01110022-FPct ry OF CUPERTINO
PERMIT APPLICATION FORM 2 2-
CUPEkTINO ,
APN #
Fee,,.Description
Date:
BAPPLOTHER
Buildti Address
1 -T-k
MECHANICAL
;BBLDGFEE
0 97 L-A
Boiler<= 100,000 Btu
Contractor:
License #
c) 4
Contact:
Boiler > 500K to IM Btu
Phone #:
Applicalit/Contractor:
�20 1M to 1.75 M Btij
Building Permit Info:
BI g�,r''� Elect
Plumb
Mech
Job Description: Je4Tr-4v---), LA -"Nd
'I-4*Al
Puv-bt. � ;/
Residential: i(t;AI;7k4�
4
Commercial:
Sq.Ft. floor Area:
0 .4- 1-
$/Sq..Ft.:
Architect/Engiiieer:
otel iiid Motel
Valuation:
t Constax - Resi/Mobile
Type of Construction:
Elec 600V 1000A
-Occupancy Gro p: f
1 of
3-80
Fee,,.Description
Fe�.( roup
BAPPLOTHER
MECHANICAL
;BBLDGFEE
Bldg Permit sq. foot
Boiler<= 100,000 Btu
Boiler > 1 OOK to 500K Btu
MFCHAN.- AL
Boiler > 500K to IM Btu
1
�20 1M to 1.75 M Btij
7911la"EmIdle
ff Boiler > 1.75M Btu
in &I V-4) IFA Z, I
�BCONSTAX
Ell W M�
1.0-wo
Ing-es"I nn�
Con. Tax for Zone
BQ
I •
otel iiid Motel
IRWITH =H, 9
t Constax - Resi/Mobile
Elec 600V 1000A
1 2-a 11 an Lfraw's
Elec 600V > 1 OOOA
--inavulfty-weal
BELEC200
Elec Svcs 600V <= 200A
��rM Add Multi
Sy
iiiiInvestigation fee
Comm. Hou�I�ee
mlwbjfikl�
1 of
3-80
� 7-
2F
U 0
U
CT OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTDR INFORMATY- T:
BUILDING ADDRESS:
10305 TULA LA
PHONE:
ARCHITFCT/FNGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000), of Division of the Business and FLpflessions Code, d license
is in full for '0
t"(.4censecia 4' Lie, il ;7j"ca
Date I a — —1Cantr for
"s,,, ARCHITECT'S DE%A
u5ic reco;
-1 unders hd my plans shall be used as pu is records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1 .5, Business and Professions Code: Any city or county
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
that Ilia is licensed porsti ' atitto me Provisions of the Contractors License Uw (Ch
(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 applicant for a permit subjects the applicant to a civil penal
of not more than five hundred dollars ($500).,
1: 0 1, as owner of the property, or my employees with wag" as their sole compensation,
j"will do the work, And the structure is not intended or offered for sale (See. 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
1 '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
i improve for purpose of sale.).
11 a, 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.
0 1 am exempt under See. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 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.
01 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 11
1 issued. My Worker's Compensation. Insurance.carrier and Policy number are:
car
Policy No.:� -7 — 0,
n'efF;'r*'r1= t4
dE FI ATION OF EXEMPTION FROM WORKERS.'
COMPENSATION INSURANCE,
'frhis section need not be completed if the permit is for one hundred dollars
i ($100) or less.)
Itiertify that in the performance of the work for which thisPermit is issued, I
ibalf not employ any person in any manner so as to become subject to the, Workers'
Compensation
on'
n Laws of California
Appl=L
us
"
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
i 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 const action lending agency for the perf6munce i
of die.work for which this permit is issued (See. 3097, Civ. C.
Under's Name,
Lender's Address i
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 prifinsinces,and state. laws relating
to building constriction, and hereby authorize representatives of this city to enteropon
theabove.mentioi purposes.
e, lxr�oc 1, or qd
�cr inspection
C) to ridemnify and keep haimiless the City of Cupertino against
0 dg ent%crsets a exp s hick truty, in anyway accrue against, said
T se mi of penni .
City conseq
Joe th
C, y cc be
CANT INDERSTAND NO LL COMPLY WITH ALL N[,,N-P
r1INT
URCE RE ULATI M to I
'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, Section15532(a)'
0 Yes
ONO'
W'
Will the applicant or future building occupant use equipment or devices which
and ppers-ii,
gra
T (IN
4 7Z
emit hazardous air contaminants as defined by the,'Bay Area Air Quality Management
District?
0 Yes. C3 No
I have ad the hazardous materials re uirements under'Chapter 6.45 of Ebb
"i"
ne
Callfors. 1
if" ' eal & Safety Code. Sectio 25533 and 25534: 1 understandthat
if th ilding es not currently av tenant, at it is my responsibility to notify the
n i in
r of r en r
o pant 0 requirements must et prior to issuance Of aiceftifi ate Of
cup . _ j
upim
ti sr 01
agent
W tel 0 11 ' ♦�_ �Vk M_ �
PERMIT NO.
9 01110022
APPLIC TION S713 DATE
11�( 2001
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
scription
,REMODEL (KITCHENJobDe& BATHRMS, NEW
ELECT PANEL),
Floor Area, Valuation
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:
-. SHEETROCK
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
GAS TEST_
507
'FINAL PLUMBING
-5 0-8.
- . -FINAL - MECHANICAL
509.-
FINAL GRADE
510
ING(a
- FINAL PjEEWG
514
WORKS
WORKS
Issued by:
7-1-2 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
6'
ISOPNIHOII
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