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02040146-FP• 0 CITY OF CUPERTINO C" OF CUPEkTNO D 2- ® e( 0 (4 APN # Fee Description Date: Building Address: .- D � L -L -l` z- 1 :19�*L a MECHANICAL O er's Name: Boiler <= 100,000 Btu Phone #: Contractor: �n � Boiler > 100K to 500K Btu License #: 61�1 C Contact: Boiler > 500K to 1M Btu Phone #: Applicant/Contractor: �) JvD "� p Fax #: Bu* i Permit Info: ldg Elect Plumb Mech escription: Residential: �� / "� ��*mggarm BUILDING Sq.Ft. Floor Area: Ind/Off/Comm/Quasi $/Sq.Ft.: Architect/Engineer: Con. Tax for BQ Zone Valuation: � 15�1" Type of Construction: L2!!�x Occupancy G oup: Quantity Fee ID Fee Description Fee Gaon BAPPLOTHER Other Appliances MECHANICAL 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 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 BELEC 1000 Elec 600V <= I OOOA ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING 1 of 3 000 V y¢a rn OOZKE] N eXCC¢ X s U ry3av u`3 aa,= X r,.i u: F Z Q izc rY Lit Z CITY OF CUPERTIIVO BUILDING DIVISION CONTRACTOR INFORN*ION: F ERI T BUILDING ADDRESS: 21405 HOLLY OAK DR CUPERTINO KITCHEN DESIGNS PERMIT NO. 02040146 e KURT AND RENEE 10562 S DE ANZA BLV APPLICATION SUB DATE 04/26/2002 PHONE: '(408) 257-4900 SANITARY NO. CONTROL NO. ARCMTECTIENGLNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH F_ i LJ L .1 L_,J LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Sec 0 7 ) of Division 3 of the B si ss and Professions Code, and my license is in full fo an I%U � ADD 6 8 4 S Q .FT . License ic. fF e i O ora or ARCHITECT'S D ARATION 'und rand my s shall be use public records Lic fe i al 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 $150000 which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement 3 6Wtt0�1, 00.; � ' ,t • Valuation tl?adhe is licepsed puisuant to theprovisioms of the Contractors License Law (Chapter 9r (commencing with Section 7000) of Division 3 of the Business amd Professions Code) or rhos tie is exempt therefrom ar�d the basis for the alleged exemption. Any violation . ?- ,: V, - _+, , .: of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (s500). 10 1 ARN NgUt flAT I ON Occupancy Type ❑ 1, as owner of the property, or my employees with wages as theirsole compensation, 102 — PIERS 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 104 — REBAR 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 105 - ANCHOR BOLTS completion, the owner -builder will have the burden of proving that he did not build or improve for purpose ofsale.). 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 Contractor's 203 — UNDERFLOOR MECHANICAL 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 204 . — UNDERFLOOR - FRAME ... ... - ._. . Contractors License Law. ❑ I am exempt under Sec. , B & P C for this reason 205 — UNDERFLOOR �: I NSULAT I ON 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 ME CHAN I CAL ❑ f 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 305 performance of the work for which this permit is issued. — 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 worst for which this permit is 307 — INSULATION issued. My Worker's Compensation Insurance carrier and Policy n bel ar 1' .0 00 r ��Poiti�po.: ��~ 308 - ..i ..- .. .-. - .. SHEETROCK �C err?/�T� JG CERTIFICATION OF EX ON FROM WORKERS' 3109 i= �EXTERIOR� • LATH'. COMPENSATION INSURANCE - -3 1 0--• — INTERIOR- LATH— (This section need not be completed if the permit is for one hundred dollars 311 - SCRATCH COAT ($100) or less.) 313 - ROOF NAIL - - - I certifythat in the performance of the work for which this Pe ct to t e Wored, l shall not employ any person in any manner so as to become subject to the Workers' 501 — FINAL ELECTRICALENERGY Compensation ion Laws of California. Date Applicant 502 - 03 - F I NAL PLUMBING ENERGY F I NAL MECHANICAL ENERGY ' NOTICE TOAPPLICANT: If, after making this Certificate of Exemption, you should5 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. 504 — F I NAL BUILDING ENERGY _ CONSTRUCTION LENDING AGENCY 505 — FINAL ELECTRICAL ' I hereby affirm that there is a construction lending agency for the performance 5 0 6 - GAS TEST of the work for which this permit is issued (Sec. 3097, Civ, C.) Lender's Name Lender's Address 507' — F I NAL PLUMBING . 50 FINAL MECHANICAL 1 certify that I have read this application and state that the above information is correct. I agree to comply laws 5 9- I NAL G DE with all city and county ordinances and state relating to building construction, and hereby authorize representatives of this city to enter upon 5 0 the above-mentioned property for inspection purposes. — I NAL NG (We) agree to save, indemnify and keep harmless the City of Cupertino against 51 — I NAL RKS liabilities, judo encs, cows and expenses which may in any way accrue against said City in co q nce of the graining of this permit. r1 APPLIC . NDERSTANDS WILL CONIPLY WITH ALL NON -POLYP Issued b Date SOUR ATIO,'S. yi ig re Applicant/Contractor Date Re -roofs HAZARDOUS MATERIALS 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 0 01I All roofs shall .be.inspected prior to any roofing material being.installed. Will the applicant or futurebuilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove errrit hazardous air contaminants as defined by the Bay Area Air Quality Management Distriet? ❑ Yes 10 all new materials for inspection. Applicant understands and will comply with all non -point source regulations. I have read the hazardous 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 equirements ich must be met prior to issuance of a Certificate of Occupantkoo�� Signature of Applicant Date All roof coverings to be Class `B" or better ' O ne ze agent Date —A