03030149 (2) CITY OF CUPERTINO PERMIT �� � • ` �� U t` N�+ �tn'RT �
BUILDING DIVISION x �, �,)�R, y Y., ,�� Jn„
BUILDING ADDRESS: PERMITNO.
DYMOND CONSTRUCTION GROUP
OWNER PERMIC 65U
1705 RUSSELL AVENUE '
p SANITARY NW 3 12 b L NO.
(408) 492-1007
ARCHITECnEN01NBER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
3 o p LICENSED CONTRACTOR'S DECLARATION
�u l hereby affirm that I em licensed under pmvit ons of Chapter 9(Commencing lob Description
with Samson?"afDivislon3ofthe BuOnm en mfessiona Codo.mdmyi'...h
in full force
s.Cl y3 Lk.a DEMO--INTERIOR DEMO (B41)
a Dao Canln r
-Am Illy
ARCHI]ECrS DECENRATIDN
Ser i rsmad my plant shall h used u public records
DyO
'.ser. Licensed Professional
150 OWNER-BUILDER DECLARATION
I hereby rof..that 1 am exempt from the Cmuraclor't License Law for the
Oo following reason.(Section IID 1.5,Business and Pretensions Cade:Any city or county
3 which requires a permit to enmtmet.aloe Mpmve,demolish,or¢pair any structure
fes^ prior to I"Issuance.aim requires the applicant for such permit to rile a signed canonical
that he is licensed pursuant in the previsions of the Commetori License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7")ofDivision 3ofthe Business and Professions Code)tar 102000
that leis eaampt therefrom,and the basis for the alleged csemp k n.Any violadon of
Sermon 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of �pF OccU anC
net¢ort than five hundred dollars(5500). '
31�gr. 0 0 P Y Type
❑L o ewer of the pmpeny,err Is oth oyvet with wages nt their cele 0M.B.t tion,
wall dothework and On no
IstualLndodorawdo forme(Sec.un W,Business
and Pro(eWoW Cade:The Cont emor.Lice¢Taw docs not apply lf an owner is NO ASS I GNEDR�IQ60$LTsP4RAI9B
own eny who Mitis mimprat such
h Improved who ar essuchw tied oraelf or Waugh his
ownemployers.provided that suchimprosemwt in not Intendedmpleded restate.1C
hoverer,Ne building or Improvement h sold within one Wert of completion,One ower-
bullder will have the burden of proving that he did not hili or Improve for purpose of
talc.). V�
1,as ower of the property,tin Business
contacting with:)Tho,Ccanuecmrs U.construct des not (Sec.7(Nd,Business end rly who
Code:)The Contractor's d
w osc Taw duct not apply to an owner of properly lice builds or improve Neuron.and,
who contracts for such pmjena with a eonvador(glicemed pursuant to Ne ConmeoM1
License Lew. O
❑Tem exempt under Sec. ,B&PC far thh mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1ereby a1Bmm under penalty of perjury arm of Now
e following declarations:
O
hend will maintain a Certificate of Concent he sel6insum for Workers Camper-
0 pmvidcd for by Section 3700 of the Labor Code,for the performance or the j
work for which this permit is issued.
❑I neve and will maintain Wicker's Compema n Insurance,ss required by Section
3700 of Ne labor Code,for Ne performan a weds for which this permit h issued.
MyWa�rkce.Campeeatle, Inwnnce nm .men
number are:
L•ardF};'glil'TC 16,y D Policy No.: Zln .L
WWW CERTIFICATE OF EXEMPTION FROM WORK S'
COMPENSATION INSURANCE
(This section meed not becompleod lHh remit isforone hundreddallam(SI(D)
tar kss.)
—._. I comity,that in Ne-performance of Ne work far which this permit is lauel,1 shall not _..___ ............... ..
employ any permn in any manner¢u m become tubjerl m Ne Wodsers'Compemadon
Laws of Calif mrIa.Dao
Applicant
NOTICE TO APPLICANT:IL aper making this Co mfiate of Emmption,you should
become subject to the Worker's Compensation previsions of the Uttar Code,you must
.J Qforthwith comply with such provision,or this permit shall be deemed reroked.
CONSTRUCTION LENDING AGENCY
-m stn. I hereby alErm Zoom its cam nosh n boding.;..y for Ne performance of
x> the work for which this permit hissed(Sec.3097,Civ.C.)
QIcrdcra Name
2 fonder.Address
J Q 1 certify Nu 1 have and this city
and County
and sum that tins above laws
relating to - V
W U rnrmn.l agree m comply with all city and coumy ardinencOf and suite hws relating to
D U building Pro Properly
hereby suNorismpreunatlsu of this city manor area Ne
4 shove-(We)agree
to use fo im nify an keep hs
(Vie)agmen to use,indemnify sod loch ha In
the Clay of Cupertino sold
ctagainst
rh ItabilInc onacquenecoftheeuatsend eapensesmiteh may In any way acerae egeWtWdCily
JT in comegmnce of Ne granting of Nis permit.
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date YeKA
SOUR REQULANS.
iI /9 rfv�`— Z�L"3 Re-roofs
Signau of ApplinnVConvecar I Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defied by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code. 0 es 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑ties No
W
ill the applicant or foto building occupant on equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
fdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Yes QNu
ave mad the hasrdtmr materiels requirements underChapter 6.95 of the Celifnn&Safety Cade.Sectiam 25505,25533 and 73534.1 undersand the lfNe building
umently ham•sweet,Nat it hmy responsibility m 'fy the ocr pmtM Ne
mya which musthmet pd ah aria Cenifinemo cu r _ Signature of Applicant - Date
— b C'3 All roof coverin s to be Class "B" or better
tmhmized agent Dom g
INVOICE INVOICE INVOICE INVOICONVOICE INVOICE INVOICE INVOI* INVOICE
CITY OF CUPERTINO
PERMIT INVOICE OPERATOR: suem
•
Sec: Twp: Rng: Sub: Blk: Lot:
APN 31607046.00
INVOICE DATE. . . . . . : 03/28/2003
REFERENCE ID # . . . : 03030149
SITE ADDRESS . . . . . 19490 PRUNERIDGE AVE B41
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . :
IMPACT AREA . . . . . . .
OWNER HEWLETT PACKARD
ADDRESS . . . . . . . . . . : 19111 PRUNERIDGE AVE B41
CITY/STATE/ZIP . . . . ,
CONTRACTOR . . . . . . . : RANDY DELAPP LIC # 22757
COMPANY . . . . . . . . . . : DYMOND CONSTRUCTION GROUP
ADDRESS . . . . . . . . . . : 1705 RUSSELL AVENUE
CITY/STATE/ZIP . . . : SANTA CLARA, CA 95054
TELEPHONE . . . . . . . . : (408)492-1007
FEE DESCRIPTION ACCT NUM CHK TOTAL FEE PD TO DATE BAL DUE
________________________ ____________ ___ __________ __________ ----------
SIM PERMIT FEES 4116 P 796.00 796.00 0.00
PlW CHECK FEE 4111 A 676.60 676.60 0.00
SEISMIC FEE RES 2013 P 10.20 10.20 0.00
BUSINESS LICENSE 4063 A 100.00 100.00 0.00
------------ ------------ ------------
1582 .80 1582.80 0.00
•
WITY OF CUPERTINO* �� 3 l
. DEMO
CITYO
CUPEkTINO PERMIT APPLICATION FORM
• APN# �'7 / Date:
Building Address:
Owner's Name: Phone#:
Contractor: License#:
1� �Yoi�c/ Coi�sT T�D� S`� 7 9/ 7
Contact: Phone#:
IGrf�3cL Go tdr� yob - 7
Applicant/Contractor:
Buildi Permit Info:
Bld Elect Plumb ech
Job scription-
i
sidential:
Sq.Ft. Floor Area:. $/Sq.Ft.:
� 5J DOc7 � �
Architect/Engineer: Valuat' n:
Type of Construction: Occupa
'tee .
Qty. if N
Ap s e Fee IDcri tion Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
• 5
r
CITY OF CUPERTINO
BUILDING DIVISION PERMIT ?t ()�+ Rt� Q IN4MATIQ1
BUILDING ADDRESS: PERMITNO.
DYMOND CONSTRUCTION GROUP
O1PI1RtaVC) PERMIT ISSU
1705 RUSSELL AVENUE
SANITARY N L NO.
(408) 492-1007
ARCHITECIDENGINEER: BUILDING PERMIT INFO
BLDG ELECT- PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION O O O O
1 hereby affirm that 1 am licensed under provisions Or Chapter 9(commencing Job Description
wiNSeetion]OIMI ofDivixien3mtho Busine an frofcssion.Code,and my licanas is
e in full forte
z LieenmC1 uc,a DEMO--INTERIOR DEMO' (B41') , P114A O
9 Dale Con DEC _ f
ARCHITECTS OEC RAT N
1 dratsnd my plans shall M1c used u public records
kLL
Licensed Professional - OV 1 O 1 L lid
OWNER-BUILDER DECLARATION V
E 1 hereby affirm that I am exempt from the Contractor's License Law for the 02 following rcaxon.(Section 7031.5,Business and Pre ensiam Code:Any city or county
a which roqulroa a permit m m
construct,after,improve,demolish,or repair any structure BU'LD'NG.
—�y prior In its issuance.iden requires the applicant for such permit On IIIc a signed ttsmmenl
�< that he is licensed pursuant to the provision Of Ne Comrumr's License Law(Chmter9 Sq.Ft.Floor AreaValuation
000
(commencing with Section 7 )of Division 3 of the Busin urvand Professions Cede)or $102000 102000
�.. that he Is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of
not more than five hundred delta.($500). �iP ` 9` 0 O not Type
❑I,as owner ofthe property,or my employees with"gas n their tole compensation, '
will d.the work,and the muctum is not Intended moRered renal.(See.7044,11utiness
and Profession Code:The Contractors Limme Law does not apply to an owner of NO ASS I GNEDR§.4g64d$TPg4140@
property who bur ids m improves Nercon,and who does such work himself.(through his
own employee,provided that such improvements are not Intended fm ale.It.
however.the building.,impmvemenl is sold within one year of e.mpletion,the owner-
builder will have the burden of proving that he did not build or Improv for purpose of
ass.).
❑I,as owner of the property,am exclusively contracting with Timm ed contractors to
concoct the project(See.7044.Business and Professions Code:)The Contractor's U. .
muse law don not apply to an Owner of property who builds or improves Neuron.and
who contracts fire smh projects with a contractor(s)licensed pursuant to the Contrsclers
License Law. ,
❑IatnesemptunderSec. _ ,B&PCforthlamss.n
Owner Data
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Comem to self-insureforWorker'sCompen-
mlion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is Issued.
❑1 have and will maintain Worker's C.on ex n Inaunnce,as required by section
3]tgl of Ne Lebec Code,for Ne performan .work for which this permit Is issued.
y Worker's Compensation lnau.ntt cam rad Policy number m:
gJyJ'Te i1towD Policy No.: L&W
Z/o J
VV CERTIFICATE OF EXEMPTION FROM WORKS ,
COMPENSATION INSURANCE
(This motion need not hecompleled if fl a permit lsforow hundred dollars($100)
.r loss.) _ -
--_ 1 mnify.that in the pmformame of the work for which this permit Is!goal.l shall not
employ any person in any mentor an as to become subject to the Workers'Compensallon ,
laws of Celifomia.Date
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of the labor Code,you must
D O forthwith comply with such provisions or this permit shall be deemed mocked.
CONSTRUCTION LENDING AGENCY -
>r r Ihereby affirm that there is a c.nalmctinn lending agency far the perrarmmde of
x the work for which this permit is issued(Sec.3097.Civ,C.)
YQ, Lend.ex Name
ow,Z Lender's Address
L)Q I certify Net 1 have mad this city
and county
and rete that dm above Information is
ly U bonding l ogar to comply with all city and coumy ominmces and mane lawn miming e .
�f, .1bovingeonswdiamand herohyautbonrtivds of Nisdly,mentor upon the
G shove-mentionedproperty forInspectionanlamppurposes.
(We)agree to cost,indemnify and keep harmless tim y a of against
ts against
In incoide,judgmcnhelaming expenses which may in any v.yeecNC agdntcoid City
;) 2 A PLIC NT of DERSTA lamming of this permit. qc�,�</;
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR �REGULAT�oNS.
- , Re-roofs
Signuur of Appl¢anVConuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building Occupant score or handle hassol material
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
.n
Codc.Sacti35533(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes []Nu
Will the epplibam or rat\art building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hemrdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes SNa
I have ad the haordnus materials requirements under Chapter 6.95 of the cafirm.
nia Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the building
don not currently haw a tenant Nat It is my maNuibilily to Ty time ace pont of the
regm.nmtu whihmnlbemdlpd In errs ceniBcama m y Signature of Applicant Date
'b o3
I.Mannirser eulhorirsd ager Date All roof coverings to be Class"B"or better