06100149 CITY OF CUPERTINO
BUILDING VIVISfON PERMIT
BUILDING ADDRESS: PRO I.11 NSTALLERS PERMIT NO. 06100149
20685 RODR I GUE S AV
PERMIT ISSUE DATE
OWNER'S NAME: 10/1912006
THOMSON RESIDENCE 519 SAN PI
SANITARY NO. CONTROL NO.
NE:
(650) 967-8800
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0
00 LICENSED CONTRACTOR'S DECLARATION Job Description
U r1 hereby af[irm that I am licensed under provisions of Chapter 9(commencing
Zwith Section 7000)of Divi.on 3 of the Business and Professions Cock,a my license is
!may infullforcean est EXTEND GAS LINE TO FIS GAS FIREPLACE
License CI Lte•N
t a Date tractor:Q74, 1441-1
RCHITEC•I'S DEC RA
a< ndc nd my plans shall be used as pub' ardls
tyU
u.in Licensed Professional
O
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
3 00 following reason.(Section 7031.5•Business and Professions Code:Any city or county $1200
which requires a permit to construct,alter,improve,demolish,or repair any swcture
prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's Incense Law(Chapter 9 Sq
t— (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 1 111
Ill 11 11 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of i00 Occupancy Type
not mote than five hundred dollars($500).
I•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(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
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,
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 owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
ccnse law does not apply to an owner of property who builds or improves thereon,and•
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B dt P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
jI 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
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code:,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performanc f the work for which is permit is issued,!shall not
employ any i y man r b' orkers'Compensation
Laws of C for' D
Applicant
NOTICE of ma end tcst of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
,J,'Z forthwith comply with such provisions or this permit shall be deemed revoked.
z R CONSTRUCTION LENDING AGENCY
E~-d.N•• I hereby affirm that there is a construction lending agency for the performance of -
fyr the work for which this permit is issued(Sec.3097,Civ.C.)
W Q L.erulces Name
z Lender's Address
U 0 I certify that i have read this application and state that the above information is
Lf.E" correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby'authorim representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rF-d C/) liabilities•judgments,costs and expenses which may in any way accrue against said City
IJ z MI
ting of this it. Date
t—d ANDS AN ILL COMPLYWITH LLNO OINT Issued by:
. � Re-roofstractoDate T Of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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
Code,Section 25532(a)? � �s All roofs shall be inspected prior to any roofing material being installed.
❑Yes m(7f No
l� 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
-mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials f inspection.
District?
❑Yes XNa 1
I have read the hazardous
materials requirements under Chapter 6.95 of the Califor- /
Er
fctyc coots25505, 533 and 25534.I undcrstatld that if do ildingpVtly ha tenant,that i y responsibility to notify Occup lof thehich t be metno uance of a Certificate of part $1 ature of Applieant ,ddtDate
l) All roof coverings to be Class B or better
onzcd ag t Datc
"N C)LOIM149
CITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPEkTINO
APN# J —O� Date: G
q- 0 � 1
Building Address: Mailing Address (i different from building address):
2—c-) &jam - t> at r 5
Owner's Name: Phone #:
Contractor: License#:
Co ct Phone: (a-'5.p Cupertino Bunesepse#:
Fax:
Bu ng Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: �^ -� >S (p -S rz-tz—: /ALE
Residential ' - X � � - /Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
S1
Cost of Project: Occupancy roup:
2 --
Type of Construction: Please check this box if the project is a
-�- second-story addition: ❑
Project Size: Standard ❑ Large E Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI 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
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 Motel BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC 1000 Elec 600V <= l OOOA ELECTRICAL 4
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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