03110110 CITY OF CUPERTINO ,•e `�- r
BUILDING DIVISION PERMIT i$CONTRAC"TBR INFQRMATIQNtt;
BUILDING ADDRESS: PERMIT'003110110
3000 STONFIRRIDGE ST
OWNER'S NAME: PERMIT 0UE DATE
LLEN HOLZMAN 11/20/2003
NE: - SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 I�
+00 LICENSED CONTRACTOR'S DECLARATION
with SeIb Description
u� 1 hereby arfvm that I am licensed under provisions or Chapter Ip
r 9(commencing Section 76fIO)(f Division 3 of the Business and Pfofessions Code,and my license is
in len force and er t. 6 (� BATH LIGHT & FAN
License
CostcLieon
-�p Date C( tract
AR TE-
'P
EI A N ) /f
IundcrstanJ my h C
)yU QJ
e0G Licensed Pmfeuionai /T
3 Oat I am exILDERempt
mDECLARATION
`"CV?
M 0 I hereby mason.(Sect Info I am Rusin (rum Nc Contraessionclofs :Any c Law(or the
my
5❑O followinguirsa (Section IID L;Business end Pr. emoli Code:Any city m county
$ which requires n permit re construct,dw alcor,impmw,demolish,ore Asir any atmemre 0
iy prions incensed e,also ntto the thovisiosofwarn foe Conch retor's icese Lew(Cned atemem
sa
that
mmon ingwJAursuanuo00)ofDivision3oheGemmenrindProessonsCudnl9 Sq. Ft. Floor Area Valuation
e�ro
Outiis..wait Ontarim T(glt of broub,a(3 of the asinces Cuda)of
Nat he is exempt Nemfrom end Ne bmla for the alleged esempdon.Any violation of
Section 7031.5 by any applicant for a permit subjects On applicant to a civil renally of 3 413?N__tAi16er0 0 Occupancy Type
not mom Ino five hundred dollen(5500).
❑ I.As owner of the property,or my employees with wages As their into compenu0on,
will do On..,it,end the sweture is not imtowd or.Rued for ask(Sec.TON,Bushels
And Prowshow a Code:The Cpntncmes Liame Lw dna oI appy Io an owner of Required Inspections
property who builds or improves Nemon,and who doessuch work himself orthrough his
own employees,provided the,such irepfowmenu art not inunded molfered foreale.If,
however,On building or impmvement is sold within ane year Of completion,Ne owner
builder will have Ne burden of proving Net he did not Wild or improve(ser purpose of
talc).
❑1,as owner of the property,Am eaclaiwly contracting with licensed wnbacnfs to
cousuuct the project(See.711N,Business and professions Code:)The Conuatmri Li.
cense Law docs not apply to an owner of property who Wilda or improves themon,ad
who contracts for such projects with a contractor(s)licensed promotion to the Comnemr's .
Lice we IAw.
❑1 em cacmpt under Sec. .B At P C for out recon
Owner Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following decimations:
1 how and will maintain a Certificate of Conscat to Ulf-imum fur Worker'[Compen'
urian,u provided for by Section 3]1%1 of the Labor Code.for On performance or the
work for which Nit permit is issued.
I have and will maintain Worker's Compensation Insurance.u required by Section
00 of the tabor Cade,for Ne performance of On work for which Nis permit is Issued
My Worker's CrInannn teniae end Polity number
Carrier: J _ v Pal icy No.:
Lo-U�
CERTIFICATE OF EX EMP ION FROM WORKERS
COMPENSATION INSURANCE
(This section need not M completed If the permit is for one hundred dollars($IOI)
or lewd
I certify Out in the performance of the work far which this permit is issued.I shell net
employ any person in any manner sn to m become subject a the Workeri Comrentall(n
Lows of California.Dam
Applicant
NOTICE TO APPLICANT:If.atter making this Cenifeem of Exemption,you should
woome subject to the Worker's Compensation pm,isions of the IaMf Crete,you must
=O forthwith comply with such Aroviarm,or this permu
ih.11 be deemed revoked.
Z` CONSTRUCTION LENDING AGENCY
I hereby affirm that there its com nseLow lending agony for the performance of
'Y. the work(a,which this parol,is issued(See.3(197,Co,C.)
Q Lender's Name
.7. z Lenders Address
J 1 certify Net I haw read this application and sure that On above information is
O. F coned I agree to comply with all city and county ordinances and stat laws relating to
C) U building conanuction.and hereby adNmim representatives of Nis city in enter upon the
4u ahove-memiowd property for inspection purposes.
y (We)agree to sew,indemnify and keep harmless the City of Cupertino Against
.F.t fA liabilities,judgments,ants And expenses which may in any way accrue gaim,mid City /
U inconuqucnceofthc grendnguflh' permit.
APPLICA NDERS N D WILL OMPLY WITH ALLLNON-POINT Issued by: Date
SO RC UL
ff G/, Re-roofs
Signanm of Applican lConwcm, Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will On applicant or future building(Redraft store or handle henrdous malarial
As darned by the Cupertino Municipal,Cab.Chapmr 9.12,and the Health and Safety
We,se❑ctYeeaa zss3z(ar �^N( All roofs shall be inspected prior to any roofing material being installed.
Will the epplicann r r um building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hrardnus sir can IyRJc load by the Bay Area Air Oualiry Management all new materials for inspection.District?
��)�Na
❑Yes ❑
I have mad On hu.odon,materials requiromenu under Chapter 6.95 of On Calif.,
nix Heel'h Safety Cole,Seniors 25505.25533 and 25534.1 down wind thaif the building
does not conently haw a¢nano Nat It i.my reswnsihility n madly Inc rxau ant of Nc
mquimmcntsw '
Zoos Date
suanccor CCNficamorac� . Signature of Applicant Date
20 O
owner( uthoraed agent Dat All roof coverings to be Class "B"or better .
11/19/2003 23: 21 5105303262 LEGALITIES INK PAGE 01
aR
CITY OF CUPERTINO o
PEt�TINO PERMIT APPLICATION FORM O) l
MN A 3 2- b� Date: 11 2-CIA
3
Building Address: l
23 00 0
Owner's Name: / / Phone #:
267
Contractor: QLicense 415 /65 G
'Contact: _ Phone #:
ApplicaadContraeter Fax #:
�• ,1•�. Y'-vLrlt�
Building Permit Info:
Bldg Elect Plumb Mech
Job Descn tion: ,%
Residential: Commercial:
Sq. oor Area: S/Sq.Ft.:
Architect/Engineer: Valuation:
SSO• �
of Construction: Occupancy Group:
.i
uant(ty Fee ID Fee Description Fee Grou
BAPPLOTHER I Other Appliances MECHANICAL
BBLDGFEE BldR 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
7BBOILER5 I Boiler> 1.75M Btu MECHANICAL
9CONSTAX I Construction Tax BUILDING
BCONSTAX I Ind/Off/Comrn/Quasi BUILDING
BCONSTAXB Con. Tax for B 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
11IB31
ENERGY
Energy BUILDING
ENERGYADD Ener Add Multi BUILDING
INVESTIGA Investigation fee BUILDING
d„ ITIGATC Comm. Housing Mit. Fee BUILDING i
# 23
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2 �Z
CITY OF CUPERTINO
'TM of PERMIT APPLICATION FORM
UPEkTINO
Quantity Fee ID I Fee Descri tion Fee Group
BREMPOWER I Power Device/Apparatus ELECTRICAL
1 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 RemodeTSigns, Marquee ELECTRICAL
BREMTHEATR I Theatrical Lighting Fix ELECTRICAL
BREMVENFAN I Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
13SF&2FAM Single & 2 Family BUILDING
BSFNA Single Family New Add 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
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
6rZEmP rxr
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