02040158 INO
CITYID013DIVSIONPERMIT •CONTRACTORINFORMATION:
BUILDINGADDRESS: PERMIT NO.
7442 TIPTOE LA SHADYGROVE CONSTRUC ON 02040158
OWNER'S NAME:
APPLICATION SUB DATE
PREETZ WILLIAM H AND EVELYN ry 6276 SHADYGROVE CT 04/30/2002
PHONE: SANITARYNO, CONTROL NO.
(408) 252-3500
ARCHTECTIENGINEER: _ BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LI
h i LICENSED CONTRACTOR'S DECLARATION Job Description
Z_o I hereby affirm sm mescrp
that I licensed under provisions of Chapter 9(com
encing
withSect5 11 ion7"J)�oQfDDivision3of the Business and Professions Code,and mylicense � BATHR P¢�GpRpAD�Eoo II&�SKYLIGHT
s U License Cl .—tom Lic.
;A U4.7
u 60 D [ Con
HrfECT'S DEC 'tC a^7n
},g 1 ndemaM my plans shall be used az public records JUL 2 2 2002
1 z 00 Lice ad Professional
OWNER-BUILDER DECLARATION
1 Mreby affirm that 1 am exempt from the Commecmr s License Law for the LDING
F=?a following maions son.(Section 7031.5,Business and ProfessCade:Any city or countyBUI
ax�o which acquires pistonan
a peut to construct,alter,improve,demolish.or repair y swnum $20000
a3� prior in itsissuance,also requires the mplicam for such Food to file a signed summent
thio he is httmed pursuant to the provisions of the Contractors License law Chapter 9 Sp ,t ]�
(commencing wim Section 7W)of Division 3 of the Business and Professions Code) ,3573FL�58rf a,.. ,, Valuation
or thai he is exempt therefrom and the basis for the staged uemption.Any violation r
of Senior 7W 1.5 by any applican1 fora permit subjects the applicant to a civil penalty N��t,f.�
of not ream than ewe hundred Aol aS500). 1Ol�N- TJtiIIallATION Occupancy Type
❑I,as owner of ma property,or my employees with wages az their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business and Professions Cods:Tho Convenor's License law,do¢nes apply to an 103 - UFER Required Inspections
wrier of property Who builds or improves thereon,and who docs such work himself
or through his own employee.provided that such improvements eR not intended or 104 - _RE BAR
• offered for sal..It however,the building or improvement is sold within ane year of -
completion,meowneobuildawill have the Wrdenofproving that hedid not Wild or 105 — ANCHOR BOLTS
improve for purpose of sale.). 106 — SEWER & WATER
❑I,as owner of to property,am exclusively contracting with licensed contractors to 202 — UNDERFLOOR PLUMBING
consumer the project(Sec.7041.Business and Professions Cade:)The Contractor's
License Law dues no apply to an owner of property who Wada or improves thereon, 203 — UNDERFLOOR MECHANICAL
mal who efLara`v n proieets with rummnnna)ettr«a pursuant m 204 — UNDERFLOOR FRAME
IRIamexempt under Se, ,tI�/�I7.DR&PC for his rosom 205 - UNDERFLOOR INSULATION
Aw°" MPENATIO�5€MAT10N 301 — ROUGH PLUMBING
I hereby affirm under penalty of perjury one of the following declinations: 302 — TUB & OR SHOWER
Ai- 303 — ROUGH MECHANICAL
\ 7) ❑ I have and will maintain a Certificate Sect or Corsican tear-bar for workers 3 04 — ROUGH ELECTRICAL
a/ Compensation,o he work
for
for by Section 3700 of me Labor Code, for the
Performance of the work roe wm,h this permit is issue,. 3 05 - FRAME
❑I have and will maintain Workers Compensation Insurance,as requited by Section 306 - HOLDOWNS
37W of the labor Code,for the performance of the work for which this permit is
issued.My worker's Compensation Insurance carrier and Policy number an: 307 - INSULATION
came Policy No.: 308 - SHEETROCK
CERTIFICATION OF MEMPTION FROM WORKERS' 3O9 - EXTERIOR -LATH
COMPENSATION INSURANCE
- _. .._...._.... .
(slDo)a ii:a:)mmnneed nntberomplemoire,ePermit irfor one hundmadon310- INTERIOR LATH -
311 311 - SCRATCH COAT
I awry mat in the performance of the work for which u,in pe.-1 Is i,smed,I 313 - ROOF NAIL. .
akin not employ any person inaappyy,,��nn' aJ�/� m come subj«no me Workers' 501 — FINAL ELECTRICAL' ENERGY
Compo den a fCaldomieltlnlr�Jr`2eOeL
AppltceFL's// ) 502 — FINAL PLUMBING ENERGY
NOTICF'i oris Certificate of Exemption,you should
Z their. bjactmmcWorkers Compensation provisions ofthe Labor Code,you most 503 — FINAL MECHANICAL ENERGY
Z O p fonhwith comply with soon provdiom:or this permit shall be deemed revoked. 504 — FINAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY
1 Hereby ah m that them is s issued(Sec.lending agency for the performantt 505 — FINAL ELECTRICAL
� �, oruthe work Nrmwmmhthis permhiaiaauea(se,.3D9zCiv.ca 506 - GAS TEST
UO I.ender'1 Name - /y
ED z Lender'sAdtlrcss 507 — FINAL PLUMBING.
U 1 certifyagree ren I have read mia'city
and
and ire i that above information is 508 - FINAL MECHANICAL
'correct.1 agree to comply with all dry and county ordinances and sum laws relating 509 — FINAL GRADE
O to aWyegeenanrad Prandhertinspectioxempmsentativa oforis city io enter upon
N W neaW(we)agienedpmpindemifyankeion pberiaea. 510 — FINAL PLANNING
L.
L (we) to save,indemnify which
me City of Cupertinoagainst
V] liabilities,judgments,costs and expenses which may in any way accrue against said 514 — FINAL PUU12IC WORKS Qv
V z City in consequence of the granting D oris permit. 7.
r. SOURCA.NTUNOTRSOVANDSAI:DWILLCOMPLYW'1THALLNON- NT Issued by: r Dale
naEim0 AppmacVCont oto m Re-roofs /
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furan,building ocouamd store or handle hazardous material Type of Roof
as defined by the Cupertino Municipal Cade.Chapter 9.12 and the Health and Safety
Cede,Section 25532(.)?
oyes ANo All roofs shall be inspected prior t0 any roofing material being installed.
Will the applicant or future Wilding occupam use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit luman ores air conmmiam s es defined by m,Bay Are.Air Quality Mistop mem
Diamv? all new materials for inspection. Applicant understands and will comply with
t
oyes R e all non-point source regulations.
1 have read the hazardous materials requirements under Chapter 695 of the
California Health&Safety Code.Se,tions 25505.25533 and 25534.1 understand Nat
if me building dm not currently have a tenant,mat it is my responsibility to notify the
onupant of the requirements which must be met prior to issuance of a Cepdicne of
nF`acy �r� Signature of Applicant Date
- Owner or authonud,gem ate
All roof coverings to be Class "B" or better
- - OFFICE
° Z CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
APN# ./2 Z Date:
- -
Building Address:
IL4La .s
Owner's Name: Phone #:
Q) I t ✓a ��-z 246'74s2v
Cont act License#:
n
Contact: jQ Phone#:
4{20 2,0 d
Applicant/Contra tor: Fax #:
01
uildin Permit Info:
Bldg Elect Plumb. Mech
Job D scnption:
sidential: cra :
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Grou '
I
Quantity Fee ID Fee Description Fee Group
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
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 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
BMITIGATR Res. Housing Mit Fee BUILDING
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DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
7442 TIPTOE LA SHADYGROVE CONSTRUCTION 02040158
OWNER'S NAME: APPLICATION SUB DATE
PREETZ WILLIAM H AND EVELYN V 6276 SHADYGROVE CT 04/30/2002
HONE: SANITARY NO. CONTROL NO.
_ (408) 252-3500
Mai ARCHITEC(ENGINEER: BUILDING PERMIT INFO
w O BLDG ELECT PLUMB MECH
H U.�.�' L= CJ �J LJ
¢a
Si LICENSED CON]RACTOR'S DECLARATION
y 1 hereby affirm that I am licensed under provisions of Chapter 9(rommencing Job Description
1 nt� with Section 7000)of Division 3 of the Business and Potossimn Cndc,and my license BATHRM UPGRADE & SKYLIGHT
in fun fo ,d t.
i z 6 Liccnsc CI. — Lic.
LL LL„ o e contm� FIN A;I rk D l
I ud HITECf"S DEC
laml re,plans snail be used as public records
a"}
i6or. LicensedPefensi°nal JUL 2 2 2002
OWNER-BUILDER DECLARATION
�'L 1 hereby affirm that I am exempt from the Contractor's License Law for the
F G following reason.(Section 7031.5.Business and Professions Cndc:Any city or county yS 2 O O O O
to D which requires a permit m construct,alter,improve,dnnelish,or repair any suucmre
3 prior to its issuance.also requires the applicant Permit to file a signed statement - - _-
-
In
he inliceewd pursuant o the provisions of the Contractors License Law(Chapter 9
(commencing with Section]000)°(UivisionJ of the Business and Professions Coda 'C���'•m 5l- a ,[ t�L)Or- C,ea-.;q a•t r u VaIUffiIO❑
or that he ii exempt theiefrntn and the basis for the alleged eieminion.Any violation - '3 7 L' D O.t�Ur " 'Y •�t
of Section 7031.5 by any applicant fora Permit subjects the applicant to a civil penalty i�I,�,,h,.�
of net moa man five hundred dollars 11500). 101A N -b'UTI bATION tr;. .ret Occupancy Type
[11.as owner,of are Front ter my employees with wages as their sole co r,mr,c ion,
will do the work,and Ne strvcmm is not immradc'd or earned for sale(See.7044,
Basins and Preressiuns Code:The Contractor's License Law does not apply to an 103 - UFER Required Inspections. . "
caner of prepeny who builds or improves thereon,and who docs such work himself
or through his we employeesprovided that such improvements is sold art not intended of 104 - REBAR
offered for sale. w huwe0n,the l have
the Orden of prow n sem within one Wild of - _ _"_ .. . ....... . . . .. . . ..
ompletiannhe owner-builder will have the burden of proving that he did not Wild or lO5 - ANCHOR BOLTS '
Improve for purpose of sale.). 106 — SEWER & WATER
prn.amcacliveycocontracting lo0Litsownerof they ---
202 - UNDERFLOORPLUMBINGm
construct the project(Sec.7044.Business and Pn ressinns Cade:)The Conwcwr's r ..
License law does not apply to or owner of property who builds or improves thereon 203 - UNDERFLOOR MECHANICAL
and who contracts for such projects with a.contctor(s)licensed pursuant to the
ContractorsLicenseLaw. m 204 UNDERFli00R FRAME
R l am exempt under Sec. .B&PC for this mazon 205 — UNDERFLOORS INSULATION
PE 'qa'N 301 — ROUGH PLUMBING
W E MDa ION CL AT10N
302 — TUB & OR SHOWER
I hereby affirm under Penalty of i jury ane of following declaration.: 3 03 — ROUGH MECHANI CAL .
`�• ❑ 1 ha,e and will maintain a Certificate of Censer to self insure for Workers
Compensation, as provided for by Section 37W of the Labor Code, for the 3 04 - ROUGH ELECTRICAL
Performance of work for which this permn is issued' 3 05 - FRAME
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3 06 — HOLDOWNS
37W of the L.1Wr Code,for mho Fulterma^ce or the work for which this permit is
issued.My WorkersCompensation Insurance carrier and Policy number are: 307 - INSULATION _
Cariicr: CERTIFICATION OFEXEMPTION:' '•r -+ •,30,8„I-. aSHEETROCK„ _ Tom. t .
ROM WORKERS\ ` 309 t'EXTERIOR't"LATH�
COMPENSATION INSURANCE
(This section need not be completed if the '------ ---_- -
Permit is for one hundred dollars
151001orlccsJ 311 — SCRATCH COAT
1 terrify that rare offoretance of the work for which this permit sissued,1
• ` - - 313---- ROOF NAIL
snen tr Lev any
Person �ja m rnme n rte theWorkers' 501 — FINAL ELECTRItCAL ENERGY
Compo i on t s f Cf at
�2eC'7
AdPI �y ,� it -- 502 -' FINAL PLUMBING ENERGY
'NOTICi ATTLICANT.Wa0er real the Certificate of Exemption,you should
become subject o the Worker's Compensation provisions of the Labor Code,you must 503 - FINAL MECHANICAL ENERGY
p2 f°Amwimcomply with such frevison.mthis drat hall bedoomed re,ekcd. 504. . —. .FINAL...BUILDING ENERGY . ..
Fti CONSTRUCTION LENDING AGENCY SOS - FINAL ELECTRICAL, .
as > 1 hereby aff mm mat more is a construction lending agency for the performance .
of the work far wmrn,this permitisissued(Sec_300.eiv.C.) 506 - GAS TEST
0 Uame
e baa az 507 — FINAL PLUMBING. . n '
U-0 Icneethat
ocom I ad with
city and
d ordinances
above mawsreionis 508 — FINAL MECHANICAL
O,U cobra I agree to comply he eb nty.necounty ommana a tat law:relating 509 - FINAL GRADE
p.V he andingconsruaion,anahcrebyamhorlmrepseamuves ofmisatymenmr span
r� Incramy for purposes.. 510 — FINAL PLANNING
I,s y 1 We)agree to rave,indemnify arta keep harmless tnc City of c.,..i^gams
v liana idea,consequence
Bests and mil of this
which may in any way ace a against said 514 — FINAL PUB I C WORKS t7V
U z City in consequence of the NDS A of WIs perm. .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- NT` Issued by: (' Date
SOURC ' ULATION. Y'
nature e1 App teantrCe tf cto m Re-roofs /
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding exemption store or handle hazardous mocrialType of Roofas defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and safety 0.
- t
Code.Section 2553200 - - _. ,. .• 1 ” .
_
:1 Yo, m AN° 1' All roofs shall be inspected.pribr'e0any roofng material being installed. .. ..._. _
N'llth npplca t f t Wilding occupant equipment a ices which If a roof is installed without first obtaining an inspection,-I agree to remove
mith - o
rd n th as definedby the Bay Area A Quality Management
�stnrt all new materials for inspection. Applicant understands and will comply with
qY' K all non-point source regulations.. 1 ,
1 have read the W men
dotes mnd rtgmrtments ane r Chapter 695 of me
Califomin Hcslm&Surety Code.Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a renam.that it is my es,ment dity l°notify the
occupant of the requirements which must h met prior to issuance of a Certificate of
°e upracy Signature of Applicant Date
All roof coverings to be Class "B" or better
;r
Osecrorromoned aagent - m ,
OFFICE