02080044ID w v
E d _ v
CIZ y y t
�C y C W�IML, a Qy U
O m u Li j� Oj < 2 U U O Lo 2 ��
`�1'd__1
O
LO
U]
8
ED
N
O
LO
07
y
C
O
_y
U
C F
O
i
W
�
O
Idi
Idl
L
CL N
1
W
W
d
U
a
3
a
d
M1a
ti
I --
LL.
~
to
N
O
W
41
U
LO
c l
C
a
O
a
Q
Qt
O
N
_
a
Q
p
LULUN
LO
O
J
d0
3
W
W
~
J
W
O
cOI
N
N
co
n
O
Q
~
Z
a
{fi
LLJ
d
C
ui
M
0:
W
O
�
.,
95
cWn
p
ru
a�
L
�
Q
Q'
r
y
Q
O'
O
Lo
Qy
O
O
H
vi
U
O
d
O
d
J
W
cc
CD
O
M
J
N
-V
CC
O
J
W
m
O
j
O
_
LO
O
U
M
_
1
_
10
:5
v`
cn
U
O
O
Q
I�I
1
)
a
w
o
J
;'•�
U
U
5
yu
y
II
O
O
O
O
o
a
-
a
a
a
O
kA
'O
«1
O
LL
CD
O
CD O
�I
CD
O
O
C
o
J
C
-
Cl)
m
O
O
N
_
in
°
O
o
0
�
m
0
0
v
r=
O
f0 O
d
U
U U
W
f
a
0
Q) QS
d
d
Q)
r
_
�S
LL
ED
N
O
LO
07
H
--I
0
N
L+]
W
a
H
W
y
C
O
_y
U
C F
O
i
U
�
O
Idi
Idl
L
CL N
1
W
d)
d
U
a
3
a
d
M1a
ti
+p
LL.
~
to
N
O
W
41
U
i
H
--I
0
N
L+]
W
a
H
W
a`r
IML
0
_y
a
x
�
u
Idi
Idl
L
ro
ISI
�
yTJ
a
%g
—
+p
LL.
~
a
N
O
W
41
i
c l
C
a
O
a
Q
Qt
O
N
_
a
Q
p
LULUN
LO
O
J
d0
3
W
W
~
J
W
O
cOI
N
N
co
n
O
Q
~
Z
a
{fi
LLJ
d
C
ui
M
0:
W
O
�
.,
95
cWn
p
ru
a�
L
�
Q
Q'
r
a`r
IML
0
_y
a
x
�
v
2
95
ro
a
c.I
0
0
c.I
rn �
� J�J
00 J
a
� 47
d C
W
x
�
v
xy
ro
a
�
yTJ
%g
,9
+p
LL.
~
a
N
W
41
i
c l
U
5
CD
tU
LCC
r�i,
ru
a�
L
U
E
c
v
y
Q
O'
O
Lo
Qy
O
O
Q
vi
U
O
d
O
d
c.I
0
0
c.I
rn �
� J�J
00 J
a
� 47
d C
W
n1% ZZZ UJF
H ¢ H
7
0Z—
F N F j
UXpaU
ra 3 y
y n
�u,r
c
LIJ
aaQ�
x�
F Z >
C F C
LL]3°`
CITY OF CUPERTINO
BU ,DINGDMSION PE*T
CONTRACTOR INI+ORIWON:
BUILDING ADDRESS:
�``
PERMIT NO.
879 LILY AV
02080044
OWNER'S NAME:
APPLICATION SUB DATE
LYON MARY L TRUSTEE
08/09/2002
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
rI L_ J
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Secti n 7 ) of Division 3 of the Business nd Professions Code, and my license
is in full f and fffec j C s—
tC
ADD
19.2 S Q . F T .
License s Lic.
Date O Con mclar AT S-
ARCHIT'ECT'S DE TION
I understand my plans shall be used as pu5lic records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affunn that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
$21580
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant forsuch permit to file a signed statement
(V!
Valuation
tbabhe is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9r
(commencing with Section, 7000) of Division 3 of the Business and Professions Code)
, .;3 5g9'R4{
V-lT� i' . • ,
or 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 penalty
of not more than five hundred dollars (s500).
- -
10 1APN IN15*DAT I ON
Occupancy Type
❑ I, as owner of the property, or my employees with wages as their sole compensation,
102
—
103
-
— UFER Required Inspections
' will do the work, and the structure is not intended or offered for sale (Sec. 7044,
Business 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
10 4
— REBAR
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
_
105
— ANCHOR BOLTS_
completion, the owner -builder will have the burden of proving that he did not build or
improve for purpose of sale.).
106
— SEWER & WATER
�❑ I; as owner of the property, am exclusively contracting with licensed contractors to
202
- UNDERFLOOR PLUMBING -
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
203
— UNDERFLOOR MECHANICAL
License Law does not apply to an owner of property who Ids or improves thereon,
and who contracts for such projects, with a con[mctor(s ceased pursuant to the
204
- UNDERFLOOR- FRAME --
am e - , B& C for s on
nea G b
tract 's L5.;R
205
301
- UNDERFLOOR 'INSUL'A'TION
— ROUGH PLUMBING
SATI DEC ARATIO
302
— TUB & OR SHOWER
[-herebenally of perju, one of the following declarations:
303
— ROUGH MECHANICAL
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's
304
— ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
305
— FRAME
❑ I have and will maintain Wo keel on Insu ired by Section
306
- HOLDOWNS
3700 of the Labor Code, foF the performance o e work for which is -'permit is
307
— INSULATION
issued. Worker's Comp
' enation Insurance c" r and Policy number are:
I.. ..
r .. ' 'Policy
- ...-. ..3 0 $--
= SHEETROCK , . ... .....-_. ... ... . ... ... ,. .. ,
Cirrrie , No
CATION OF EXEM FROM WORKERS"
'. '305 '
�' . EXTER�I OR `LATH :
COMPENSATION INSURANCE
310
-, 1 NTE Z I OR- 'LATH
" (This section need not be completed if the permit is for one hundred dollars
311
- SCRATCH COAT
(S 100) or less.)
- 313-
— ROOF -NAIL -
I certif as in the performance of the work for which this permit is issued, I
shall not o p on in any 'net o as o beco a subject to Workers
501
- FINAL ELE CTR I CAL• ENERGY
Compensati ia. / �t
-APPlican
502.
503
-. FINAL .PLUMBING .ENERGY ..
— FINAL MECHANICAL ENERGY
NOT CA f, after ma 's tate of Exemption, you should
beco Com provisio the Labor Code, must
ubjec[ er's pens n sof you
forthwith' comply with such provisions or this permit sha be deemed revoked._ _
504
- FINAL _ BUILDING ENERGY -
) � CONSTRUCTION LENDING AGENCY
505
- FINAL ELECTRICAL '
I hereby affirm that there is a construction lending agency for the performance
of the work for whish this'peimit is, issued (See. 3097, Civ. C.)
506
— GAS TEST
Lender's Name
Lender's Address
507
- F I NAL PLUMBING
508
— F I NAL MECHANICAL
I certify that I have read this application and state that the above information is
4 correct. I agree to comply with all city and county ordinances and state laws relating
509
- F I NAL GRADE
to building construction, and hereby authorize representatives of this city to enter upon
I the above-mentioned property for inspection purposes.
510
�y
— F I NAL PLANNING
(We) agree to save, indemnify and keep harmless the City of Cupertino against
514
— FINAL UB C W $7
liabilities, judgments, costs and expenses which may in any way accrue against said
Ciry'n
consequence of the grantino,of this permit.
r
. 'T.,UN RSYSNDS WIN LCOMPLYyy HAL N -POINT
Issued by:
Date
Re -roofs
nature' f App icant/contractor Date
HAZARDOUS MA RIALS DISCLOSURE
Will the applicant oh future building occupant store or handle hazardous material
Type of Roof .. - ... ... .
defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code; Section 25532(a)?
C
-❑Yes - Io
, I '
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
District? '
all new materials for inspection. Applicant understands and will comply with
C1 Yes No
all non- oint
source regulations.
I have read the hazardo materials requirements under Chapter 6.95 of the
'California Health & Safety Code; Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have aienant, that it is my responsibility to notify theIQ
occupant of the requirements which must be met prior to issuance of a Certificate of
V i?C
Occupancy.
ignature
pplicant Date
All roof coverings to be Class `B" or better
caner or authorized agent Date
OFFICE
CUPERTINO
•CITY OF CUPERTINO•
PERMIT APPLICATION FORM
oZv,Y0°el�z
APN # G, ,3
Date:
Building Address:
S'i /,1 uFEr-r/ND
Owner's Name-
Phone #:
X0 V_ . j3- .7 /
Contracto :
s
License #:
Contact:
Phone #:
Applicant/Contractor:
Fax #:
Buildi rmit Info:
Bldg lecd (mech
Job Desc ptign:
Res tial:✓ Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
�e -i�[ t -c
Valuation:
I /
Type of Construction:
y—, A I
Occupancy Gr up:
Quantity Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other A liances
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 <= 1000A
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <= 200A
ELECTRICAL
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BEWESTIGA
Investigation fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUILDING
BMITIGATR
Res. Housing Mit Fee
BUILDING
BMNEWMULTI
New Multi -Family Res
MECHANICAL
BNEWMULTI
New Multi -family Res
ELECTRICAL
BNUCOMME
New Comm Electric
ELECTRICAL
BNUCOMIVIM
New Comm Mechanical
MECHANICAL
BNUCOMMP
New Comm Plumb
PLUMBING
� �v36z
CITY
ILw of c my sin NO CONTRACTOR INFORMATION:
PERMIT
LDING ADDRESS PERMIT NO.
79 LILY AV 020TION Y80044
B DAM
RARY L TRUSTEE APPLICA08/ 09/2002
NE: SANITARY NO. CONTROL NO.
z Z ARCHITECTIENGINEER: BUILDING PERMIT INFO
00
m BLDG ELECT PLUMB MECH
Z u L_D u
5y i LICENSED CONTRACTOR'S DECLARATION Job Descri tion
QZ- Ihon by 700 Etm thoiod3Imp.f theBeines p and
Professions
Code.anr 9 d
mmecense ADD 192 SQ. FT. FIN .ALE®
ng
F=t', is in SectioneOWIefect. on3ofrhe Business and Professions Cnde.end mylittnse 4•
Y,y j in full force and effect.
s.ni a License Claae Lic.N
3 a F
Data
Conwcmf MAR 2 8 2003
ARCHITECT'S DECLARATION
O<J 1 undcnrand my plans shall be used as public records
Mr
w z<O Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
I hereby arfitm that 1 am exempt from the Commmui s License Law for Ne
F Z following reason.(Section 7031.5,Business and Professions Code:My city or county $21580
S C which requires a pemit rto constrict,abet,improve.aimprove.demolish,or repair any structure
o g
a3
(cootuoo<n,sensed eon"nomtothenprovi torso ho CootrracorstL mme Lnw(ChnPttt9 d ., w3 EC ,.G„1:ipaOr,pP08 ,.,j ,,,, Valuation
7"JV-JVLL VlJ
g with Section 70K of Division I of the Business and Profession Cade) ..t a;\ 9
or Neimnix eampttheefom a' ed exam um.An volatio. " ""
of 5mion 703.5 by any applicant for a permit subjects the applimm to a civil penalty:
of not more Nan I've bonded douara n", 101APN V1°J*DATION "I"'' Occupancy Type
111.as owner of the property,or my employees with wages as their sole compensation,
will net the work,and , ode:T e is ntrtmended ora ex forsoleno,
(Sec:to an
'
owner
of pandro erty Who b Code:The roves thereon,
,and w law does not apply m an 103 - UFER Required IDSpectlon$' •'
ownerof IT
Wholoy. urimprovese,such
imp no
does such work himself 104 REBAR
of N ggh s own employees.emodin Nat such improvements art n or intended m
..coded f-'-BIC If.however.the building "" .. .._... .. _ . - ____ _....._ ...... .._.._.._ __
g or'mprov<mem s o1J Luh rte year'of' "
<nmpmnnn.meownefbumerwulnavemeWNennrprnv,ngthatnemanntwoeor I05 - ANCHOR BOLTS ,
improve for purpose ofsele.). 106 - SEWER & WATER
:°4as ower ofNegrop,y.arnimiui ' —20'2 -__UNDERFLOOR._PLUMBING - -,-;
viycontag with ikenscaconvxt
,
construct the project(sea.7(l Bminesa and Prnresfinns Code:)Tne cnmranco's 203 - UNDERFLOOR MECHANICAL`- ,
License Law does not apply to an owner of property who builds or improve thereon,.
-rnd.who contracts fo.,tudi projects.with a conwmoda)licensed pursuant Lime - --2 04 "UNDERFLOOR- "FRAME'
Convaaors License Taw.
°l am exemptgwe,Sec BSPCrm Nisrpaxn, 205 - UNDERFLOOR': I'NSUL'A'TION
Owner " ease'"" " 301 - ROUGH PLUMBING
WO..,,
ORKER'SCOMPENSATIONDECLARATION 302 - TUB & OR SHOWER
Ithereby effort under Malty gfPerjury encnnnefollowing declarations: 303 - ROUGH MECHANICAL
0 I have 6nd'will maintiin'a Ccniticax'of'Consent to self insure for worker'x 3 04 - ROUGH ELECTRICAL
.Compensation, as provided for by^Section 3700 of the Labor Code. for the
performanceofwork mf which this p<wit is ispued., , 3 05 - FRAME
-' °1 haveand will andminin worker's' pe
Comnsaiion Insurance,or on,uime by Section 3 06 - HOLDOWNS
3700 ohe Labor Cade,for the performance of me work for which this permit is� 3 07 - INSULATION
is ed My W kers Compensation Insurance c ru and poli aY numbs m
Nis: Z308 1 iSHEFT,TROCK ` i: ...t.
c i,CBRTIFICATIONOFE%EMPTIONFROMWORKERS' f f}.a' ! !30,9 ;EXTERIOR'--LATH
COMPENSATION INSURANCE' is _ �
31'0,i-`-.INTEL IOR'"--LATH" ------.--- -- -.-..
„i.,. .
"t ('llussecuohneednotbecompleted inhepent,ts fofone hunmeddollars t �
(slWlenem.j 311 - SCRATCH COAT
.: I<ntr thd( to cannot nkr n2ntndpeinu�':1. Bea 1' "`313' ROOF NA7,L'," ,� _.....' .' ' ..' -.....
than t employ any personc in rainy and o to Become sub3ect to the Workers' 501 - FINAL ELECTRI CAL'i'ENERGY'
Applicant xtion ass. rcanrnma.,pate ...502. -.. -FINAL._.PLUMBING-.ENERGY.
.--_.. ..-
NOTICE TOAPPLICANEH:anermapinglhi;cemficare of Exemptcddybpshoajd' 503 - FINAL MECHANICA'L' 'ENERGY
'become subject the
1 'd
Tie's
open aeon pr v'ons bfthe Luhor Cwle,y must
Q 0 forth int comply nhschprovision, tin perm,ahaRbee rued revoked 504, - FINAL_-.BUILDING. ENERGY.--,,,.,, �...... .._.._..._...._
9 5.
tcotthemisacoNLEry INCACENCY - - 05 - FINAL ELECTRICAL
Y gag cY Pttr .. __507 . . ....
-U p 506 - GAS TEST
as 1 h b eB'rm Nat them is a construction lending en for N m,antt'
sof th kf hph Nt pant .sued(Sec J09) Cv C. 5
-lsnde Name ..- .. .._ ..._.. .. .... ... .. _._._.
p z -Lendef Add ;- � = FINAL PLUMBING 1
emfy Nm 1 have reed this appbcmion and trate Not the above mformauon u 508 - FINAL MECHAN I CAli
doccl.I agree to comply.with II ityand county rdinuncf and state s tting 509 - FINAL GRADE
ro t.7 ItaWilding c t ct and hereby authorim representativesof his city to enter pon r
;the"ve mentioned pperty for inspection prposes , 510 - FINAL PLANNING
Ca
(We)rpeo indemnify and keep harmless the City ofCupertina against
�.. y fi bilin judgments.costs d expenseswhich y in any y againstmid 514 - FINAL UB C W Q
C.7 rZJ
City laC NT inceofth loading D thisperpt r. /
APPLICANT UNDERSTANDS AND WILL'COMPLY N'ITH ALL NON'-POINT" � VY /
soortcE REtui;.7loNs,_;"I Issued by: Date
SignatureofApplic /Contmcor ;" . .`.' ""Date'. Re-roofs
ant
1 ' HAZARDOUS'MATERIALS DISCLOSURE
Will theppli t mr future'building ce
c tu
Pe ne or handle hezaMo s material
—Type of Roof_ -. .. ............_.. .....
Cupertino Mun c pal Code
m d m 1 Chapter 9 12 and the Health unit Safety i
n def epsti by Ne
�CtWe Seno �5533(al I I6ti y'.P: e 't .ftt".
All roofs shall be inspected prior to any roofing material being Installed
W II thpplt tu
torfprt building occupant use equipment or deccs which' If a roof Is installed-without first obtaining an inspecttoni-I`agree to'remove
com,hisramotissur conmmmants as defined by the Bay Arta Air Quality Management
D t uall new materials for inspection Applicant understands and will comply with
°YF' °Not t r ail non-point source regulations
1 loom' n mrd
n vi materials q re cots under Chapxr 6
adt95 of the
California Health&Safety Cade Sections 3550525533 and 25534.1 understand that
if the Wilding does no;currently have a tenant;that it is my responsibility to notify the ...... . . .- ._, _. .. -._.._..... ..... . . .___ __.. .. . . ....... _. ..-.
6ciripint more negorcmeoil which'mu t W met poor o¢surince of a Ccmd,mo of
Oc
Si nature of A Meant Date
g _..
OFFICE � to be Class B" of better
0agentt "
rte r Nonm�l Date r 1
_,: .-. roo ..-. .. ... ._. . . . ._.._ .'...._-. ..