02120082CUPERTINO
CITY OF CUPERTINO
PERMIT APPLICATION FORM
I of 3
Fee Description
Oth-e—r A
MECHANICAL
Construction Tax 1 1111111
1
Ind/Off/Comm/Quasi
Con. Tax for BQ Zone
Hotel and Motel
BUILDING
FORMER*
Constax — Resi/Mobile
BELEC1000
Elec 600V <-- I OOOA
ELE TRICAL
# 001,
Elec 600V > 1000A
ELECTRICA L
BELEC2 00
Elec Svcs 600V <= 200A
ELECTRICAL
Energy Add Multi
Investigation fee
RIMS "N,
Comm - Housing it. Fee
BMITIGATR
Res. Housing Fee
G
__Mit
New Multi-Fan�i_
MECHANICAL
New Multi-family Res
ELECTRICAL
New Comm Electric
ELECTRICAL
New Comm Mechanical
malml UUMILVII
New Comm Plumb
I of 3
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
COYRACTOR
INFORMATION:
�c r�
BUILDING ADDRESS:
ROWE CONSTRUCTION
CO\ INC
PERMrr NO.
19985 PRICE AV
02120082
oR'SNAME:
960 SMITH
RD
APPLICATION SUB DATE
EORGE AND MARY MONK
G
12/19/2002
p" ONE:
(831)722-1204
SANITARY NO. CONTROL
NO,
ARCIIITE TA NGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB
M EC, II
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
p
I hereby affirm That 1 am I cenard unde Provisions of Chapter (a, ano,re ng
wish
7deffecoi�ixion Bnrthe Basin .an'Pmrex =inns cnJe[a— neumyreense is
PORCH REPAIR
FINAL =D
11
fWl lyy,rn�c and effect (t-�o ZJ l
-r
its
U Z Contractor
ARCIIDIiCr Obi
FEB 2 6 2003
1uoJCr(tandyy� 'h I�� p C I
rG�r, ///
Licensed`
OWNER - BUILDER DECLARATION
WILDING
1 M1crchy .Itirm Ihat 1 am escmpt from the Contractor License Law for the
following reason. (Section 70)1.5. Business and Professions Code: Any city nr county
which requires a Ismaili to construct. alter, improse. demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit m file a signed statement
Sq.
Ft. Floor Area
$16100ation
mat he is licensed Pmarmill,, heproskionsofine Contractors License Law (Chapter 9
(commencing with section 70O(B of Division 3 of the Busincca and Proressinns Code) in
that he is escmpt theafrum and the basis for the alleged exemption. Any archaic. of
Occupancy Type
Section 7011.5 by any applicant for a permit subjects the applicant m a civil penalty of
not more man five hundred dollars ($510).
0 1, as owner of the property, or my employees with wages as their sok comrcnsatio^,
;equred
Inspections
will do tbe work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Profesaions Code: The contractors License law does not apply to an owner of
102
- PIERS
property who builds or surpluses daemon. and who aces such work himself or through his
. employees, provided that such impmwmentsam notinwnded orolfmcd fersale.if.
10.3
- UFER
however. the building or improvement is sold within one year ofcempletion, the owner.
104
- REBAR
bonder will have the burden of proving that be did not Wild or improve for purpose of
sale.)
105
- ANCHOR BOLTS
0 I, es owner M the propti am exclusively contracting with licensed contractors to
106
- SEWER & WATER
construct me project (Sec. 70,V4. Business and Professions Code:) The Conuacmri Li
come, law does not apply to an owner of property who builds or improves demon. and
202
- UNDERFLOOR PLUMBING
who contracts for such projects with a contracmr(s) licensed pursuant in the Contractor's
203
— UNDERFLOOR MECHANICAL
License Law.
❑lam exempt under Sec. ,B &P C for this rearm
204
- UNDERFLOOR FRAME
Date
205
- UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
301
- ROUGH PLUMBING
I hereby affirm under penally of perjury one of the following declarations:
302
- TUB & OR SHOWER
1 have and will maintain a Certificate of Consent) self-insure for Worker's Compere
3 03
- ROUGH MECHANICAL
ration. as provided for by Section 3700 of fire laber Code, for the performance of the
work for which this permit is issued.
304
- ROUGH ELECTRICAL
0 I have and will maintain Worker's Compensation Insurance, as required by Scction
3 0 5
- FRAME
3700 of she IaMr Code, for the perfcrmancc of the work for which this permit is issued,
My Worker's Compensation lnaurance ginfic, and iey.amher me:
306
— HOLDOWNS
C,,aip e. +c u te a:tJoS— Gbeh0 -7
�� - 307
- INSULATION
ATEOF %M NFROMWORKERS'
308
- SHEETROCK
xfWfWJ
'AI- COMPENSATION INSURANCE
rrobsc,honnced notbenm,plemd iffle permit minion. bundreddollacv(1I01)
309
- EXTERIOR LATH
orless.)
310
- INTERIOR LATH
I certify that in the Performance of the work for which this permit is issued.( shall nth
311
- SCRATCH COAT
employ any person in any manner so as to become subject n the Workers Compensation
Laws of Calif at.. Date
313
501
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
Applicant
NOTICE TO APPLICAN'I:If, after making this Cenilieate, of Exemption. you should
become subject to the Workers Compensation porvi,cmaof me Labor Code, you most
502
— FINAL PLUMBING ENERGY
forthwith Comply wall such provisions or this pcturn shall W deemed mvnked.
503
- FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
I bomb) alarm thm there is construction lending agency for the performance of
504
- FINAL BUILDING ENERGY
the work for which Box Permit is issued (Sec.v197.Cie.C.)
Lender's Name
505
506
- FINAL ELECTRICAL
- GAS TEST
Lender's Address
1 comfy that I have mad this application and sure that the above information is
507
- FINAL PLUMBING
correct.( agree,, comply wish all city and coumy ordinances and suite laws relining m
5
FINAL MECHANICAL
Wilding cm¢wction, and hereby WdWn c representatives of this city to enter upon the
abovomentioned property for inspection purposes.
09
- FIN E
(We) agree m save, indemnify and keep hmnders the City or Cupertino against
liabilities, judgments, costs and c Tones which may in any way tame against said City
5
N G
w�a
in consequence of the granting of this pemail.
APPLICA - UNDERSTANDS AN rWILLCOMPI,Y_WITII.ALLNON -POINT
Issuedby5l
WORKS Date
v
SOU RLG L TfONS.
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Re -roofs
Type Of ROOF
Sig t of APPlica II onurydy - a
Hconor �OIIS MATERIALS DISCLOSURE ✓
Will the applicant or future building oecu,m nt suite or handle hasandom masrial
as defined by the Cupertino Municipal Cale. Cluper 9.12, and the Hcalth and Satiny
din section 25582(.)?
All roofs shall
be inspected prior to any roofing material being installed.
❑YCS No
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant in future building occupant use equipment or devices which
emit .v sir contaminants s define) by the Bay Area Air Quality Mawgemcnt
all new materials
for inspection.
District?
Dinrict? JJ
❑Yes (�Na
I have read the hamolous materials mitiaemcats under Ch:rper 6.95 of the Cabdor
nia Ilealth Yin Salcty Code. Sections 25515.25513 and 25554.1 undcound ban ifthe building
des not currently haw a M ^ant that it is my responsibility to mNl y. aa'u ant or the
rngmr vlhiylainxt 'me .can sccnmeate roe a,". pa.c
Signature of Applicant
Date
� I i ��
All roof coverings to be Class "B" or better
Ow f or awhorired agent a e
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CITY OF CUPERTINO
BUILDING DIVISION PEkivf1T
�`I QR
BUILDING ADDRESS:
ROWE CONSTRUCTION CO INC
PERMIT NO.
19985 PRICE AV
02120082
OWNERS NAME:
980 SMITH
RD
APPLICATION SUB DATE
GEORGE AND MARY MONK
12/19/2002
PHONE:
(831)722-1204
SANITARY NO, CONii0l_ -NO
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
licensed
I hereby affirm that I a licensed und' revisions of Chapter 9 (commencing
in son "a'
Section 7000) Division 3
Job Description
with of _ I
of the Busim Professions Code, and my license is
I n o
flit and effec Li L I
Lt. Class #
5� 1 .0 :?_ Contractor
�E�ARCHLTE
PORCH REPAIR
Licensed Professionl'
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area $ 1 902ation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
6 XPW
XffiAtbeil 0
Occupancy Type
not more than five hundred dollars ($500),
0 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
±e+
102
"-equired Inspections
- PIERS
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
103
- UFER
however, the building or improvement is sold within one year of completion, the owner-
104
RE BAR
builder will have the burden of proving that he did not build or improve for purpose of
-
sale.).
105
- ANCHOR BOLTS
E] 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
202
- UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
203
- UNDERFLOOR MECHANICAL
01 am exempt under Sec. II & PC for this reason
204
- UNDERFLOOR FRAME
Owner Date
205
- UNDERFLOOR INSULATION
WORKERS COMPENSATION DECLARATION
301
- ROUGH PLUMBING
I hereby affirm under penalty of perjury one of the following declarations:
302
- TUB & OR SHOWER
C] I have and will maintain a Certificate of Consent to self-insure for Worker's Compen'
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303
- ROUGH MECHANICAL
work for which this permit is issued.
304
- ROUGH ELECTRICAL
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
305
- FRAME
3700 of the Labor Code, for the performance of the work for which this Permit is issued.
mer and
My Worker's Compensation Insurance ja . Vicy number am:
306
- HOEDOWNS
,
Wi Ay-- 7
6 V_ P —5-5-5 — 00 Cl!!
307
- INSULATION
T'"IOF FX%MUA0N FROM WORKERS'
C401PENSATION INSURANCE
308
- SHEETROCK
(This section need not be completed if the Permit is for one hundred dollars (V 00)
309
- EXTERIOR LATH
or less.)
310
- INTERIOR LATH
I certify that in the performance of the work for which this permit is issued, I shall not
311
- SCRATCH COAT
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
t
Applicant
313
501
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
502
- FINAL PLUMBING ENERGY
503
- FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
504
- FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
505
506
- FINAL ELECTRICAL
- GAS TEST
Lenders Address
I certify that I have read this application and state that the above information is
507
- FINAL PLUMBING
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
5
FINAL MECIPLANICAL
above-mentioned property for inspection purposes.
09
FIN
FIN DE
E
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
5
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in consequence of the granting of this permit. WITH ALL NON-POINT
AOP P
Issued by? 1
WORKS Date tdJ
S U
Re-roofs
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Section
Code, 25532(a)?
0 Yes W1.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials
for inspection.
District?
C] Yes JAIINo
I have 'cad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health& Safety Code, Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility 10 notify 11"cu In, 01 the
hi�k =�e_ ace"" icita, of U
'n �irz-�
�. pieic�;
Signature of Applicant
Date
.1 t
All roof coverings to be Class "B" or better
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