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CITY OF CUPEPERI v F �-k $ �
BUILDING DIVISION
BUILDING ADDRESS: TOM MCNAI R PERMIT NO-03080010
22261 MCCLELIAN R11
OWNER'S NAME: PERMIT ISSUE DATE
TOM MCNAIR 11/17/2003
PHONE: SANITARY NO. CONTROL N0.
A RCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1
00 LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing lob Description
Z a with Section 7000)of Division 3 of the Business and Professions Code,and my license is
�y in full force and errect. NEW 2-STORY SINGLE FAMILY DWELLING
License Class Lac.N
a Date Contractor LIVING SPACE 3311 SQ.FT. /GARAGE 427 SQ.FT.
ARCHITECTSDECLARATION THIS PERMIT IS REPLACE #01050208
I understand my plans shall he used as public records
JyU
rO y Licensed Professional
a y OWNER-BUILDER DECLARATION
f 1 hereby affirm that 1 am exempt from the Contractors License Law for the
❑O following reason.(Section 7031.5,Business and Professions Code:Any city or county
<$Pa` which requires a permit to construct,alter,improve,demolish,or repair any structure
Z prior ht its issuance,also requires the applicant forsuch permit to frlc a signed statement
x a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
f—O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $365534
i 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 penally of APN Number Occupancy Type
not more than rive hundred dollars($500)_
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Bdsiness 35704067 . 00
and Professions Code:The Conuactor's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors .
License Law.
JZP am exempt under Sec. .B&P C for this reason
Odyn Date
CWORKER'S COMPENSATION DECLAICA N
I hereby affirm under penalty of perjury one of the following declarations:
r
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which,this permit is issued. `#
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,fee the performance of the work for which this permit is issued.
My Workers Compensation Trat rance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($I00) .
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any pco in any manner so to been c u 'ct to the Workcrs'Compensation
Laws of CaliDate
Appli nt
NOT) ICANT:If,after making this Certificate of Exemption,you should
been subject to the Workers Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCT,
ON LENDING AGENCY
�-. 1 hereby affirm that there is a construction lending agency for the performance of
lYi 7 the work for which this permit is issued(Sec.3097,Civ.C.) \
La Q L.endcrs Name
ZCL,D
Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
LT.F" correct.I agree to comply with all city and county ordinances and state laws relating to
p U building construction.and hereby authorize representatives of this city to enter upon the
C3. shove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
f!I liabilities,judgments,toss and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit. r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULATI
''� �l Re-roofs
of Applicant/Conlractor 'Date'
HAZARDOUS MATERIALS DISCLOSURE 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 Safely
Calc,Section 25532(a)?
C3 Yes fw1Nu All roofs shall be inspected prior to any roofing material being installed.
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 hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Dyes $No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25X15,25533 and 25534.1 understand that if the building
dors not currently have a tenant,that it is my responsibility to notify the occupant of the
mqu' mcnswh' uanccofaCertificate ofOcc panty. Signature of Applicant Date
roratuhorirsdagcnt 1 7a1e All roof coverings to be Class "B" or better
9
aC11F'
YOF CUPERTINO
NEW SINGLE FAMILY DWELLING 3 v
aft
CUPEI�11N0
PERMIT APPLICATION FORM
APN# Date:
Building Address: Mailing Address (if different from building address):
Z Zz Cv I M G G���- -o-►�t
Owner's Name: Phone#:
N1 (asv 140 l b40
Contractor: License#:
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Single Story ❑ Two-Story ❑ Three-Story P!�- Basement ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
331 ) z OrG= 6Fi 1 Co
Cost of Project:
,zW, 000
Type of Construction:
v - N
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K 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 <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A 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
Z -2,
1 of 3 7 7'