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01100033-FParr of CUPEkTNO Y G1F CCUPIEI THNG P EIMIIT A?? LECCATIIGl\\T ]FORM APN # Date: Building CA. Owner's Name: U Phone #: Menton 5 52'1-1 Contractor: License #: BBLDGFEE Bldg Permits . foot Contact:, Phone #: BBOILERI Boiler <= 100,000 Btu App licant/Contractor: Bu' 'ng Permit Info: BldV Mech o Description: ? 0daA &KSS't% T Residential: Commercial: -f7Af AQ) A QWIIR_ Sq.Ft. Floor Area: $ /Sq.Ft.: MECHANICAL Architect/Engineer: o Valuation: ° ° a)o Type of Construction: Occupancy Group: Quantity ]Fee ID Fee Descri tuon Fee G¢rou 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 1 M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILERS 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 BELEC1000 Elec 600V < =1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy 1BUI[LDENG BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee „; BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING, T-Y 1 of 3 //\ CITY OF CUP]ERTINO BUILD£NG DIVISION PERMIT BUILDING ADDRESS: 10555 RIDGEVIEW CT. CONTRACTOR INFORMA7M XZ �Uh S /tom” I PERMIT NO. 01100033 OWNERS NAME: APPLICA ON S DATE COMPAQ COMPUTER CORP. BLDG-6 / err a g may, d r 10/04/2001 PHONE: 0 O ZC ARCHI- ['E.CTIENGINEER: �UW F ZIL yaa LICENSED CONTRACTOR'S DECLARATION Z: n � Z __ � I hereby affirm that I am licensed under provisions of Chapter 9 (commenting K E m with Section 7000) of Division 3 of the Business and Professions Code _ and my license Y is in full force and a l(jn/ '.]`., yVl/`' -�) z ce.¢ License Class Lic. # 0 a V Date o Contractor S UL t 0 vF,, ARCHITECT'S DECLARATION y y I understand my plans shall be used as public records : ul i p C Licensed Professional R r � OWNER- BUILDER DECLARATION ul — yr I hereby affirm that I ain exempt from the Contractors License Law for the [_- Z C following reason. (Section 703 1.5, Business and Professions Code: Any city or county f2 p which requires a permit to construct, alter, improve, demolish, or repair any structure rn = ec prior to its issuance, also requires the applicant for such permit to file a signed statement °• 3 — that be is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 c ® Z z® Pa � 2a � P Z U ® E" U (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 Section 7031.5 by any applicanrYor a permit subjects the applicant to a civil penalty of nor more than five hundred dollars ($500). ❑ L as owner of the property, or my employees with wages a's their sole compensation, '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 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.). ❑ Las owner of the property, am exclusively contracting with licensed contractors to construct the project (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 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, 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 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:. I C (m ar»er: �l� ��• �h 5. CW'olicy No.: \14 CERTIFICATION OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shah not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant - NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY' I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 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 liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTAND A' W 0 \1PLY WITH ALL N N- P041rT SOURCE REGULATIONS. ((� 15�4� Signature of Applfc=11C cmr T Date HAZARDOUS MATERIALS DISCLOSURE 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)? ❑Yes No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ` f� El Yes (�No I have read the hazardo'u's \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 a tenant, that it is my responsibility to notify the occupant of tote requiperp9uts which must be met prior to issuance of a Certificate of ��vro „pry 1 Owne or jidilicrizd agent Date ( ede) z7 /- 2 4Z 2- S' NO. CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB MECH f—1 L--:J L❑ Job Description TENANT IMPROVEMENT. (REMODEL PANTRY FOR ADA UPGRADE) Sq. Ft. Floor Area Valuation APN Number Occupancy Type 101 - FOUNDATION 102 - PIERS Required Inspections 103 - UFER 104 - REBAR 105 - ANCHOR BOLTS 106 - 'SEWER & WATER 202 - UNDERFLOOR PLUMBING 203 - UNDERFLOOR MECHANICAL 204 - UNDERFLOOR FRAME' 205 - UNDERFLOOR INSULATION 301 - ROUGH PLUMBING 302 - TUB & OR SHOWER 303 - ROUGH MECHANICAL 304 - ROUGH ELECTRICAL 305 - FRAME 306 - HOLDOWNS 307 - INSULATION 308 - tSHEETROCK 309 - EXTERIOR LATH• - 310'- INTERIOR LATH 311 - SCRATCH COAT 313 - ROOF NAIL 501 - FINAL ELECTRICAL ENERGY 502 - FINAL PLUMBING ENERGY 503 - FINAL MECHANICAL ENERGY 504 - FINAL BUILDING ENERGY 505 - FINAL ELECTRICAL 506 - GAS TEST 507 - FINAL PLUMBING 508 - FINAL MECHANICAL 509 - FINAL GRADE 510 - FINAL PLANNING 514 - N WORKS Issued by: Date Re -roofs Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Applicant understands and will comply with all non -point source regulations. Signature of Applicant Date All roof coverings to be Class "B" or better OFFICE