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02060072-FPCHTY GIF CUPERTENG CITY or 1r ERMET A 1r J.L ECA T1LO ]FORM APN # � � � _ O 3 � Date: Fee IIDescrn tnon Fee Group Building Address: ) 2 z12 3 P, vas / II F- 60 `-lluo 95-0 / �- Owner's Name: I 7i- Imif s T. ?7 $L,4 ' To Phone #: 4/0 v Construction Tax Contractor: License M BCONSTAX Ind/Off/Comm/ uasi Contact: Phone M BCONSTAXBQ Con. Tax for BQ Zone Applicant/Contractor: Fax #: BCONSTAXH Hotel and Motel 9 ldg :ription: rmit Info: Elect Plumb Mech Constax — Resi/Mobile 4 C R�1: S4�Residential: Elec 600V <= 1000A Sq.Ft. Floor Area: S /Sq.Ft.: BELEC 1001 Elec 600V > 1000A Architect/Engineer: Valuation: BELEC200 �- Type of Construction: Occupancy coup: Energy Quantity Fee RD Fee IIDescrn tnon Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUII. )ING BCONSTAX Ind/Off/Comm/ uasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC 1000 Elec 600V <= 1000A ELECTRICAL BELEC 1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V'<= 200A ELECTRICAL B EN ERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA 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 BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of 3 27. elS woo tv U G F Z u] y q � i Z p t: �42< :O U i30 . tiOq N } 1 a p ul v. F Z Q ce FC c Is. i h ® Z C Z C ®� U Z CITY BU NG DIVISION CONTRACTOR aNT(GRA070N. MOT BUILDING ADDRESS: PERMIT NO. 22423 RIVERSIDE DR 02060072 OWNER'S NAME: APPLICATION SUB DATE TOY THOMAS T AND MAY F TRUSTEE 06/13/2002 PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license ADD 135 SQ . FT . / SHOWER is in full force and effect. License Class Lic. q Date Contractor ARCHITECT'S DECLARATION I understand my plans shall be used as public records t Licensed Professional OWNER - BUILDER DECLARATION 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 which requires a permit to construct, alter, alter, improve, demolish, or repair any structure $1316 5 prior to its issuance, also requires the applicant forsuch permit to file a signed statement g ,t � r ,ga ' fl pCS Valuation that he B licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) , , 3 SSR_ 1B ; U 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 ($500). 71��j��.�.,7j�j g�qt�y_� 10 1�N 1" V V LV LAT I ON Occupancy Type ❑ I, 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 Contractor's License Law does not apply to an 103 - - UFER Required Inspections owner of property Who builds or improves thereon, and who does such work himself REBAR or through his own employees. provided that such improvements are not intended or 10 4 - offered Tor 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 0-1, 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 Contractor's License Law does not apply to an owner of property who builds or improves thereon, 203 — UNDERFLOOR MECHANICAL and who contracts for such projects with a contractor(s) licensed pursuant to the 2 04 - UNDERFLOOR FRAME C�pnitiattor's icense Law. & PJlame plunders ,B P C for this reason 205 - UNDERFLOOR INSULATION Owner Dale 6(ty /oy 301 - ROUGH PLUMBING WORKER'S C MPENSATION DECLARATION 302 - TUB & OR SHOWER I hereby affirm under penalty of perjury one of the following declarations: 303 — ROUGH MECHANICAL CAL 1 ❑ 1 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 or the work for which this permit is issued. 305 7� — FRAME ❑ 1 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 307 - INSULATION issued. My Workers Compensation Insurance,carrier and Policy number are: 308 - SHEETROCK carrier: Policy No.: ' CERTIFICATIOVI''FJLEMPTION FROM WORKERS' 309 — EXTERIOR LATH ' COMj ENSATION SURANCE - 3 10' - '----- INTER'IOR- LATH (This section need not be compTe[' if the pem it is for one hundred dollars 311 - SCRATCH COAT ($100) or less.) 313 - ROOF NAIL I certify that in the performance of the work for which this permit is issued, 1 ps /Zcome subject to the Workers' 501 - FINAL ELECTRICAL ENERGY Compensation in: f Califomra3n�Di Cngerjo Applicant L Ql _ / /Z, ((.�,5 502 503 - FINAL PLUMBING ENERGY - FINAL MECHANICAL ENERGY NOTICE TO APPLICANT: If, after making t1lis 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. 504 - FINAL BUILDING ENE RGYi. CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL ' Thereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) 506 - GAS TEST Lender's Name Lender's Address 507 _ - FINAL PLUMBING I certify that I have read this application and state that the above information is 508 - FINAL MECHANICAL , correct. I agree to comply with all city and county ordinances and state laws relating 509 - FINAL GRADE to building construction, and hereby authorize representatives of this city to enter upon the above - mentioned property for inspection purposes. 510 — FINAL PLANNING (We) agree to save, indemnify and keep harmless the City of Cupertino against FINAL PUB WORK liabilities, judgments, costs and expenses which may in any way accrue against said 514 - WC City in consequence of the granting of this permit. APPLI UNDERSTANDS AND L COMPLY WITH ALL NON - POINT` Issued b (/ Date soi RGn U u°NS. 4V /3/,o Z y: �ignature of ApplicantlContractor Date Re -roofs HAZARDOUS MATERLMS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material Type of Roof as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety ' Code, Section 25532(a)? ❑Yes No 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. A_ pplicant understands and will comply with ❑Yu all non -point source regulations. 1 have read the hazardous materials requirements under Chapter 6.95 of the Califomia 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 ohich m ust be met prior to issuance of a Certificate of �f_F 44-31,111 Signature of Applicant Date -f/f All roof coverings to be Class `B" or better Owner or authorized agent Date OFFICE