03120036 (3) CITY OF CUPERTINO
BUILDING DIVISION PER ' COI' CR 1GTQXjNk'ORM 1�!„
.Sad-y„z ''A; Pr.'
PERMIT NO.
BUILDING ADDRESS: [AW H FRY CONSTRUCTION COMP Y . 03120036
PERMIT ISSUE DATE
1AARCHITEC'NENGINIER:
ER'S NAME:
SANITARY ROL NO.
NE:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l�
+ 0, LICENSED CONTRACTOR'S DECLARATION JobDescripon
1 hemby affirm that 1 am licensed under provisions of Chapter 9(cocing
'j with Sued..7") 3 of the,Bminaw and Prafexsiunx Confused my license is
WtaOfomea derfec'' s zy7f REPLACE WINDOW & DOORS
4-E Data Class Contuser 'm N Fly L•o✓s> «- OCT 01 Y004
Z"G Data 19-4-ri
J�Q• ARCHITECTS DECLARATION
a I unticrstnd my plans shall W used u public rcenrJs �'aLI•
in U
NC
3 Licensed ProfessionalS OWNER-BUILDER DECLARATION
CmarION
I hereby affirm on 11. exempt from Ne Canlrns Co License Law for the
Oo which followingreason.
permit
7031.5,Business,aftessand Professions or repairAny
or county
which requires a e..s.re construct,alter.i t for such
demolish, fie.sig any structure
tpoor hat he itscensed pursuant
reunites the teapplicaof for Contrarmiuoicense Law(ned Chapter
Valu tlOn
texa
that he.h.jiwitpursue..mthaofDivisionftheCom winces License Lion,CopmrY Sq.Ft. Floor Area
F m (c n he I,wesu with hereiro and of basis
3 w the f1waged cas and Professions I.6nde)er
Net he is exempt therefrom sntl Ne breis for the alleged exemp0on.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 AY� 1$@r0 0 Occupancy Type
not mom Nan five hundred dollar(5500).
1,as owner of the property,or my employees with wages as their sole Commandos,
will do the work and the swcmre is not intended or offered for Suits(Sec.7W,Business Required Inspections
and Professions Code:The Co intern's License Law does not apply to an owner of q P
property who builds or improves thereon,end who does such work himself or through his
awn employers,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion.the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
.❑1,as..or of the pmperty,am exclusively contracting wit licensed convectors to
conswct to project(Sec.7044,Business and Professions Cotler)The Contractors Li-
cense Law docs not apply loan owner of property who Wilds or improves thereon.and
who contracts for such projects with a convecbKa)licensed pursuant to Jai CanuactorS
License Law. -
❑Imnexemptand mSec .B&PC(mthismason
wnerData
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty,of perjury one of the following declusadons:
❑1 ban and will maintain a Cenificam of Consent to self-insure for WorkersComper-
salon,as provided for by Section 3700 of to labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
33700 of the labor Code,far the performance of the work for which this permit is Issued.
My, orker'a Compensation insurance nodes end Pal bet am:
Ca •T Li7r�- Po,toy tlo �I �1(2Z7�
CERTIFlCATE OF EKEMPOON FROM WORKERS'
COMPENSATION INSURANCE
(Thlsuctiov need not becompleted If the permit Is Boom,hundred dollars($100)
.flees)
I certify that in to Nrfmmence of the work for which this permit is issued,l shall not
employ any person in any manner so as in become subject to the Workers'Compensation
Law.of California.Date
Applicant
NOTICE TO APPLICANT:It,after making this Ccnificat of Exemption,you should
became subject m the Worker's Compensation provision of We Labor Cade,you most
,JO forthwith comply with such provisions or this Permit shall W deemed revoked.
y .~N. CONSTRUCTION LENDING AGENCY
[-i I hereby affirm that them is a construction lending agency for the performance of
lilt> the work for which this permit is issued(Sm.3(X97,Civ.C.)'
U A Lender's Name Z��',, L
ender's AddressVQ 1 ccsdfy Loat 1 have seed tis eppllntian and sole Nal the above information is
comaaL l agree to camply wit all city ane coup erroad snces and sole laws r upon woV building conswnion,and hemby amhome rcplesenm.ives of tis ci.ymen¢r upon Ney above mentioned pmperty for inspection purposes.
r a (We)agree to save,Indemnify End keep harmless the City of Cupc nine against
C-r W r:Eabilidu,judgments,costs and expenses which may in any way accrue against said Cityin s �� D
U H APPLICAeNTeUNDERSTANDSAND of We furamin,of Ihis rraft. s
WILL COMPLY WITH-ALL NON-POINT Issued by: Date /2
,I cut.,�r Or
C �z'8 Re-roofs
Signature ofApplicanUCo factor Data of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will Ito applicant or future building occupant stare or handle haeardow mamdal
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Code.Section M532(a)1 ?SN. All roofs shall be inspected prior to any roofing material being installed.
Yea
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanolo s air contaminants in defined by the Bay Area Air Quality Management all new materials for inspection.
Disvin?
❑Ycs
I have read Loc hvardow materials requirements under Chdpmr6.95 of the Califoo
a Health&SafclyCodand e,S.odur,25505,25533 25534.1 undo dtatifthe Wilding
-n tcurrently have a Roam,that it is my responsibility to t fy do cecupanr of the
quirt hich h9Aa prim. asuancerfsCenlfc. o(Oenapmey. Signature of Applicant Date
Owner ser autharimdagcnl M Dam
All roof coverings to be Class"B"or better
SIM4M
to-®r hato1ite�-gi
• 274 E. Hamilton Avenue, Suite C
Campbell, California 95008-0240
Voice: 408-871-7273 Fax: 408-871-7274
October 15, 2003
Wm. H. Fry Construction Company
10351 San Fernando AvenuecL2003
Cupertino, CA 95014-2832
DEC 1
Re: Field inspection for epoxy anchors
Merala Residence, 20881 Tula Court, Cupertino, CA 95014
SSE Project: 1452-02
On October 15, 2003, 1 visited the aforementioned site, at the request of Bill
Fry (Fry Construction Company), to provide structural observation for the
installation of 7/8" diameter threaded rod tie-down anchors bolts for new retro-
fitted Hardy Frames. Listed below are my findings:
1. All holdowns and tie-down anchor bolts were properly located.
2. "SET" epoxy, by Simpson Strong Tie, was used as required.
(ICBO # ER-5279)
3. 1 was informed that the drilled holes where wire brushed prior to my arrival.
4. The drilled hole depths were measured in my presence.
• 5. The hole depths were in conformance with design documents:
• 20" minimum for 7/8" diameter threaded rod holdown anchors.
6. Sample holes where re-blown in my presence and found clean. Any holes
that were not acceptable were re-brushed and re-blown in my presence.
7. The epoxy was applied in conformance with design documents.
8. The tie down anchors w re properly inserted into the pre-epoxied holes
in conformance with a ufacturer's installation instructions.
Please call our office t 4 8-871-7273 ' you have any further questions or
comments.
Sincerely,
s, SSIO L e4,
EZEiy GiyF
4
� 316 COPY A �
Kent Sabri S MS, 31,250
Principal wry Ftp• Q
yc STRUOIJQ�F��
STATE OF
•
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DEC 0 8 2003 i
AppROVfp e
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3 ; DATE pJST.
4 ,r ,. � ec�ntatior un,
`1 SIGNEU...- clans ti � os
Tpesk pt ol tP^ o at of. etaCians
ake anN cnanti eS
Perthis.ton tr9m
Written
lawisame
without f CnPer1'n0°
„ oho Uatlding ttePC Ott o
jan and sP;citicado a('.of this P o be a
NGT be veld XU tion of anY ProvtsiotV .
, a of he ,Stat Aw'
�PenV City Ordinance
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'i •CITY OF CUPERTINO� �2 0 03 6
CITY OF PERMIT APPLICATION FORM
•CUPEVINO
APN# ,359iSoDate: '
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Building Address:
ZuBF% Tun C�
Owner's Name: Phone #:
/r/nc/c 1W -1L/.
Contractor: License#:
Win SZO-7C�j
Contact: Cupertino Business License#:
/
ildi Permit Info:
Bld .- Elect El Plumb ❑ Mech El
Job escription: 3 Via, oo+ Y ; �cr o/ps.�...,�,
esidential z ,, Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of P lect: Occupancy Group: r
Type of onstructio
046-k-
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> l OOK to 500K Btu MECHANICAL
BBOILER3 Boiler>500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS 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 Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V > IOOOA 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
,_3 7 (7
Iof3 /�� 2q `
OITY OF CUPERTINO
aTMOF PERMIT APPLICATION FORM
CUPEICTINO
AOL
yQuantity Fee ID. Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfrn MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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&qv *ITY OF CUPERTINO*
CITY OF PERMIT APPLICATION_FORM
CUPEkTINO
uanti Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct ' MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING '
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary BldgPermit BUILDING
BTEMPSVCS Tem Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical s foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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