03110108 CIIL
TY OF CUPERTINO ""` - -
BUILDING DIVISION PGMIT CONTRACTOR M
INFORATONI
BU I LUNG ADDRESS: _ PERMIT NIb3110108
OWNER'S NAME: PERMR LSSUE DATE
.EVE BUSBY 11/20/2003
ONE: SANITARY NO, CONTROL NO.
ARCHITECfyENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
joo LICENSED CONTRACTOR'S DECLARATION O O O
I p 1 IM.hy sift.that 1 am licensed under pmvisiuna of Chapter 9(commencing Job Description
tl with Senion7IXR)of Division 3 of Ne Busincssand Pru(essinm Code,and my license is
o !1underaland
45 IGS L BATH LIGHT & FAN
Lic.sDae Cunuamar
ARCH CI'SDEC R my plans be me b' re rds
y6
a$� Licensed ProNWoal
OW NERBUILDER DECLARATION
d lE I Wmhy affirm Nm I am exempt from the Comment's License Law for the
p 0 fallowing meson.(Section 7131.5.Business and Pre feasimes Code:Any city or county
5$ which requires a Permit to cnnswct,alter,improve,demolish,or repair any structure $550
ti prior to its issuance,also raptures the applicant(or such permit to file a signed Hammenl
ss< that he is licensed pursuant In the provisions of the Cowraclofs LiRnY Law(Chapter 9 Sq. Ft. Floor Area Valuation -
FO
(commencing with Section 7(=)of Division 3 of the Business and Professions Coda)or -
$ Nat he is exempt du nefrom and Ne beau for Ne ailegcd exemption.Any Anleston of
Section 7D31.5 by any applicant for a pennitsubjects the applicant to a civil penalty of 3 2��c0 Occupancy Type
not more Nan Eve hundred della.(5500).
I,as owner of the property,or my employers with wages As their ole compensation,
will do the we&.and be structure is not intended or offered fonsle(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License, does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employers,provided Nat 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 Nu he did not Wild or improve for purpose of
sale.).
❑ h as owner of the property,,B exclusively contracting with:) no m Comment"nors to
come La the project Isec.](44,Business and rty who Wi ds or I The nrad
Li-
come law does not apply m ts owner of property who Wilda or improve thereon.and /
who contracts for such projects with econwnorts)licensed pursuant mthe Contractor's
❑I Am exempt under Sec. .B&P C for this recon
Owner Data v/v
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury ore of the following declaralose
I have and will maintain a Ceninae of CA.At to self-losure for WorkeYs Compton-
cation,As provided for by Section 37011 of the labor Code,for the performance of the
work for which this permit is%good.
1 have and will maintain Worker's Compensation Insurance,As required by Section
7W of the labor Cade,for he performance of the work for which this permit is issued. ,
My Worker',Compp�ensation Insurance carrier and Policy number am:
Cartier. 5--'77 _-2 Polity No. _p —p
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thus sctinn need not Mcomplced if the Permit is for unto hundred dollars(51 W)
or leas.)
1 certify,that to the perfnrmerme of the work for which this Permit is found,l shall out
employ any person in any mermerso As m bemmc subject to the Wormos Commmation
Laws of Califoreia.DAM
Applicant
NOTICE TO APPLICANT:IL after making this Cenificem of Exemption,you A mZ
become subject to the Worker's Compensation provisions of the Lather Code,you must
.,O forthwith comply with such prevision or this permit shill be decreed revoked,
Zy CONSTRUCTION LENDING AGENCY
I hereby affirm that there its construction lending agency for,loo,Performance of
be work for which this permit is issued(Sec.3(197,Civ.C.)
fA 0 Lender's Name
=z Lender's Address
U 0 1 ennify dust 1 have read this application and note set on,above information is
" P correct.I A,=to comply with all city And coumy oulinaret.end sue 11w5 mlattng to
0U building construction.And hereby amhedm o:Presentatives of this city to cmc,option le
W above-mentioned propeny for impaction Purpmea
y (We)some la As-,indemnify and kap harmless the City of Cupertino against
y liabilities,judgments,costs and expenses which rosy in any way name against said City
U z In consequence he ommin f I roll.
APPLICA OER A 'WILL PLY WITH AL NO�OINT Issued by: Date
SOUR 7
/y r"I Re-roofs
Signature of ApplicantlConu rcmr Date I
.HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicant or future building occupant store or handle h wdous material
As defined by the Cupertino Mon pa Code.Chapter 9.13,and the Health end Safety
ode.secdon zss3z(a)7 i All roofs shall be inspected prior to any roofing material being installed.
7rcq ❑Y
No
Will Nc applicant or fuwrc ending accnpant na egmpment or devices winch 'If a roof is installed without first obtaining an inspection,I agree to remove
It hayardous air conmminan cfincd by the Bay Area Air Quality Management all new materials for inspection.
knot]
❑Yes ❑No
I have read the haraedrmama arials requirements under ChsPmr6.95 of the Califor-
nia Healtb&Safety Code,Savmss 253(15.M533 and 25534.1 understand dues if de building
dors not croscmly .rant,Nat it y rcapoos.biliIM a
ty to notify c,fdm ofthe
uiramantsw Ani-it cm rare Signature of Applicant Date
!! 2v All roof coverings to be Class"B"or better
Owner tar authorized egcm ' am
i9/2003 23:21 5105303202 LEGALITIES INK PAGE 09
pay
A1 F CITY OF CUPERTINO
�UPATINO
PERMIT APPLICATION FORM �� 0 os
APN # ' U / Date:
Building Address Z
Owner's Names, Phone#:
-:253 —3 -79-S
Contractor: / C I License#:
415 /4. 54
Contact: - Phone
Applicant/Contraet(!! . Fax #:
Building Permit Info:
Bldg Elect Plumb Mech
Job Descri tion: ,Q
Residential: iUaZftl G.ri/ Commercial:
Sq. oor Area: S/Sq.Ft.:
Architect/Engineer: Valuation:
We of Construction: Occupancv Group:
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 IM Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS 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
BELEC 1001 Elec 600V > 1000A ELECTRICAL
_ BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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CITY OF CUPERTINO
uP TYOF PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tL Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair ter Heating MECHANNICAL
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 'Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
J BSEISIVIICRE Seismic Fee Res BUILDING
BSF&2FAM Single & 2 Family BUILDING
BSFNA Single,Family New Add BUILDING
BSPECIAL Special Inspection 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
l♦ B 2 E PA t= t x r
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