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CITY OF CUPERTINO
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DIVISION - PERMIT
FxoNTItA iINk'ORMATION:
BUILDING
-
BUILDING ADDRESS:
PERMIAN BUILDERS INC.
PERMIT NOO 3110061
1000 STEVENS CREEK
R'S NAME:
47770 WESTINGHOUSE DR.
PERMITISSUBOATE
IMWALLE/STEGNER
11/12/2003
NE:
(510) 979-9081
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
- P
I hereby affirm that I am licensed under visions of Chapter 9 (commencing
with Sectio 7 1)uf Division Sof NC Businca dPrufcssions Code, and myl" en '
inf Eforee eIfm. fl
TI- 3 GAS LINES & 1 LINE
Licenseh LI0.k
Ge Imcwr
.WATER
PINALED
ARCHITECTS ATION
I understand my plans shall M uscJaz ¢ rccnNx
FEB 12 2004
Licensed Professional
OWNER.BU ILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors Liccn aw for the
following mason. (Section 703 1.5, Business and Profes.iooa Code: Any ity ur county
which requires a permit m construct, altar, improve. demolish, or repair any structure
BUILDING $8750
prior m its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant o the provisions of the Contractors Liccmc LAW (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
35907005. OO
Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of
not more than five hundred dollars (S500).
❑ L as owner of the property, or my employees with wages as thei"cra compensation.
-
Required Inspections
will do the work, and the suoctum is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves themon, and who does such work himmifor through his
own employees, provided that such improvements Are not intended or offered for sale If,
'
however, lie 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
sato.).
❑ 1, eA owner of Be, property, Am exclusively commuting wim licensed contract.. to
construct Ne project (Sec. 7044, Business and Professions Code:)Top Convector's Li-
cense law does not apply to an owner of property who Wilds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. ,B&P C for this reason
r Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the fallowing declaratiuns:
I have and will maintain a Certificate of Consent to aelf.insure for Workers Com,sm-
saran. as provided for by Section 3700 of the labor Code, for the perfarmance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, As required by Section
3700 of the labor Code, for the Performance o(Uhwgri for which this permit is issued.
y rkAeA Cnmpiortmi en nsUmnCC CdRIG and tby number m:
—.._I I I�
'er. V i lPdliry No.:
CERT( ECAIE•OF 1 N FROM WORKERS'
COMPENSATIONSATIONINNSURANCE
(This section need not ho completed if the Permit is Ramona hundred dollars (SKI
or less.)
1 certify that in the performance of the work for which this Permit is isswd, 1 shall not
empley i ny person irony manner set as m become subject to the Workers' Compensation
Iowa of California. DOM
Applicant
NOTICE TO APPLICANT: If,. after making this Certificate of Exemption, you should
become subject m the Workers Compensation provisions of the labor Code, you must
forthwith comply with Such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby aRrm that there is a construction lending agency for the performance of
the work for which this permit is issued (Set. 3('97, Civ. C.)
Lenders Name
Lender's Address
1 certify that 1 have read this application and sum that the above information is
carted. 1 agree to comply with all city and county ordinances and sum laws relating to
building construction, and hereby aulho sa mpnountedwe of this ci ty to cater upon the
above-mentioned prrperty for inspection purposes.
(We) Agmc to save, i crn fy keep harmless the City of Cupertino against
liabilities, judgment 11 n expo, which may in any way awmc egainat acid City
9
in consequcncc of %nti of a crmit.
APPLICANT RST D COMPLYWITHIALL NON -POINT
Issued by: Date - d
SOU C M ;
Re -roofs
Type of Roof
11AV04
Si 1' A tic. ,cmr Dem
BE MATERIALS DISCLOSURE
Will Ocapplic for furore building uccupam store or handle hvaNrus maudal
Oe0nc0 by tha C er inn Municipal.Codc, Chapter 9.12, and the Health and Safety
zss m)+
All roofs shall be inspected prior to an roofing material being installed.
P P Y g
Ely.Section
❑YeaNe
g
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
it haeardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
MCI?
❑Yes Au
Ihavc read ircmcnu under Chapmr695 of the Califory
MAH" c andM3u4. 1underaund that if the huiWing
Wn.&5
does not c c y Aesponsibility m notify the rxcaloom of dscrcyulom
to 1caofacemfieamofawPany.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
aatnnmi,ed Ag-,ftta
s
CU IN*
t •
CITY OF CUPERTINO
l ! ! ! ♦ O FORM M
N 6 /
APN # .�.. '�-
Date:
Building dress: Mailing Address (if different from building address):
i>
Owner'same:
1LOAAX)G-s
Phone #:
Contractor:
License #: ..
Contact: tn Phone: 5to. 979, 9051 Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb f< Mech ❑
Jab Description: d7� U aE;�,
Residential ❑ Commercial
Sq.Ft. Floor Area:
c
$/Sq.Ft.:
MECHANICAL
Cost of Project:
Occupancy Group:
Type of Construction:
Please check this box if the project is a
second -story addition: ❑
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BAPPLOTHER
Other Appliances
MECHANICAL
MECHANICAL
Boiler> 1 OOK to 500K Btu
MECHANICAL
«i
500K to I M BtuMECHANICAL
I
Boiler > 1M to 1.75 M Btu
MECHANICAL
IIII
Boiler > 1.75M Btu
MECHANICAL
gin
Construction Tax
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BUILD�
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Elec Svcs 600V <= 200A
ELECTRICAL
4 •�,•�
Energy
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En�rgy Add Multi
• till ♦
II Investigation
Comm, Housin Mit. Fee
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CITY OF CUPERTINO
U
BUILDING DIVISION PERM-
. .......
BUILDING ADDRESS:
PERMIAN BUILDERS INC.
PERMIT N003 110061
21000 STEVENS CREEK RD
OWNER'S NAME:
47770 WESTINGHOUSE DR,
PERMIT ISSUE DATE
IMWALLE/STEGNER
11/12/2003
PHONE:
(510)979-9081
SANITARY NO. CONTROL NO.
APCHITECTIENGINFER;
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under rvisions; of Chapter 9 (commencing
w So to 7 )ofDivision 3ofthe Busmes, d Professions Code, and my I' an *a
d
in full force effect,4.
TI- 3 GAS LINES & 1 WATER LINE
License Lic.#—
Contractor
ARCHrmcr�s ATION
2
I understand my plans shall be used as W
-
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Licens aw for the
following reason. (Section 7031.5, Business and Professions; Code: Any ityorcounty
which requires a permit to construct, alter, improve, demolish, or repair any structure
$8750
prior to its issuance, also requires the applicant for such permit to file asigned statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
35907005.00
and the basisfort-he alleged exemption. Any, violation of
. ... .... ... , __
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of_
not more than five hundred dollars ($500).
0 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7D44, 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 himsel I or through his
own employees, provided that such improvements are not intended or offered for 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.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and .
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self -insure forWarker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
C] I have and will maintain Worker's Compensation insurance, as required by Section
3700 of the Labor Code, for the performance of thew for which this permit is issued.
EKZ5 (I�rker's
Compensat trierandki�y numbetj Aicy
�CERTIFICAOF
No.:
EXEMPTION FROM WORKERS'l
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foe one hundred dollars ($100)
or less.)
I certify 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 subject to the Workere Compensation
Laws of California. Date
Applicant
---
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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See, 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of Ns city to enter upon the
above-mentioned for inspection
property purposes.
(We) agree to save, i aminify keep harmless the City of Cupertino against
n ex q which may in any way accrue against said City
P) liabilities, judgmen expo w
in consequence of mi of is crinit.
ce
PPLICANT D COMPLY WIT HjALL NON -POINT
APPLICANTG
"
Issued by: Date
S ou CE it
A
Re -roofs C4
Signature licall actor Date
RD US MATERIALS DISCLOSURE
Type of Roof
Will theapplic t or future building occupant store or handle hazardous material
as defined by the 7Certino MunicipalCode, Chapter 9.12, and the Health and Safety
Code, Section 255 (a),
All roofs shall be inspected prior to any roofing material being installed.
E] Yes ><No
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 hazardousair contaminants as defined by the Bay Area Air Quality Management
I '
all new materials for inspection.
District?
byes
I have d t sm ials requirements under Chapter 6.95 of the Califor-
niaHcalth&S c cc ns 05,25533 and 25534, 1 understand that if the building
does note e y a to i is y responsibility to nofiry the occupant of the
e
y.
reqlurem is riorwi ancc of Certificate ofOccup 7y
Signature of Applicant Date
03
All roof coverings to be Class "B" or better
Owner authorize a i Dsitcl