02050134-FP HT Y OF CUPERTEN00O /
CITY OF
Cu PTY OF FSE IT AI�I�UCCA` EGN FORM
APN# � �� � � Date: � A
uilding Addre_ss:,
19
13
Owner's Name: {�1-EPhone#i:1 qoe '77.3 - 146 e
Contractor: License M
Contact: ^^ (( 'Phone#'
5;e Nec�a�e 400 - 26 -7/ 70
A tJContraptor: Fax M
Build' g ermit Info:
Bldg t ,Plumb Mech
escription:
Residential: 6 ���� Commercial:
Sq.Ft.Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation42
:
-3
Type of Construction: Occupancy oup:
Quantity ]Fee RD ]Fee Description Fee Group
APTFEE EACH STORY OVER 3
HOTELFEE EACH STORY OVER 3
OFFICEFEE EACH STORY OVER 3
BAPPLOTHER Other Appliances 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
BIENERGZY Eimeirgy BU[LDEN G
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm.Housing Mit. Fee BUILDING
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-FamilyRes MECHANICAL
BNEWMULTI New Multi-family Res ELECTRICAL
of3
0 (937S-
1
CITYOF CUPERTINO
BUILDING-DIVISIONP1 CONTRACTOR INYO ATEON.
9UILDING ADDRESS: PERMIT NO.
7893 ROBINDELL WY 02050134
AME: APPLICATION UB DA
HUGO E AND E-PING S 05f 22/2002
PHONE: SANITARY NO. CONTROL NO.
1
0 o o ARCHITECT/ENGINEER: J BUILDING PERMIT INFO
^ BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
y N z Job Description
Z
0 y !hereby affirm that I am licensed under prow'ions of Chapter 9(commencing DEMO
P in F-m with Sectin 7 )of Div"' 3 of the Business a fessions Code,and my license
z Y is in full f d effec
s 2 6 Licer Cl Lic.#
°' a u to Contractor
F
u,0< ARCHITECT'S D
�
y.� I understand my plans shall be used as pu c records
Lu
ria[ p p Licensed Professional
OWNER-BUILDER DECLARATION
m= I hereby affirm 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 $13350
q whicKrcquires a permit to construct,alter,improve,demolish,or repair any structure
a 3_' prior toitsissuance,also requires the applicant for permit m file a signed statement
that tie i.klictnsed pursuant[o the provisions of the Contractors License Law(Chapter 9 3,6} .�tn Sl�.� .e1, i Valuation
(commencing with Section 7 of Divisicn 3 of the Bgsmess pnd Professions Code) 'i' ,1,, Y,'at tYJ'15,'1Oi'. f9't9 .r s .
or that he iA eiempi lherefromiaryd the basis for the alleged eaerpptlod.Any violation
of-Section 7031.5 by-arty applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).
NO AN V9NkO INSPECTIONS Occupancy Type
❑I,as owner of the property,or my employees with wages as their sole compensation,
wllldc the'work,And-the structure is not idtended or offered for sale(Sec.7044,'
Business and Piofessions Code:The Contractor's License Law does not apply to an Required Inspections'
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 iold 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.).
-Li -- .__.. ..
- - . ... ... .. .. .- .. ..- ..._ . . . ._ _._._. .__.-.. _ ... _ ._ ._.. _ .... 7,-
<r. O l,� ..as owner of the property,am exclusively contracting with licensed contractors to "
construct the project(Sec.7044,Business and Profusions Code:)The Contractor's
--- License Law does not apply to an owner of property who builds or improves thereon,
,. _and.who contracts for.such.projects with a conuactor(s).licensed pursuant to the
_ Contractors License Law: .
❑1 am exempt under Sea B&P C for this reason
Owhei-' Date '
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,one of the.following declarations:
❑ I have and will'rnaintain a Certificate of Consedt to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
pertorrriance of the work for which this permit is issued.
❑I haveanti will riiaintaln Worker's Compensation lnsurince,as required by Section
3700.of the'Labor Code,for the jerfcrmance of the work for which this permit is
issued.My Worker c' tpensatlon Insurance carrier and Polity number
artier.
•CERT,IFICATION OF EXEM M.WORKERS',
., COMPENSATION INSURANCE.
'(This section need not be completed if the permit is for one hundred dollars -
(3100)or less.).
I certify that in the performance of the work for which this permit is issued,1 i -
shail not employ any person in any manner so as to become subject to the Workers'
Compensation Lawi of California.Date
Applicant - - - - -
NOTICE TO APPLICANT:If,'after making this Certificate of Exemption,you should
become subject to-the Workers Compensation provisions of the Labor Code,you must
® ® forthwith comply'with such provisions or this permit shall be deemed revoked.
•� "c6NSTRUCTION LENDING AGENCY '
I hereby'affinn That there is a construction lending agency for the performance
> of the work for which this permit is issued(Sec.3097,Civ,C_)
Le
nde'r's Name' _
Lender's Address ,
_ ® 1 certify that I have read this application and state that the above information is
:fidH 'correct;l agree to comply with all city and county ordinances and state laws relating
® (, to building constructidn,and hereby'au esentatives of this city to enter upon
�z the above-mentioned property for i action -oses.
es,j agree to save,Inde tfy as ep harmless the City of Cupertino against /
- w-,V] liabilities,judgments,costs d ses w ay in any way accrue against said
e� City in consequence of th ranting o rhi permit
q APPLICANT UNDER NDS VD
ON LYWITHAL OfiVT Issued b Date
OUR E REGULAT S. Y<
gnatgre of Ap can tract - D e Re-Ioofs
HAZAR U M.. RIALS DISCLOSURE
Will applicant or Euro build' g occupant store or handle hazardous material Type of Roof - - - - -
- at defined the Cupertino Mu icipa ode,Chapter 9.12,and the Health and Safety _
Code,S on 25532(a)^. • _
Yes' All roofs.shall be.inspected prior to any.roofing material.beinginstalled. _
• Will.the applicant or future building occupant use equipment or devices which If a roof is installed without fust 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
°'Yes all non-point source regulations,.
' I have read the hazard m s requirements under Chapter 6.95 of the
California Health&Safety d, coons 25505,25533 and 25134.I understand that _ _ -
if the pudding does not eptly ha e a a that itis my responsibility to notify the
occupant of the req.' menu vhi be et prior'to issuance of a Certificate of
Occupancy. ignature of Applicant _•, Date
All roof coverings to be Class `B"or better
[) ner or orize to
OFFICE