01100098-FP t�T Y ®IF COUP ERTHN®
�•
��++ CITY OFp�I P RMH 1L APP LECATE®1V FORM
�1..UPEkTING
APN# �v.� .— . -- 02, Date:
/0— / ?
0— / ? —
Buil ... gAddress•:
Owner's Name: Phone#:
V
Contractor:�i C � C License#:
Contact: t C Phone#:��
Applicant/Contractor:
Building Permit Info:
1 Elect Plumb Mech
Job Description: A,,-r6�
esidentia : Commercial:
-Sq Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: Snoo
Type of Construction: Occupancy Group:
—Quantity ]Fee IID Fee Descir➢ tion Fee Grod
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 MECHAMCAL
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
BEN ERG Y Energy BUILIDIIY(G
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
1 of e ��
CITY OF CUPERTIINO
BUILDING DIVISION p RM1Q O �NTRA TUIR is O M AT
BUILDING ADDRESS: �4 PERMIT NO.
7558 HEATHERWOOD DR MCKENNA LANDSCAPE" 01100098
OWNER'S NAME: APPLICATION SUB DATE
BUCKEL JOHN J AND ELIZABETH R 15573 BENEDICT LN 10/17/2001
Cl PHONE: SANITARY NO. CONTROL NO.
(408) 356-1842
0 O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
z to" BLDG ELECT PLUMB MECH
F U E; L____1 I=1 L_) L-1
m¢�
LICENSED CONTRACTOR'S DECLARATION
N z Job Description
Z
= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
�,-aa with Section 7000)of Division 3 of the Business and Professions Code,and my license ADD ARBOR.
x is in full force and a act
ce aee Class Lia kVy
3
0
Contractor
h ARCHITECT'S DECLARATION
y I understand my plans shall be used as public records
a p O Licensed Professional
X o OWNER-BUILDER DECLARATION
w- I hereby affirm that I am exempt from the Contractor's License Law for the
C Z¢ following reason.(Section 7031.5,Business and Professions Code:Any city or county
mx G which requires a permit to construct,alter,improve,demolish,or repair any structure $5000
tit C,2, •prior to its issuance,also requires the applicantdor such,permit to files signed statement ... _.
a 3- that h$is licensed pursu(tnt to the prbvisimu of the Contractor's License law(Chapter 9 �alllatlOII
(commencingwith Section 7000)or Division 3 of the Bosinrss nd Professions Code y t'�. tQ( j[n'�D)r' a 'Z , �. t r ,
or that he is exempt therefrom and the basis for the alliged exemptioti.Army violation L�3 "" '"" ' "U ; ''
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500). 1 0 PuD N rMftAT I ON Occupancy Type
❑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, 1:02 PIERS
'Business and Professions Code:The Contractor's License Law does not apply to an 103 - UFE R 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 104 - REBAR
offered for sale.If.however,the building or improvement is sold within one year of 10 5 - 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
O l 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
License Law does not apply to an owner of property who builds or improves thereon, 203 - UNDERFLOOR MECHAN I CAL' '
and who contracts for such projects with a contnctor(s)licensed pursuant to the
Co204 - UNDERFLOOR FRAME '
ntractors License Taw.
❑1 am exempt under Sec. B&P C for this reason 205 - UNDERFLOOR INSULATION
Owner Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: 302 V 2 - TUB & OR SHOWER
303 - ROUGH MECHANICAL
❑ I have and will maintain a Certificate or Consent to self-insure de Worker's 3 04 - ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 0( the labor Code, for the
performance of the work for which this permit is issued 305 - FRAME
• ❑1 have and will maintain Worker's Compensation Insurance,as requited by Section 306 - HOLDOWNS
• 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 numberare: 307 - INSULATION
ea;;�LGi'S '• Policy JWoco19A1-Onl 3,08 - ;SHEET,RQCK
'CERTTFICATION OF EXEMPTION FROM W,OR"RS'j- 309' '-EXTERIOR LP,TH
COMPENSATION INSURANCE'
(This section need not be completed it the permit is for one hundred dollars 316. INTERIOR LATH .
($100>arlesea 311 - SCRATCH COAT
I certify that in the performance of the
m
work for which this petit is issued,I 313 - ROOF NAIL
shall not employ any person in any manner so as to become subject to the Work=s 5 01 - FINAL ELECTRICAL ENERGY
Compensation Lavii of California.Date
Applicant - ' ' 502 - FINAL PLUMBING ENERGY
-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 503 - F I NAL MECHANICAL ENERGY
® o forthwith'comply with Such provisions or this permit shall be deemed revolved.
504 - FINAL BUILDING ENERGY
toCONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perfon.. 5 0 5 - FINAL ELECTRICAL
of the work for which this permit is issued(Sec.3097,Civ.C.) ; 506 - GAS TEST
Lenders Name
�.z Lender's Address 507 - F I NAL PLUMBING
O ® I certify that I have read this application and state that the above information is 508 - F I NAL ME CHAN I CAL
fit'H, correct.I agree to comply with all city and county ordinances and state laws relating 509 - FINAL GRADE
OU to building construction,and hereby'authorize representatives of this city to enter upon
a4 W1 the above-mentioned property for inspection purposes. 510 - F I NAL PLANNING
[y..@y ('We)agree to save,indemnify and keep harm ess the City of Cupertino against
b V] liabilities,judgments,costs and expenses which may in arty way acme against said 514 - FINAL P C WORKS
U r%.� City in consequence of the granting of this permiL' ` '
APPLICANTUR UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
�a a'i.G..-.. /OLl /B I
Signature o pplicam/Contractor 'Date' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
iU the applicant or•funim building occupant store or handle,hazarilm material Type of Roof
•- as'degned by;the Cupertino.Mutdcipal;Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?, � / .� • .
oyes"- j�Nn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or furtare999building occupant use equipment or devices which If a roof is installed without first obtaining an inspeeti6n,I agree to remove
emit hazardous air comaminan az defined by the Bay Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
. ❑Yes o all non-point source regulations.
I have lead the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Seifions 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 the requirements which must be met prior to issuance of a Cettificate'of
occapmcy' / Signature of Applicant Date
Own=or authorized agent g
All roof coverings to be Class«B„or better
• Date
- OFFICE