03110111 CITY OP CUPERI'iN0
nuILnlNC OfVI Sloth PERMIT GQNTRACTOR INFORMATION: .
a RUI LDINGADDRESS: PERMIT N003110111
23010 STONEBRIDGE ST
OWNER'S NAME: PERMPPIEEUEDATE
_)KI SAGARA 11/20/2003 .
NE: - SANITARY NO. CONTROL NO.
ARCHITEC IENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 �mm (� 0
`00 LICENSED CONnRd code,CONTRACTORSDECLARATIONof CON Job Descrl tIY t�P'��d®
f F 1hereby affirmtbut lemftheB0underand PimneorChapter9(commencing p d
with Seelion]IXN))uf pivision3of NC Businees and Pmfessinns Code.and.1 net..is
in mu mete and�.� 44 5 /6 BATH LIGHT' & FAN
License�I n� L1e.« _ 42003
Dam Conor for DEC
e A IITE A TIO J
Q 1 understand V s /�
.,0tm L_iccnseJ Professional BUILDING'
g � OWNER-BUILDER DECLARATION m
<I I hcrchy otTrm Nm 1 em exempt from Ne Cnmractor's License Law for the
po following reason.(Section 703 IS.Business and Protestants Cade:Any city err county
Ss m which requires a permit to consumer,cher,improve,demolish,or repair any structure $550
hy Pd.,n its issuance,also requiresthe applicant for such permit mile a signed atatemem
mm6 that he is lice used pursuant athe provisions ofthe Connector's LicenscLaw(Chapter 9 Sq.Ft.Floor Area Valuation -
F$)commencing with Section 7(100)of Division 3 of the Business and Professions Code)or
.. Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of -
Section 7031.5 by any applicant for a Permitsubjeeu the applicant to a civil penalty of 3 4'3`NaQAAor0 a Occupancy Type
not more than Ove hundred dollar,(S500).
❑I,as owner of the property,or my employees with wages as their salt compensation,
will do the work,and Ne sticture is not intended or offered for sale(See.7014,Business Required Inspections
and Pr(cssiuns Code:The Contractors License Lew does not apply to an owner of
- q p
property who builds or improves thereon,and who does such work himself orthrough his
own employees,provided that such improvements are not intended crorfered for sale.If.
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving than he did not build or improve for purpose of
sale.)
❑ I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Codi The C.ntractors U.
cense Law does not apply to an owner of property who builds or harrows themon,and
who contracts for such projects with a conuacar(s)licensed pursuant to Ne Conwaor's
License Law.
❑ I ran exempt under See. .B&P C for this resort
Owner Date
WORK ER'S COMPENSATION DECLARATION -
1 hereby off-under Penalty of perjury one or the following decimations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- -
satian,as provided for by Section 3700 of the labor Code,for the performance of the
w rk for which this Permit is issued.
_ I have and will maintain Worker's Compensation Insurance,as required by Section
r, 37W of the labor Con,for the performance or the work forwhich this permit is issued
e- My Worker's Compensation Insurance carrier and Policy number am: q '
P' Carrier: 5 • 4-- k— ' Polity No.: 4 -v-d `7 LL_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE . .
mils section need not he completed IDhe permit is for one hundred dollars(SI(m)
" err last.) ..
1 certify that in the performance of the work far which this permit is issued.I shall nut
employ any person in any manner ser s to become subject to the Workers'Compensation
Laws of California.Dan,
Applicant
NOTICE TO APPLICANT:If,after making this Canaan,or Exemption,you should
become subject no the Worker's Compensation provisions of the labor Cnde,you must
JD forthwith comply with such provisions or this Permit shall be deemed revoked.
r CONSTRUCr10N LENDING AGENCY
j-+m--m I hereby affirm that there is a construction lending agency for the Performance of
One smrk(ur which thin remit is issued(SO.3097,Cie C.) -
W Q Lendm's Name
=Z Lender's Address
U I certify that I have read this application and sort than the above information is -
(~ Carted.I agree to comply with all city and county ordinances and sure laws relating to _
U building construction,and hereby audown rcsc
prencelives of this city a enter upon the
U above-mentioned property for inspection purposes. -
(We)agree to save,indemnify end keep harmless the City.(Cupertino against
i liabilities,judgments,costs and expenses which may in any way accrue against said City /
V Z in consequence of the granting of this per /
APPLICANT UN STAND N L CO Y WIjH ALL NO -POINT Issued by: Date I
SOURCE REG IONS /y
h/70 0 Re-roofs .
Signature of ApplicandContractor etc -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicantur future building occupant sore or handle haomdous material f .
as rented by the Cupertino Municipal,Code,Chapter 9.12,and the Health and Safety
ode,Section 25532(a). ///��7 All roofs shall be inspected prior to any roofing material being installed.
[-3 Y. er No
Will the applicant a ruturc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
R hazardous air conuminanu fncd by the Bay Area Air Quality Management all new materials for inspection.
istrict?
❑Yes ONO
I have real the hmahlous materials squireacnes under Charter 6.95 of the Calif.,
nia Health&Sefety,Codc,Suctions 25505,25533 and 25534.1 undersand that it the building
does not currently have a tenant that it is my resp ireffi lit)to noJly theoccu t of Ne
requirements which ustbcmetpd.rt, once of e rtireeof OccuBep Signature of Applicant Date
• ZQ o
Owner or Da All roof coverings to be Class"B"or better
11/19/2003 23:21 5105383202 LEGALITIES INK PAGE 07
;z CITY OF CUPERTINO led Z
ITY F J
PERJTINo PERMIT APPLICATION FORM
# 3 Z 30-' Date:
Building Address:
A30 1
Owner's Name: Phone #:
Contractor: � License#:. � . I � • 415 /654,
Contact: . Phone #: `
Apphcant/Contraoter• Fax #:
Building Permit Info:
13 Idg Plumb Mech
Job Descn tion:
Residential: iO �i 2,�/ Commercial:
Sq. . oor Area: S/Sq.Ft.:
Architeci/Engineer: Valuation:
SSo• azo
of Construction: Occupancy Group:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu I MECHANICAL
7BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to dM Btu MECHANICAL
BBOLLER4 I Boiler> IM to 1.75 M Btu MECHANICAL
BBOILERS I Boiler> 1.75M Btu MECHANICAL
BCONSTAX I Construction TaxI BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
IBCONSTAXBQ Con. Tax for BQ Zone BUILDING
13CONSTAXH Hotel and Motel BUILDING
BCON'STAXR Constax—Resi/Mobile BUILDING
I1BELEC1000 Elec 600V <_ IOOOA ELECTRICAL
BELEC1001 Elec 600V > I OOOA ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENF.RGY Ener2y BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
'2
I of3 �
11/19/2003 23: 21 5105363262 LEGALITIES INK PAGE 04
CITY OF CUPERTINO
uP.CITY PERMIT APPLICATION FORM
uadd Fee ID Fee Description Fee Group1
BR-EMPOWER J.Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP J Remodel Res Appliance ELECTRICAL
BREMSIGNAD I 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
BSEISMICRE Seismic Fee Res BUILDING
BSF&2FAM Single & 2 Family BUILDING
BSFNA Single Family New Add BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM SwimmingPool 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 I Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbin Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
3 of 3