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03020120 (4) CITY OF CUPERTINO BUILDING DIVISION AT�aI.@OLjrs,v" ,- :,+ r• :`. INC]ADDRESS: DLEY COMPANY PERMITNO. IID 21760 STEVENS CREEK BLVD 03020120 WNER'S NAME: 19 S 3RD ST PERMIT ISSUE DATE MC SHANE THOMAS J AND BIRUT S 02/27/2003 PHONE: (4U8) 3 /4-0900 SANITARY NO. CONTROL NO, ARCHITECTIENOINEER: BUILDING PERMIT INFO ] BO EO PLUOMB MECH y�Q LICENSED CONTRACTOR'S DECLARATION Job Description O I le, train.that I am It round under p alone of Chapmr 9 commenein{ p wish Section 7,n) fD 3 ofthe Husinu���r�irafculnns Cotle.a commeesuts � infullfomeen e a 7° TI--REPLACE POST ^2a Licen Cl , Lt.11 v� Dem 7r / Rshall t(TS D I m �my au shall bo used u M1lk `/ Sat 5� Licemed Pn,fcstlonsl O OWNER-BUILDER DECLARATION _ 13 Hs I Mean allhm Nat 11. ucmpt from the Canoes Co e:Any c Law for the m o which re Meant.permit t Eons3,Brut•...and Rnfoumm Code:Any city or county $ which requires a permit re enmwcL alter.improve,demuNh,or mash any aternom F- S' Pdormiu luued Pursuntto thuhoisimmmfor such Contrator'so NeuLnedsumment gg C (comma ccemedPumuanamthcprovlainnenflrtheStriness ndProelao(Chapmr9 Sq.Ft.Floor Area ion $ (commencing exe exempt Seafours and of basis n3 orthe exeandon.Anynns Cnde)of .. Nat be r 31.3 b mmefrom sod the aper for the cls the exemption.to Any lviolad lemurs of Section a it=five any red della for a permit subjects the applicant to a civil penalty of not mom that raw hundmtl dollars(5500). r Occupancy Type ❑I.u ownm ofthe property,army employees with wages As their sole compensation, willdo the work,sod theswetum isnotintended oroBemd ferule(Sec.7044,Business and Pro(eulom Cade:The Conuselors blame Lew docs not apply to an owner of 102 - P I ERS Required Inspections property who Wilds or lm proves themon,end who dace suc h work h impel f or qu ough his mvn employees,provided thatsuch lmprovemenu am not Intended orortered forum.if. 103 — UFER however.the building or improvement is sold within oneyear ofcompledon.the owner. lO4 — REBAR builder will have the burden of proving that les did rent build m improve for purpose of sale')' 105 - ANCHOR BOLTS ❑I,u owner of the property,am exclusively mntuotin{with limnud cm=w to 10 6 - SEWER & WATER ..,net the pmj.a(See.7044,Business and Professions Code:)The Contractor's L6 come Law does not apply As an owner of Property who builds or Improves woman.and 202 — UNDERFLOOR PLUMBING who contracts for much project,with a convecmmi)licensed pursuant to that Contractors Law. 203 - UNDERFLOOR MECHANICAL re u exempt under See. ,B&P C for this rcuon 204 - UNDERFLOOR FRAME Owner Dam 205 - UNDERFLOOR INSULATION WORKERS COMPENSATION DECLARATION 301 - ROUGH PLUMBING I hereby ARM under penalty ofpeduq one ofthe following declarflons: 302 TUB & OR SHOWER ❑Iluve sod will for by eCcNOam of the Labor ulfdnsorthe performance of due 303 — ROUGH MECHANICAL eation,u provider for by Section 7'100 of the laboi Code,for the porformanCe of the work for which this permit lsiauetl. 304 - ROUGH ELECTRICAL ❑1 haw and will maintain Workers Compensation insurance,As required by Section 3 O S - FRAME 3700 of the labor Comm,for the PeRolmanee of the work for which this Permit is issued. 305 — HOEDOWNS My hers p ation I pqn f airier end Policy n bar am: pI r 307 - INSULATION sr, EEMM��PP11p��oflHT��NJyy No.: O_ CERTIFICC MPENSAT1el INSURANCE s 308 - SHEETROCK (Thls=tionnudnotkcomplcudiftheP itlsforonchundmddollan($IMI 309 - EXTERIOR LATH or lea) 310 - INTERIOR LATH I Certify that in the performance of the work for which this Permit is Wood.I shall not311 - SCRATCH COAT m employ any Person In soy mamr an As Inbttmmc subjec 1.the wort2re Compensation Laws of California.Dam 313 - ROOF NAIL Applicant NOTICE TO APPLICANT'.Ir,after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY Q Dbecome subject An the Worker's Compensation provisions of the LAW,Code,you mum 502 - FINAL PLUMBING ENERGY foMwiah comply with such provriom or this permiuhall be dcemcd mvmkcd. CONSTRUCnONLENDIN0A0ENCY 503 — FINAL MECHANICAL ENERGY j 2 w'7 F kforwhefnrmthatthcrctsacomtroc.3097,Civ.agencyfnrthcperformance of 504 - FINAL BUILDING ENERGY 2S i~ the wurkorwhchthrpemhrwud(sce.7o97,ciw.c.) Iandeh Name 505 - FINAL ELECTRICAL W Q az ^I-Acce,Add. 506 - GAS TEST O Q I certify that I haw read this application and sum that the above information is 507 - FINAL PLUMBING Iy F comm 1 agree to comply with all city and county ordinances and sum laws totaling m FINAL MECHANICAL Q V building convection,and hemby oullmee mpresenmives of this city to on mr upon me — W above-mentioned property for Impomion purposes. O F I GRADE eNT. me E.Indemnify and keep harmless the City of Cupertino egaipet NG `hmen ,c uwdexpenseswhichway1.anywayseeroeagauatuidClay O I 5U ICA CA s parblk� UN a STANDS AIN ILL COMPLY WI ALL N-P 5 WORKSuL Issued by: DateRe-roofs PIicwUContramo am HAZARDOUS MATERIALS DISCLOsU Type of Roof applicant or Futuro building mcuphe Cupertino M nicipal Codc,Chapmr 9.12,and the Health and Safely 5532(a)7,o All roofs shall be inspected prior to any roofing material being installed. ❑Yes No Will the applicant r foto building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit haurdoua air conte raw u de0ncd by the Bay Arca Air Quality Management all new materials for inspection. District ❑Ya Nu (have mad me r nusmatcrhls mqulromentsundcr hapmr6.95ofthe Califor. niaHulth&SafciyC ctRmsn505,25533ad25634.1un rand atifm, iming J currently he mnwa that ithm ms ibilirymno t up tnf me req w tam be t loll enfaccrolka All Signature of Applicant Date nein nth fsadagem DALVJ All roof coverings to be Class"B"or better SUBMITTA�' � 1 rip .�sk �(�# 00F �� APPROVED IN ACCORDANCE WITH THE CITY OR CUPERTINO CODES AND ( DIN0 - F B 2 7 20 31GNED This set n' Fans and r ecifications MUST a', all times and it is un B- to MM aup ...... same :°.th^or ""Atin permission' from d a; I'opt., C:y of Cupertino. t samp'.nR of this plan and speciflcet:.fn3 ,e lie d to pa mit or to 'jee a a vio!atian of ir! pfc' . C c.pmnr Statr (4,p v t \ l ©i--FCSS - - -_ Sezen Stru turas ]Engineering s toN�\" ' - scope-off work s limited only to the oQR S tRUCI strodural items sp ifica!ly covered in the ��`` Fti �2��` �✓ straeetWW ealcula ' nL AR other stnKtoral � 0.3116 and n06FstU6eCtu work is outside 0611' E%P•3.31.2004 scopeoff, rorlt and not been addamssed. P. \� ' .._. Sezen Structural ngineering 274 E.Hami ton Ave., Suite C _ J Campbell, C 95008-0240 - --- - _ _ a-._.._.. r A Y OF CUPERTINO CU�EY OF PERMIT APPLICATION FORM APN# �j Date: 2E, Building Address: Owner's Name: Phone#: C� 3l — Ccnntractor: License# ©0 Contac! b,,, Cupertino Business License#: Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Job escription: nn [� Residential ❑ 1`e rp L. \'�F Commercial Sq.Ft. Floor Area: $/Sq.Ft.: st of Project: Occupancy Group: Type of Construction: Quantity Fee ID Fee Description =FeeGroBAPPLOTHER Other A liances BBLDGFEE Bld Permits . footBBOILERl Boiler<= 100,000 Btu BBOILER2 Boiler> 100K to 500K BtuBBOILER3 Boiler> 500K to 1M Btu 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 MoWfeeBUILDING l BUILDING BCONSTAXR Constax—Resi/ DING BELEC1000 Elec 600V <= 1TRICAL BELEC1001 Elec 600V> 10TRICAL BELEC200 Elec Svcs 600V < TRICAL BENERGY EnerDING BENERGYADD Ener Add MDING BINVESTIGA InvestigationDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3