00050102 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTORJNFORMATION: . 000S O /0 Z
BUILDING ADDRESS:
n�J _, /If�� SANI'1'AHY NO, APPLICATION SUBMITTAL DAT
OWNER'S NAME: '(V//K(//i^r .J\' 6
N k 1182 v< TMe �14--1 e N❑IC
CONTROL
AORI1ECIMNGINEER V"/'yI
_ BALDING PERMIT INTO
goo 4� — 2 -6�
wG
LICENSED CONTRACTOR'S DECLARATION
>-O u,— I hereby afrw that 1 am licensed under provisions of Chapter 9(comnrercing Job Description
F,mtw with Seen..7001 Division 3 of Ne Business and Professions Code,and my her.a is
y f j in full force and cR IZ A
rc0 iF License CI ss Lie.M 50"eJ �(/(� �� s,�p sirs
m 3 Cost
a Data _f I E TS DEC. \..I`^^^C/'tel. 1�pV(v/fzx..xniJ)t�-
t O g ARCNfTECTS DECLARATION
1 understand my plans shall W used as public records
zm¢i
.Mao
Licensed Professional
.n. OWNER-BUILDER DECLARATION
H z� T bemby all,.that I am exempt from the Contractors License Law for the
5HO following msson(Section 703 t.5.Business and Ro(miom Code:Any city Or county
i3 which rtyuirts a permit m conswm,eller,improve,demolish,or rtpalr any awctuu Sq. FL Floor Area araf)1 Valuation
Wim to its issuance,also requims the applicant for such permit to file a signed'.mmcnt vvV /
that he is licensed pummnuo the provisions or the Contractors icense Law(Chapter 9
(commencing with Section 7000)of Division3 of the B.a..and Professions Cade)or APN Nu bar Occupancy e
Nat he Is reempt Nmefrom and tins basis for the allrgd exemption.A,violation of ( / P y TYP
Section 7031.5 by any applicant for n W.it mbjrem Ne applicant ro e civil losIV of (� dnS
red mart Nen Ave hundred doll.($500).
❑l,m w aofthe oa nY. myempl ymswiNwage u. iradcrompcmasian. Required Inspections
will dothc work,ed she swmurc cions intens mow d for Ne(Sec.7009.u,so,a
and Professions code:The Convacmr'a License law door ser akWi us lf owner or
propay who builds pe improver shemw,and who doer such work himself of through
for
his own esweve the provided Nat such improvements art en intandd en offered for
.lesIf,hosver withe Wilding mimprovementisadd did Outneywof prove fort,the
wncrW ildcr will M1avc she bumd<n of proving Net W did nal Wild or improve for pur-
W.ofuln).
1,as mvner of the property,w e.durivrly connacdng with Bertrand antrvaon m
onswct the project(Sr,7W.Business and Professions CdO:)The Conoanm's Li.
came law does nut apply tw m owner of property who Wilds or improves draeem.and
who contracts for such projects wish a connotations)licensed pumant to Or Contractor'
License law.
1 nn esempt under Sec. .B&PC fm Nis mason
Owner Dna
WORKER'S COMPENSATION DECLARATION
1 hereby of on under penNy of perjury one of the following declandiom:
1have and will marry eCtion37 Cent of are atmCards, um for Worker's Co of re
anon,as provide fm by Section 3700 of the IaWr Cade,fm rhe pamlorratce of the /
work for which this permit is issue.
1 have and will maintain
is Compensation nurw�r)zreeq_uv�d b
y Section
J ofNe LaWCode,for r aofthe work far which this pewit is ssued.
i mseeernm yMyWorC. rSCtpolicy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need wt bccompletd ifthr Front is foesonchurdredddlnn(5100)
or less.)
1 terrify that in the pamfow.rwe ofthe work for which this permit is issued,l shall
Out employ any peow.in any manner so as to become subject m the Workers'C.W.-
.tion Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
beer.subject to the Worker Compensation provisions of the LOW.Code,you man
forthwith comply with such provisions or this perrnm Nall be deemed rooked.
fBCONSTRUCTION LENDING AGENCY
0 I hereby• w that construction iso<muction lacmfomw�ce ding agency for dre pof
Z W the work for which Nw
Qui Peit Is issued(Sec.3097,Civ.C.)
Cedes Name
a } lenders Address
W1 certify than 1 have read Nie application and state dial Nma
e above Information is
Q. Acorrect.I ague to amply with all city nal county oeinaned a asum laws relating m
.7 Z building consrucuon,and hereby authorize representative,of this city to enter Open the
U O aWva-mentioned property for inspection purpose.
W F (We)agree to ave.indemnify and keep harmless the City of Cupertino against
Q V incaitien,judgmemr.coon ed expense which may in any way ecerve against said City
} W iAPPLICAel UNdre IiRVFAngof Nis pewit.
ti � APPLICANI'UNI31?Rti,ANDS ANIS WILLCOMI•LY WI'I'II ALLNON-POINT
U Z SOUR('}iH�1.AT )NS.�
Sigmas rtwf Appli V omm�m Due �
f RDOUS MATERIALS DISCLOSURE
Will Ne a, mat or future Wedding mcupmtsmrenr handle hazardous mnerid Re-roofs
u defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Type of Roof
Core.Section 25532m)7 yP
❑Yes
Will the epPlicmror future building mcupmt use equipment or devices which All roofs shall be inspected prior to any roofing material being
emir hazardous so comaminsnu as defined by the Bay Arca Ah Quality Management installed. If a roof is Installed without first obtaining an inspection
"^e" I agree to remove all new materials for inspection. Applicant
❑Yes r�o
'I have mrd the hazardous mamnd.requiretnenm ends.Chapter 6.95 a the Cdi- un erstands and will comply with all non point source regulations.
fmnis Health&Safety Code,Sections 25505,25533 and 25530.1 undeotard Net if the r
building does. wntiY MveatenanL the,it is my responsibility m worry the occupant
of
Inch mai t poor to iasuanee of a Caif wt pf y 'y
sense N /I ar fSl) Signature of Applicant Date
neer car euNa z agent k4are
All roof coverings to be Class"B"or better
OFFICE
CITY OF CUPERTINO
• 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christya
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lor:31605053.00
DATE ISSUED... ....: 05/16/2000
RECEIPT #......... : 12248
REFERENCE ID # ... : 00050102
SITE ADDRESS .....: 1OB83 N WOLFE RD
SUBDIVISION .. .....
CITY ............. : CUPERTINO
IMPACT AREA .......
OWNER ............: WHAT'S IN
ADDRESS ....... ...:
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-3548
RECEIVED FROM ....: TIM
CONTRACTOR . ......: ALLEN, TERRY L LIC # 21073
COMPANY ...... .. .. : ALLEN ELECTRIC
ADDRESS ..........: 100 RAYS CIR
CITY/STATE/ZIP ...: HOLLISTER, CA 95023 '
TELEPHONE ........: 0306381950
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
SENERGY PERMIT FEE 77.00 23.10 0.00 23.10 0.00
BREMSIGNS NO SIGNS/MARQ 1.00 22.20 0.00 22.20 0.00
EPP ITFEE FLAT RATE 1.00 35.52 0.00 35.52 0.00
P 'ICOM VALUATION 3,000.00 - 0.63 0.00 0.63 0.00
6
TOTAL PERMIT 81.45 0.00 81.45 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------""--- ------------------
OTHER 81.45 VISA
.......
TOTAL RECEIPT 81.45
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........
101 FOUNDATION 103 UFER
104 REBAR 105 ANCHOR BOLTS
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
514 FINAL PUBLIC WORKS
a