The URL can be used to link to this page

02100020*CITY OF CUPERTIlN(P ary of PERMIT APPLICATION FORM CUPERJINO O 2_� 0-a-v 2- 0 APN # 3i L Date: �, Z Building Address: , Owner's Name: - -- jcc d JLJ l4 Phone #: Contractor: License #: MECHANICAL Contact: Phone #: Applicant/Contractor: Fax #: B 'lding Permit Info: Bld F, Elect Plumb Mech /,,� .� � � f -Residential: C is . Sq.Ft. Floor Area: $ Sq.Ft.: Architect/Engineer: Valuation: BCONSTAXH Hotel and Motel Type of Construction: Occupancy G up: BCONSTAXR Constax — Resi/Mobile Quantiq Fee ID Fee Description Fee Group 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 BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V < =1000A ELtCTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Ener2v 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 BNUCOM /fM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING ��ql 1 of 3 LUOZ O K W t= V Z v�,ay t nz Z OZ= , 3:0LO iNWr� uai°_�p0 aX °m� m-'y ��O 0 Q z0 �(/) r--t fit ; at � �Dz UO Fa U CITY OF CUPERTINO BUILDING DIVISION PER T CONTRACTOR INFO... ION: BuIL2I2G.3',MFsCUPERTINO RD PERMITNq02100020 ow OSCKENIUS JAN H ET AL APPLWAT19I"(RTTE/2002 // / PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACT'OR'S DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter (commencing DECK EXTENS I ONob Description with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. N Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER - BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the $18400 following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to conswct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the prbvisions of the Contractor's License Law (Chapter 9 33A 993 Wb- dAr80 Valuation (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 J-UAPN-NIhYiNiNJATi0N Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars (5500). 102 — PIERS ❑ 1, as owner of the property, or my employees with wages as their sole compensation, — Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business Professions Code: The Contractors License Law does to and not apply an owner of 104 - REBAR 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, 105 — ANCHOR BOLTS however, the building or improvement is sold within one year of completion, the owner- 106 — SEWER & WATER builder will have the burden of proving that he did not build or improve for purpose of sale'). 202 - UNDERFLOOR PLUMBING 1, as owner of the property, am exclusively contracting with licensed contractors to 203 - UNDERFLOOR MECHANICAL construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and . 204 — UNDERFLOOR FRAME who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. 205 - UNDERFLOOR INSULATION ❑ 1 am exempt under Sec. , B & P C for this reason 301 - ROUGH PLUMBING Qwplr - ` ate 4 302 - TUB & OR SHOWER WO KM'S COMPENSATIONDECLjr1GN 1 303 - ROUGH MECHANICAL 1 hereby affirm under penalty of perjury one of the following declarations: 304 — ROUGH ELECTRICAL ❑ I have and will maintain a Certificateof Consent to self-insure for Worker's Compen- sation, as provided for by Section 3700 of the (tabor Code, for the performance of the work for which this permit is issued. 306 - HOLDOWNS ❑ 1 have and will maintain Workers compensation Insurance, as required by Section 307 - INSULATION 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 are: 308 — S HEETROC K Carrier: Policy No.: 309 - EXTERIOR LATH CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 310 - INTERIOR LATH (This section need not be completed iflhe permit is forone hundred dollars ($100) 311 - SCRATCH COAT orless.) 313 - ROOF NAIL I certify that in the pc1,fQrrygnce of the work for which this permit is issued, i shall not 'Compensation 5 01 - FINAL ELECTRICAL ENERGY employ any person in n n rsoz tob comesultiecytol rrkers Laws of Cali7ia. Da c'� • L(/C% •C 502 503 - FINAL PLUMBING ENERGY - FINAL MECHANICAL ENERGY Appiicam 0 26 —• N I E T PPLICANT: If, after making this Certificate of Exemption, you should the Worker's Compensation the Labor Code, subject to provisions of you must 504 - FINAL BUILDING ENERGY forthwith comply with such provisions or this permit shall be deemed revoked. 505 - FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of 506 - GAS TEST the work for which this permit is issued (Sec 3097, Civ. C.) Lender's Name 507 508 - FINAL PLUMBING - FINAL MECHANICAL Lenders Address 1 certify that 1 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 509 - FINAL GRADE building construction, and hereby authorize representatives of this city to enter upon the 5 FINAL PLANNING 1 above - mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against 14 FIN I WORKS liabilities. judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date V SO CE REGULATIO S. Re -roofs Type of Roof - rc of Applicant/Contractor 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, 25532(a)? All roofs shall be inspected to any roofing material being installed. 0Yes 334e prior 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 az d fined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes u 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- niaHcalth &Safety Cade, Sections 25505, 25533 and 25534.1 understand that ifthc 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 iss ance of a certificate of occupancy Signature of Applicant Date s 1 All roof coverings to be Class "B" or better JWadi or authorized agent Date oe« �tur M ogaa 3yV CLL�� w�p0 hZt D 'M z z° eW. � �z UO_ OF V) U7a- A CITY OF CUPERTINO '• ' " " �q BUILDING DIVISION PERMIT CONTRACTOR INFORMATION au11121 MEsCUPERTINO RD PERMITNT2100020 �iT89CKENIUS JAN H ET AL APPLICATI(ll•�I1CSV2002 // 77 PHONE: SANITARY NO. CONTROL NO. ARCHITECTIENCINEER: BUILDING PERMIT INFO BLDO ELECT P0 LUMB MECH 0 0 LICENSED CONTRACTOR'S DECLARATION I herehy.f0rm that l am licensed under pmvisionsnf Chapmr 9 (commencing DECK ob Description EXTENSION with Section 9rMM)of Division 3o1 the Business and Professions Code,and my license is �ii�P �e�� in full force and effect. !'� e License Class Lic.as Dam TSDECL ARCHITECTS DECLARATION I JAN 2 � 8 ^003 understand my plans shall he used as public records C Licensed Professional OWNER - BUILDER DECLARATION BY Q �'� I hereby affirm that I om except from the Commerce., License Law for the ®I G 4 O O following reason. ( Section 7131.5, Business and Professions Code: Any city or county which requires a permit tu construct, aluc. improve, demolish, or repair any structure prior to in issuance, also respires the applicant for such Permit o rile a signed statement that he is licensed Pursuing tot the provisions of the Connacwr's License Law (Chapter 9 3kq.H3.0tibAAI@zO Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Codc) or that he is exempt therefrom and the basis far the alleged exemption. Any violation of N-N Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of nut mom Nan five hundred do[].. ($50B. 102 — PIERS ❑ I. as owner f the progeny, or my employes with wages as their role competwtion, Required Inspections will do the work, and the swmure is not intended or offered for sale 7(164, Business and Prefiguring Code: The Com ucloes License law does not to an owner of apply 104 - REBAR property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements arc not Intended rroffered forsale. If, 105 — ANCHOR BOLTS however. the building or improvement is sold within ore year o(completion, the owner- lO6 — SEWER & WATER builder will have the burden of proving that he did not build or improve for purpose of axle). 202 - UNDERFLOOR PLUMBING 1, as owner of the property, am exclusively contracting with licensed central a to 2 0 3 - UNDERFLOOR MECHANICAL comunet the project (Sec. 7044, Business and Professions Code:) The Contract Li- can seLawdoesnotapplytoanownerofpropertywhobuildsorimprawsthereon ,and 204 - UNDERFLOOR FRAME whocormacts far such projects with ecomrnt9or(a7licenxa puravamw the Conrenrr'e License Lew. 205 — UNDERFLOOR INSULATION I am exempt under Sec. B &P C for this noun 301 - ROUGH PLUMBING !!- == - 4 ��WO 302 303 - TUB & OR SHOWER - ROUGH MECHANICAL �''}�am KERSCOMPENSAT1oN DOCZWON I hereby aRrm under penalty of perjury one of the fallowing declarations: 304 — ROUGH ELECTRICAL 0 l have and will mainWn a CcAficam of Convent in self imum for Worker's Compen- e labor Code, for performance of the aation, u provided for by Section 37M of th the 3O5 — FRAME work for which Nis permit is burned, 306 — HOLDOWNS ❑ I hale and will maintain Workers Compensation Insurance, u required by Section 3 07 - INSULATION 3710 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation lnsuanee canner and Policy number are: 308 — SHEETROCK Carrier: Policy No.: 309 - EXTERIOR LATH CERTIFICATE OF EXEM PnON FROM WORKERS' COMPENSATION INSURANCE 310 - INTERIOR LATH (Thissectionneed nodMcompleted ifthe permitisforrne hundmddella .(gIM) 311 - SCRATCH COAT orlcas.) 313 - ROOF NAIL I certify that in the tie men the work ror which this permitisissned ,Ia hall nor 501 - FINAL ELECTRICAL ENERGY until n an .on in n n rso tu omc su ec mkcrs'Cnm nsadnn ofceliitza. �� Las DO • • 502 503 - FINAL PLUMBING ENERGY - FINAL MECHANICAL ENERGY �S5 Applicem yam- niloZE,.(� '— NQII(aETO•APPLICANT: If, after making NisCenifcncof Exemption. you should b� subject to the Worker's Compensation provisions of the laMn Code. you mum 504 - FINAL BUILDING ENERGY forthwith comply with such provisions err this permit shall he deemed revoked. 505 - FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY I hereby affirm that there is. cingroG n lendingagemcy for the performance of 506 - GAS TEST the work for which this permit is issued (See. 3(97, Ch.. C.) Lender's Name 507 508 - FINAL PLUMBING - FINAL MECHANICAL Lenders Address is correct, l 28MC to comply with all city and county ordinances and sou laws misting to I cenify but 1 have (cad this application and sum that the aMwe inter 509 - FINAL GRADE upon t building consuucdion, and hereby aulhorirc mprescnmtives of this city m corer upon the 5 FINAL PLANNING propurty for purposes. (We) .gee to save, indemnify and keep Wordless; the City of Cupertino against 14 FIN WORKS expenses costs and expensewhich may in any way accmc against said City /. /. in of AAPPLICANT of the granting of this permit, APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: 11 aC Date V �/ SO CEREGULATI S. Re -roofs Type of Roof it m of ApplianVConracwr Dam HAZARDOUS MATERIALS DISCLOSURE Will the applicmd or future building occupant store or handle huaNOU mamrud defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety I,.SeeStm25532(a)7 ❑Yea gir All roofs shall be inspected prior to an roofing material being Installed. P P Y g g If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant tor furore building rccupam use cyripmenl or devices which emit hauNous air cuntaminaner m JS fined by tM Bay Area Air Quality Management all new materials for inspection. Diari.L Ycs �j/ Chaper6.95 1haveread these, mamr)5.255 Sections 3and2 Sunder if reCulding nix Health& SafcryCuJC ,Sectinm25N)5,2553Jand355J4.l undcrvanddwif Jm Wilding dins not currently have . mmm, that h Is my responsibility In modify the oc upam of the requirements which mug medpnorui ancenfaCeNOeamorOCapamy. Sign atureofApplicant n�:e All roof coverings to be Class "B" c r better rnramhowedagent Date' DECK EXTENSION Jan Stoeckenius /Julia Tien 22386 Cupertino Road Cupertino, CA 95014 R� 100, 11 rQ- q F w CUPERTINO ROAD ion AK e a-� c ' co CQ J } i E 0 I 3 µ l° � �: •� (� ..F � tiµ d �s a ;�, x� ws ' (i RED ufl, M 1 - O INI-ui z E hi' mac' f�6 U H3 MIA HE ED Ta Z > O o CI LOI 010�- ER � C=ff EI vEFd Will 6-8 7g HT U H3 MIA HE ED Ta Z > O o CI LOI 010�- ER � C=ff EI vEFd Will p 21 vffg�-rv!- I—� u- P- A — A 0 6-8 p 21 vffg�-rv!- I—� u- P- A — A 0