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02110097won �V~ Z Fah Z OZ= X0aV Ld U) nn o aam� W h ~Z4 �CFC Q, C! 0 Z� fir Uj W� aQ Z U OL Q U� CITY OF CUPERTINO BUILDING DIVISION P]EI T- C(DNTU i, INFO BuI9_DVQ_3 p_tE4TEVENS CREEK BLVD MENEMSHA DEVELOPMENT GROUP PERMITN02110097 owBDUARD JONES 525 S. DOUGLAS ST. APPLICATTPtIS151Q4I1 2 0 02 PHONE: '(310)343-3430 SANITARY NO. CONTROL NO, ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing g��y p' TI--INSTALL PA �'P 1 1 VN °WALLS with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full foreea deflect. O License L' . ELECT �� ^ /MECHANICAL Date onvaztor ARCHITECTS C A I N � 1 understand my shall be use a blic plans records �J Licensed Professional OWNER - BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the following reason. (Section 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure $90000 prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 37506007.00 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 or APN Number Occupancy Type p y yp not more than rive hundred dollars (5500). 101 — FOUNDATION ❑ 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, Business and Professions Code: The Contractors License Law does not apply to an Required Inspections owner of 103 - UFER 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, 104 — REBAR however, the building or improvement is sold within one year of completion, the owner. 105 — ANCHOR BOLTS builder will have the burden of proving that he did not build or improve for purpose of sale.). 106 — SEWER & WATER ❑ 1, 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 Contractors Li- cense Law does not apply to an owner of property who builds or improves thereon, and. 203 — UNDERFLOOR MECHANICAL who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's 204 UNDERFLOOR FRAME License Law. - [] I am exempt under See. , B & P C for this reason 205 — UNDERFLOOR INSULATION Owner Date 301 — ROUGH PLUMBING WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER I hereby affirm under penalty of perjury one of the following declarations: 303 — ROUGH MECHANICAL ❑ I have and will maintain a certificate of Consent to self -Insure for Workers Compcn- 304 ROUGH ELECTRICAL sation, 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 Worker's Compensation Insurance, as required by Section 306 — HOLDOWNS 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Po icy numbe�r am: 307 — INSULATION ` �� Ca • t stn laf Cep ZAP o.:���" 308 — SHEETROCK CE FICATEOF— EXEMPT ROM_WORKERS' COMPENSATIO NSURANCE 309 — EXTERIOR LATH (this section need not be completed if the permit is for one hundred dollars ($I00) 310 - INTERIOR LATH or less.) 311 - SCRATCH COAT I certify that in the performance of the work for which this permit is issued, I shall not 313 — ROOF NAIL employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date 501 - FINAL ELECTRICAL ENERGY Applicant 502 — FINAL PLUMBING ENERGY NOTICE TO APPLICANT: If, after making this Certi(ealc of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must 503 - FINAL MECHANICAL ENERGY forthwith comply with such provisions or this permit shall be deemed revoked. 504 - FINAL BUILDING ENERGY CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of 505 — FINAL ELECTRICAL the work for which this permit is issued (Sec. 3097, Civ. C.) 506 - GAS TEST Lender's Name 507 - FINAL PLUMBING Lender's Address 1 certify that I have read this application and state that the above information is 508 — FINAL MECHANICAL correct. l agree to comply with all city and county ordinances and state laws relating to 5 FINAL GRADE building construction, and hereby authorize representatives of this city to enter upon the above - mentioned property for inspection purposes. ]- O — 1 LANK I G (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities. judgments, costs and expenses which may in any wayaccmcagainstsaidCity 5 4FI LI WORKS in consequence of the ranting of this pertnil. APPLICANT RSTANDS AND WILL COMPLY WITH At: POINT Issued by: Date SOURCE CATIONS Re -roofs Type of Roof C e© g Ali o ppltcam/Contrac r Date HAZARDOUS MATERIALS DISCLOSURE lo Will the applicant or future bull ing occupant store or handle hazardous material as defined by the Cupertino Munic' I Code, Chapter 9. 11, and the Health and Safety Code, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes o 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 emit hazardous air contaminants as incd by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes u I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health &Safety ,Sec uons25505,25533 and23334. 1 understand thatifthe building does not current ve a tenant, that it is my responsibility to notify the occupant of the mquireme ichmustbe riort ' uanc faCertifica fOceap ey. Signature of Applicant Date G All roof coverings to be Class "B" or better O yerer orauthoriudagcnt Date `lL (CHTy OF CCU1? ER7HN CUPEkTINO CITY OF PER MHT APPLICATION FORM 0 2 1/0-0 ? 7 APN # Date: .� ®O J� ` •O Building Address: IRM D Owner's Name: Phone #: GL BCONSTAX Contractor: License #: (PA71 TO Contact: Phone #: 0&+ ,) I :lo - Applicant/Contractor: Fax #: BCONSTAXH Bu•lding Permit Info: ldg Elect Plumb ech escription: T W�-t-jVN 6 e-1 -rkoU WA.ti,U 13CONSTAXR Sq. .Floor Area: $ /Sq.Ft.: .. BELEC1000 � chitect/En ' r: Valuation �1 1 W ® ��O Type of Construction: Occupancy Group: l VA e \`» Qumnfl Yee ID ]Fee Descrn don ]Fee Groulp 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 13CONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 � Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL B ENIERGY Energy BUIILIHI\IcG BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BYMWMULTI New Multi - Family Res MECHANICAL BNEWMUI TI New Multi-family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMIVB4 New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of 3