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02100165o0, 00 u Z OZ�=O ~tj K V 3 W 0 HW� HOC or 6�$ Oz z0 N a> cW. Q oz U _O 0U Fa Uz CITY OF CUPERTINO BUILDING DIVISION PE - T CONTRACTQRINFOR ION:: BUI Ap RiNr0NITA WY PERMITNO 2100165 ow,gp}I IKT-:RO SANIADDAR APPLICATIP15"P"T12 0 0 2 ONE: SANITARY NO, CONTROL N0. ARCHITEC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MUCH LICENSEDCONIBACnder provisions Ihert000)ofby featlamhceeuinderndProfr¢onsCode,andmmmenseis GA LINE (FROMIONRM&'0OTO KITCHEN) with Secdcemda)ec Division Jof theBninw and Prnfcaiom Code. entl my license is in full forte end effect �''!I, 4 11 8 `+ aw g — 1 License Class Lic.x � .r Dam Conuumr ARCHITECTS DECLARATION NOV/I VV 6 J I understand my plans Shall he used as public record{ �,t ,'� Lqoo� Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 an exempt from the Contractors License law for the V Lg�'�� $3300 following moon. (Section 7031.5. Business and Professions Code: Any city or county which requires, • permit m ennUuct Siler, improve. demolish. or repair any structure prior in its issuance, also requires thp applicant for such permit to file a signed summcnt Nat he is licensed pursuant to the prevision or the Contractor's License law(Chapter 9 " 3�g9&t41Fl A@® Valuation (Commenting wife Section 7") of Division 3 of Use, B Winces and Profession Cade) or that he is exempt therefrom and thclbab for Use alleged exemption. Any violation of PNN OGGD panC y Type Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of r:or more than BK hundred dollars ($5oo). 102 — PIERS ❑ 1, as owner of the property. or my employees with wages u then sole compensation. 1:03 T3FER will do the work. and the structure is not intended or offered for sale (Sec. 70414, Busircss Professions Code: The Convectors License Law does Required Inspections and not apply to an owner of 104 - REBAR property who Wilds or improves Merton, and whodoessuch work himself or through his own employees. provided Boatmen improvements are not intended at offered for sale. If. 105 — ANCHOR BOLTS however. the building or improvement is void within ane year ofcompletion. feepwner- 106 — SEWER & WATER Wilder will have the Wrden of proving feat he did not build or improve for purpose of ale.). 202 — UNDERFLOOR PLUMBING 01. as Owner ofthea pnpenyamexclusively Contracting wish uanedcnnua<romto 203 — UNDERFLOOR MECHANICAL construct the pmjecl (Sec. 70,14, Business and Professions Code:) The Conuacuara Li- nse Law don not apply to an awrmr of property who Wilda or improves thereon. end 2 04 — UNDERFLOOR FRAME uanoneach projects wifeaconmcror(s)Ecenmd pursuant rothe Conuutor'a 205 — UNDERFLOOR INSULATION LLaawtmr ❑ I am exempt under Sec. .B&PC for this mason 301 — ROUGH PLUMBING ne Data to 1,4 u2 302 — TUB & OR SHOWER I'S COMPENSATION D RATION 303 — ROUGH MECHANICAL I hereby affirm Penalty Penalty of perjury one of the following declarationeu 304 — ROUGH ELECTRICAL I bare and will maintain a certificate of consent to self -insure for Worker's Com,en- 3O5 — FRAME tion, u provided for by Section 3700 of the labor Code, for Use performance of fee work for which this Permit is issued. 306 — HOLDOWNS 0 1 have and will maintain Workers Compensation Inuraim. as required by Section 307 — INSULATION 37M of Ne Labor Code, for the performance of she weak for which Nis permit is issued. My Workers Compensation Inumnte carrier and Policy number are: 308 — SHEETROCK Carrier: Pal icy No.: 309 - EXTERIOR LATH CERTIFICATE OF EXEMPFION FROM WORKERS' COMPENSATION INSURANCE 310 - INTERIOR LATH (Tau.,.. need not heenmpleted ifdse .it is faro. hundred do11an(S1011) 311 — SCRATCH COAT or].) 313 — ROOF NAIL I mnify that in the perronsarec of the work for which this Permit is issued, I shall not 501 - FINAL ELECTRICAL ENERGY employ any pc rrrsoa to become subject m the WnkerSCompmeartion L.wsmc.ifn a ma 502 - 503 — FINAL PLUMBING ENERGY FINAL MECHANICAL ENERGY ��'yyplica��I IWiLj TO APPLICANT: If. fear making this Ccn(ficate of Eacmption, you should W mCmbjentothu Worked ompcnation previsions of the Labor Code, you must 504 - FINAL BUILDING ENERGY forthwith ..,I, wife such provision or this permit shall W decreed ranked. 505 — FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY 506 — GAS TEST Iherthy a10rm that there isacoWtssmtion lending agency lnr the perfurmante of the work for which this permit isissued (Sm.3W7.Civ. C.) Leader's Name 507 — 508 — FINAL PLUMBING FINAL MECHANICAL Lende'aAdd. I Ceniry that 1 have read this application and stem Nat the above information is 509 — FINAL GRADE correct l Agra to Comply with all city and county ordinances and sure laws ralating to 5 — FINAL PLANNING construction, building consction, and hereby audamix, representatives or Nis city enter upon the above mentioned property for Inspection purposes. 5 4 — FIN LIC WORKS We) agree to an. indemnify and kap hrtmless the City of Cupertino against liabilities,judgments, costs and expenses which may in any way accme against said City in coaegance of dm granting of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date t C/ SOU CER ATIONS. Re -roofs Type of Roof '1111231,2- rgnawrc of Applintractor 1 ZARDOUS MATERIALS DISCLOSURE Dem Will the applicant or future Wilding acupant store or handle harudous material as defined by Be Cupertino Municipal Coda, Chapter 9.12, and the Health and Safety Code, Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed. 0 Yes NNo Ifaroof is installed wi[houbfirst ob[ainingan inspection,Iagree to remove Will the applicant or future building Occupant use equipment or devices which nit InZilous air contaminants a defined by Use Bay Area Air Quality Management all new materials for inspection. "strict, ❑Yes IKINu usemriuls requirements under Chapter 6.95of the Califm- 1 have mad the l svardom me Health& Safety Cale. Satiun25503,25533 and 25534.1 undcmwM than(the building does not currently hast A mnant Brain u my res u ibility to ratify the occupant of the mqulremnts ebmnvWmetpriormkssum fa Certlrmamoroaupenty. Signature of Applicant Date 23 All roof coverings to be Class "B" or better CN r praatnnriac egcnt pro • • 36" OCT 2 3 2002 42 _ i7" BY 'p1 S�i0.5% N C4 stove C4 32 4-23 i2 —`' ^ 71i2" iH� fa it 7A"3CE yJITH THE CfiY 05 ; �v f ES AND ZORf .(AANCES fllll�frft' lal� ?SI...-- bW lidlAi M t''oe V s at all times and it is un nW4d1, lto =E;j ary changes or alteration:. In,:fiff y.jft,,t ;mitten permission from hufes- City of Cupertino. fno atiMtryRm�6lihrs plan and specifications ,ii W PZA to pe!mit or fo be ar Vii at e ar;faiion of any prr01' .; F, e , —,,P nr Sh..,. ". Ds. Mt CITY OF CUPERTINO _115, CITY OF CUPERTINO �GS� PERMIT APPLICATION FORM Quantity Fee ID APN Date: I o 2 3 0 2 BAPPLOTHER Building ress: I D 3 41 To N t'f A W. AY MECHANICAL Owner's Name: S vMj -r o q m D D AR- Phone #: [l. p g_ 2,5 3 9 0, 2 BUILDING Contractor: T. License #: BUILDING Contact: J �e E o 4 YA L1 e- Phone #: BUILDING Applicant/Contractor: Fax #: BUILDING uildin Permit Info: Bldg Plumb Mech Constax — Resi/Mobile Jobb ription: ar w a 0.s t'rt 9ar-k,�e esidential: 'lo Commercial: BELEC1000 Sq.Ft. Floor Area: $/Sq.Ft.: BELEC1001 Architect/Engineer: Valuation: A Amh Type of Construction: Occupancy Grou . Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTA)MQ 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 BMNEWMULTI New Multi -Family Res MECHANICAL BNEWMULTI New Multi -family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING r L. 1 of 3