d,�9 (commercmg
0 estiodPm2rton-Olde"ed my license
w }WisnsW�;;
Job Description
- p
TI—UPGRADE<TANKr & GAQbLINE -f
_/
hi en
u br
'NALEDCo
A A N record
AUG 0 8 2002
o Liters dPmfeatianal .
OWNER -BUILDER DECLARATION
affirm
1 hereby an that 1 am exempt from the Contractor's License Law for the
a fallowing mason. (Section 7031.5. Business and Professions Code: Any dry or county'
O improve, demolish,
BUIL. DI NG $128000
which.rsquires a permit m structurecons ract, alter,
or repair any
poor to its usmnce, alio requires the applicant(orsuch Permit o file a signed statement.
F[, F1�,op Ayea-, •, s.
i,.1�.\13^%fjSl�l(J.'J'G 'OU9 i`L: 1t.Ja�'
Valuation
- Brad
ra B. licensed puteuml1.onpesustI naoftheConvationILiren.Lov(Chattel9
(commencing with Division 3 of the Business and Professions Cade)
•Section700D)of
n that be ii exempt Nercr r rn and the basis for the allege) eiemptioo Any violation
)Ik,r
of Secmm 7031.5 by my applicvn for a permis subjects she vpplicnm m a civil pcnalry
of not marathon ave hundred dollars ($5W),
101 AP F4` U ATION
"�•T' Occupancy Type
o I. as owner or the property, or my employee with wages as their sole compensation.
PIBRO
- - - --- - -': -•- - -' - ---- - - - -- _ - - -'- '-'--'---
_
103 - UFER - Required Inspections t. .
.will do the- work. -and thestructim isnot intended or critical par sale (Sec 7¢4H-
I Bu mesa andProfe.' Corde: The Contractor's License Law does not apply toan
owner of pmpeny Who builds or improves thereon, and who does such work himself
or through his own employees, provided Nat such improvements are net intended or
1 Q 4 - REBAR
go pmvenun y
"AtRrcd for sale: 'IEhowcvciaheboildin 'r ire - iii sold within orb itui of
_ _ -__ . _
"'-" '""_... _._._.___....__..-....,__..._.._.__..___---_.__.___.__.._..____.-
,.: ,, �, ♦r.
105 - ANCHOR BOLTS
completion.the owner -builder will have the burden of proving that he did not build or
impm.e for Purpose of wle.).
106 — SEWER & WATER
pent'iinnlv y g ._.. .._
la i t t d ntraemor's
... .-... ..._.. .. ...._. ._ . ..._._. .
202 — UNDERFLOOR PLUMBING
txor's
construct theLaw
License Law tact oat apply m m owner Mpmpeny won)buildsTice or improve. Nerean
ud t., no (Sec. Ito an Busiown ss and Profession, Cade ) The improves
203 — UNDERFLOOR MECHANICAL -
.{ wh
..and wire contracts for such projectswith a.cantramurlM IicasscJ Aunuant.m Ne
c oa=t L< a
._.._... .. _..... _ ......._... .__ .,_... _.....__,_._...... __.......................
2'04 - UNDERFLOOR FRAME
°Iam rl�l pt des B&Pcfrtmsrcsgn
205 - UNDERFLOOR`INSUliATION
t
.;owne< 1?. •:.i •.,Dt-ai"`'`�' i.
-
301 - ROUGH"IPLUMBINGJ '
•-WORKER 'S COMPENSATION DECI-ARATION
-
302 TUB & OR SHOWER
R Ihereby af renam.cl .a ally .ofparjurymiormefollowing de=mrations: -
_
303 ROUGH MECHANICAL
° 1 have and will 'a of Consent to self -insure a roe worker's
3 04 — ROUGH ELECTRICAL
byiOchte
..maintainid
Comrrhanceof he provided for by Section PIN) of the Labor CMc, for the
irtiforthar¢e of Ne work for which this permit is issued.,
3 0 5 - FRAME
ID 1 have and will twimniri Wader's Compensation Insurance, as required by Section
306 — HOEDOWNS
3700 of the Libor Code, for the perforprowe'of N<work for which this petmh is
�Mywrkernmsq _ hdPl<y rt a :
_ a....
307 - INSULATION
c i%Plmy a
-
308,,— .SHEETROCKI,;,• T
i is, 'CERTIFICATION OF EXEMPTION FROM WORKERS
` '' ' COMPENSATION INSURANCE - t'a
_ 3 0 9' — -EXTERItOR `LATH '
_.,._. 310"t,— `:PNTERTOR...LATH,
'181�1r(Tlic, union need not be compldeJ if the permit is for one hundred dollars
311 — SCRATCH COAT 1
C tf t W i the rform-ance or the works for which this' min is i. sued, I
- ' 313-' -ROOF ` NAIL';__" '
•'call 1 pl,yapy. t yin' 'w as toti�comesuh)anotficWorkers
".
501 - FINAL ELECTRICALENERGY
i I If. C If
car, pc'art.Date-
Appl ret - -
— ---- 502- "—-FINAL PLUMBING' --ENERGY-' '- --'-- —
503 - FINAL MECHANICAL ENERGY •, r
.
NOTICETOAPPLICANTIf ur-k gdaiscmBI' rE mpta ra n la
bbmc,ubjcmtoth K rkcri Comet t ,rbvs,n for r oLaboCs,a.'yu.. rust
forthwith comply with such provisions or this pcamit shall M dcemcd revoked.
--.-.504 --.-FINAL- .BUILDING ENERGY
1'CONSTRUCTION LENDING AGENCY
-'
505 — FINAL ELECTRICAL
yf-but antrce
Ihercby afRtmcio I dingeg d
on.
thetNerctsp'wa
kt m=nN.a ttid: d(s Jo97eiacj
506 - GAS TEST.,
Leod
Lhecr.Adartss.
507 - FINAL PLUMBING ;....
c r
r, bAlc utfy th t lha a recdlhi ppletn d.tm[hit the bvenformation is
508 — FINAL MECHANICAL
y cares", agto cs pl> with all cryand countyiordirsones and state laws relating
'
509 — FINAL GRADE .
to budJmgemomet ima hereby iuthrepresentativesof th <ty menterupnn
the„baae.mtmmn=d pt.. pert, for mspeeticin rpotet.
510 - FINAL PLANNING
dad keep hamil<si the Citybf Cap crtino against
L (We)agrte tri ter 'loMemall
O liabilities, judgm n which may is any way "eme a most said
514 - FINAL U WORKS
&i��
in e,mmgt i fo gflhis permit.•\PPLIC.1,; '
ri
~City
R' I•,1 H :C Mt Ly WI TH'ALL'h'O` P Jl"'
Issued by: Date
• SbURCE'RE .(
ignntureate_pmi i1Cmaemr ;'.,.'., :,.. ..,,.. to".:
Re -roofs .'
,t ' HAZARDOUSMATERIALS DISCLOSURE-'
w0 th .pIhcanfmr Boom build's occupant store 6, handle hat andenal
-._ _._.__. .. .... ... .. ., .. .
. Type Of. Roof ... ...... .. .. ....... .
III df db deC t'Y" IC li Ch t 4R tilt H nh
r v p' r anlery
Cad S t 215311 Y
,
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All roofs shall be inspected prier to any, roofing material being installed. _, •
..Will th applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminants as def ed by the Bay Area Air Quality Management
t D.r ter „
all new materials for inspection. Applicant un_74derstands and will comply with
_ r C] Yes ,.
!
.:. ......
all non -point source regulations..; , '1
I ha o cad the hazachi materialqtr remrnes u der Chapter 6.95 of the
25505, 25573n d255J4l understand at
Cai forma Health &REM,
--if in buildin8 doesmmahm it is ter rc,smwibiliry to n of the
o2ctiphm of Ne re he met prior to issuance of n Can ac m of
O==dpm=r';
ignature of Applicant Date
All roof coverings to be Class "B" or better
ner.m censors a
_,gen,,,,at
-. ..... .l..� .....OFFICE .. ... .... - . _ _
®r,
; ? UII'I['Y ®IF C UP ERTRN(D
CITYO RT' 2KP -�A 1L I( N Y®llVl�'1L
CUPS QF 11 `,� 1�
'575-11 -p,,72-q D
0 �- C-> re:� 6) / �?— �--
APN #
Date:
]Fee Groep
Building Address:
Other Appliances
Owner's Name:
P��QlSlf C/L A@ .
Phone #:
Boiler <=100,000 Btu
Contractor:. de,W�
License #:�,
Boiler > 100K to 500K Btu
Contact: �
Phone #:
Boiler > 500K to 1M Btu
Applicant/Contractor: 4, woe" J�
Fax #:
Building Permit Info:
Bldg Elect PlumbMech
BBOILER5
Boiler > 1.75M Btu
Job Description:
-esidential:�/�
Comm cial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
BCONSTAX
Architect/Engineer:aluatio
BUILDING
,,S i
Type of Construction:; WAX �
u ancy Grou
Quantity Fee ED
]Fee Description
]Fee Groep
BAPPLOTHER
Other Appliances
MECHANICAL
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
BELEC 1000
Elec 600V <= 1000A
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
�BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
B1EN ERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
Investigation fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUILDING
BMITIGATR
Res. Housing Mit Fee
BUILDING
1 of 3
n BUILDING DIVISION PERMIT
CONTRACTOR aTOR- A770M
BUILDING ADDRESS:
PERMIT NO.
19030 STEVENS CREEK B
AEMER NORMAN & ASOC.
02040122
OWNER'S NAME: ..
APPLICATION SUB DATE
ROBINSON IIL CO.
5393 PACHECO BLVD
04/22/2002
PHONE:
SANITARY NO. CONTROL NO.
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ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
'.!'L+•jt by affirm that Ifvrt licensed under provisions of Chaptnr.9 (commencing
•` wijh Sect 9 ):'of bivisiop-9 of Oe Btt��ttttess and Pm Ill 9* is Code ' d my license
is in fulle d e L� /� L'° ! /fid ( �. -
- Ligense'bus rc. q �l'��fOCJ QJQr
I understagU my plsEd7,aa/ records
Licensed Professional/J
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or couniy'
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 file a signed statement
dratpe is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 71d*,of Division 3 of the Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemprion. Any violation
of Section 7031.5 by any applican{ for a permit subjects the applicant toa-civil penalty
of not more than five hundred dollars ($500).
❑ 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 Contractor's License Law does not apply to an
owner of property Who builds or improves thereon, and who does such work himself
or through his own employees. provided that such improvements are not intended or
offered fur sale: 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.).
p[,as owner of,dte property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
License Law does not apply to an owner of property who builds or improves thereon,
and who.,contracts for such pmjeets with a eommctor(s) licensed pursuant to the
Contractors License Law,
❑ 4.am,exempt, under Sec. , B & P C for this reason
.rtOwner 'I:;. v Date '
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this pemtit is issued.
❑ I have'and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor'Code, for the performance of the work for which this permit is
issued. My Workers Com cation Insuran c cr and Policy number aro:
'er.'' rVbi policy
'CERTIf; KATION OF EXEMPTION FROM •W,ORKERS't
" COMPENSATION INSURANCE'
(alis settion need not be completed if the permit is for one hundred dollars
(S 100) or less.)
I certify that in the perfornance of tfie work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the Workers'
Compensation Laws of California. Date '
Applicant '
NOTICE TO APPLICANT: If, after making this Cemficate of Exemption, you should
become subject to the Worker's Compensa , provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY '
I hereby affirm that there is a construction lending agency for the performance
bf the work for which this permit is issued (Sec. 3097, Civ. C.)
L'inder's Name '
Lender's Address
[ certify tha[ I ha0e read- Uili application,and state that the above information is
corieci. 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 above-mentioned property for inspection purposes.
(We) agreW,Omdemn and keep hamtless the City ofCupertino against
liabilities. judomases which may in any way accrue a ainst said
City in conseqf this permit.APP.L[CANTD \VILj. CQ>IPLY WITH ALL ��: P7SOURCE RE/M:I / / -•� /i
HAZARDOUSMATERIALS DISCLOSURE
Will *the applicant or future building occapar store or handle h ous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cod'e: Section 25532ta)?
❑Yes o`
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
District?
❑ Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety de ecC s 25505, 25533 and 25534. 1 understand at
if the building does t u e eerie[, that it is my responsibility ro n ti the
occupant of the tea r en ' s.b' met prior to issuance of a Cert c to of
Occupancy. //+7 v
or
(925)671-9200
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I_7 LJ L--7 [--1
Job Description
TI -UPGRADE TANK•& GAS LINE
$128000
37N'�at
'I�:7ZFlo:UfiTe ., i.
101 HY1V MAT I ON t
103 - UFER Required Inspections'
104 - REBAR.
105 - ANCHOR BOLTS
106 - SEWER .& .WATER
202 - UNDERFLOOR PLUMBING
203 - UNDERFLOOR MECHANICAL
2'04 - UNDERFLOOR -FRAME
205 - UNDERFLOOR"IN5ULATION
301 - ROUGH PLUMBING'
302 - TUB & OR SHOWER
303 - ROUGH MECHANICAL
304 - ROUGH ELECTRICAL
305 - FRAME
306 - HOLDOWNS
307 - INSULATION
308'-'". SliEE`I'ROCK,
3 0 9 - EXTERT OR' ' LATH
310... =:.,INTI RIOR7LATH
311 - SCRATCH COAT
313 - ROOF NAIL ,
501 - FINAL ELECTRICAL ENERGY
502-- FINAL PLUMBING ENERGY
503 - FINAL MECHANICAL ENERGY
SO4 - FINAL BUILDING ENERGY -
505 - FINAL ELECTRICAL
506 - GAS TEST
507 - FINAL PLUMBING.
508 - FINAL MECHANICAL
509 - FINAL GRADE
510 - FINAL PLANNING
514 - FINAL UB C WORKS
s V
Issued by: Date
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing, material being installed. .
If a roof is installed without fust obtaining an inspection, I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations. - • •.
y /Signature of Applicant Date
All roof coverings to be Class 'B" or better
OFFICE