02070145CITY OF
CUPEkTINO
CITY OF CUPERTINO 6 10 7 OP -1r,
PERMIT APPLICATION FORM
APN #
Date.
Fee Description
Building Address:
0400 ST UF -^j5 ciz r- C fc-
Owner's Name:
Phone
C, , Cq&0 -7-,7-1 C_
cl C/ 3 o2 ,301
Contractor:
,,9? -5-50 C- /,A?- 7"6 0 cb,V1,; -k C ro 5
License #:
2ol,;?-? 7
Contact:
,qktr,y�
Phone #:
V06 --.T77 —
Applicant/Contraqtor:
Fax #: 7 1W 7
JQJ
Building Permit Info:
lt'ldg - Elect Plumb Eeqj�
- ToDescription:
Residential: Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft
Architec,t/ifngineer:
/*& C-
V, ati: C) 0
413 -
Type of Construction:
ccuphncy Gro �
ee".aT Z.—Wfqve-,--ti-
1
1 of 3
Fee Description
ua
Other Appliances
Construction Tax
Ind/OfPCop2E�Q
Hill
JQJ
Con. Tax for BQ Zone
Hotel and Motel
Constax — ResWobile
Elec; 600V <-- 1000A
ELECTRICAL
BELEC1001
j Elec 600V > 1000A
--CTRICAL
BELEC200
Elec Svcs 600V <-- 200A
ELECTRI AL
MIMNNIRMMINWIM�
Emer�ymd -Multi-----
0.19) t -4 V
investigation fee
1.1
BMITIGATC
Comm. Housing Mit. Fee
Res. Housing Mit Fee
New Multi-Familv Res
MECHANICAL
New Multi -family Res
.3 a mo im I I
New Comm Electric
ELE TRICAL
New Comm Mechanical
MECHANICAL
RIM
New Comm Plumb
1 of 3
CITY OF CUPEY2TINO
BUILDING DIVISION
PEI, JT
820100 RSTEVENS CREEK BLVD
ASSOCIATED
CONTRACTORS COR7"T2070145
offff&60 TITLE
840 JURY CT APPLICAT,iOdI�I %'� 4'72 0 0 2
PHONE:
4089771400
SANITARYL7NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L—i
LICENSED CONTRACTOR'S DECLARATION}
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
'TENANT
1
I MPROVEML9keSCt ptloil
with Settion7 OO)of Division 3 of the Busine ed Professions Coded my license
is in full fo and eff,
6z 9
--cense C Lic.
ARCHITECT'S DE
4
'
ION
I understand my plans shall be used as ublic records
t
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby I
affirm that am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
14
i 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 lie, bdicensed pur;uint to thg provisions of the Contractors License Law (Chapter 9
_
t (commeacm with'Section 7000).of Division 3 of the Bpsiness and Professions Code)
C or that he fs exempt t(terefrom ariq the basis for the alleged exemption. Any violation
`- ` �°f -
a
: - + t
ValuationY
OMctiorr70315 tiy'anyappiicanr for'aPermit subjects the applicant to a civil penalty
of nor more than fV6 hundred dollars (£500).
.
Occupancy Type
! El 1, as owner of the property, or my employees with wages as their sole compensation,
102 -
PIERS
wi1T'do the; Work: and the structure'is net intended or offered for sale (Sec: 7044, `
_
Required Inspections
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
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
C
- 105 - '-
ANCHOR BOLT.?
completion the owner builder will have the burden of proving that he did not build or
improve for purpose of sate )
106 '•'
SEWER & MATER
ill, asOwner of the property, am exclusively contracting with licensed convectors to
_ 20-2 -
UNDERFLOC7R -PLUMBING .
construct the project (Sec, 7044, Business and Professions Code:) The Contractoes .
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.
_.. _. 2.04 .._.- ._UNDER.FLO9R,
• '
ontractars License Law.
01 amexempt undegSec. - _ B & P C for this season
..
205 -
_ ._. .
UNDERFLOOR I�NSUT ATI ON
.... , ,
Owner ' Lute
301 -
ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION3
0 2 -
TUB & OR SHOWER
' I hereby affirm under penalty of perjury One,of,the following declarations:
303 -
ROUGH ME CHAN I CAL
'.. L) I have and will maintain''a Certificate of Consent to self -insure for Worker's
304 _
ROUGH ELECTRICAL
Compensation
ce as provided for by Section 3700 of the Labor Code, £or the
performanceof the work for which this permit is issued.
3 0 5 -
FRAM","+
_
D I have and will maintain Worker's CompensationaworInsurance, as required by Section
306 -
HOLDOWNS
3700 of the Lobar Code, for the periorntancc of the work for which this permit is
307 -
INSULATION
isiue& My Workers.'Compensation Insurance carrier and PoIicy'number are:
5•iA`T�. �J1Jl�. .
308
SHEETR®CK .. .. ,
_
Carver.
CERT fi p
IF1CATI0N.()F EXE ON FROM WORKERS* '
309 -
'
-'EXTERI OR LATH'
.'. coMPE SATaar?�NsuRaxcs
_ .....-31.0..--,.INTERIOR.._.LA.T.H..._..___..,
,
' '(This section heed not be completed if the permit is for one hundred dollars
311' ' --
SCRATCH COAT .. , :::' : • e ' �`.'
ar less.)
(s100I)71
_ 31,3 —
ROOF. NAIL
' i tertify that in the performance of the work for which this perrnia is issued, I
shall not employ any person in any manner go as to become subject to the Workers'
,
501 -
F I N'AL E,+1_ip'',*�."+,TR,TCAI: , �ENE�1s �" Y , .
Compensation Laws of California. Date -
Applicant '
502 -
F I NAL PLUMBING ENERGY
NOTICE TO APPLICANT: if after making'this Certificate of Exemption, you should
503 _
, , .........
F I NAL MECHANICAL ENERGY
betome'subjeci to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with'suchprovisions or this permit shall be deemed revoked.
504
F I NAZI BUILDING ENERGY
` CONSTRUCTION LENDING AGENCY
505 -
FINAL `
ELECTRICAL506
thereby affirm that there`is a construction tending agency for the potfonfmance
-
`
GAS TEST
of the'work'fof wbidh tits permit is mssged,(Sec 3097, Civ.'C.) "'
Lenddr'sxame - .:_ ....., ;..:
c307 _
508 -
FINAL PLUMBING _. . .
FINAL MECHANICAL—
t enders Addres§
I certify that I have read this application and. state that the above information is
correct:.I agree to gOmply with all city and county ordinances and state laws relating
% 0 -
FINAL GRADE
to building constmction.'and hereby authorize representatives of this city to enter upon
theabove-mentioned property for inspection purposes,
510 -
F I NAL PLANNING
,
!We) agree to save; 4demrisfy'and keep harmless Lhe City of Cuperiino against
514 -
FINAL PUBLIC WORKS
liabilities, judgments, costs and expenses which may in any way accrue against said
City in ,consequence of the •granting of this permit , . • ...
APPLICANT UNDERS'fANDS'AND WILL.COMPLY WITH ALTL NO -POINT
t'-�
f
-N
so' cE noNs '°
Issued by:
Date
Vfoieof Applie. on r, . :- . . . ,�• ''Date
HAZARDOUS MATERIALS DISCLOST AE
11' , Will dieapplicani` or f ltuit'[manding occupant stare or handle hazardous materialt
Of Roof
as defined by the Cupeaino Municipal Code, Chapter 9,12, and the Health and Safety
-
Colla, Section 25532(al? ,
°Yt$
All roofs, shall,be
inspected prior to any roofing. being. installed._
Will the applicant or future building occupant use equipment or devices which
emit hataidous air contaminants is defined by the Bay Area Air duality Management
..
If a roof IS Installed without first obtalniIl an ins ection, I a ree t0 remove
g P g
District'
nYesr,a
all new materials for inspection. Applicant understands and will Comply with,
-point
all non source
regulations: „
'Thava'rebd the hazardous"'matedils-requiremirmi under Cliapfer 6.95 of the
Californfs Health &Safety Code,Seciions 25505, 25533 and 25534.1 understandthat
if the building does notcurrendy have a tenant, that iiismy responsibility to notify the
occiipimi of the requirements which must be met prior to issuance of a Certificate of
Occupancy. ,' ..
Signature of Applicant
Date
All roof Coverings to be Class "B" or better
er pr an her zed open, ' Dau I
CI'OF CUPE
BU
BUILDING DIVISIONSION PERMIT
f CONTRACTOR.INFORMATION:
BUILDINGADDRESS:ERMIT
20100 STEVENS CREEK BLVD
ASSOCIATED
CONTRACTORS COR
T2070145
offNMO TITLE
840 JURY CT
APPLICATdON SDB 72OO2
L `S
ONE:
SANITARYVNO.� CONTROL NO,
4089771400
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
U F
LICENSED CONTRACTORS DECLARATION
Ihereby arrnmtuaIA.licensedaAd,, na,mines ofCh ner96ommemcing
TENANT
7� e$Cil 1100
IMPROVE ML9k?
with genian)000)af Divia;an3ar the Bnsineis/nd 70s1mC911 mylieense
is In full fo a arc
7 �. $ I
��WN /F�, B per®
Ilff 0 `U PS11ia tL—o
License CI Lic. ix
C° t
ARCHITECI"SDEL RATION
SEP 1 2 2002
1 understandrd
my plans shall W used as public recos
Licrnscd Prafcssianal
OWNER-BUILDERatI DECLARATION
,(firm that 1 License Law for she
1,herebyreason,
entrant from the Cosions
Co
1. Professions Code: Any city
rtmoa (Section 70364 Business and
which
1J .DT.bUd U0.YlV(�e'
re s demolish. ore sccounty
se. de swaurt
which requite enamor to cimsbe ol¢A as
W... A sirany
for mad tantrum.
.priono;a;ensid
_ _s;,. a i .s;s
� 'l j 1• r'' r• t ''y
"' ��`' ^'"' '�! •.°. i..'• :- L r 1.• '". L: l : :, n. . •
Valuation
pvlsorcquir,powitionsot Conansrm;uoicense aw(Chater9
(commencingand Professions Code)
witpSectioi tothe provisionsof theheBmines License Law(ChapterCd)
ciihli.Scadan 7001and ba;is o of
in that e A a ede x
m that he ii eAempt ihcicfmrn'And the basis for the Alleged exemption. Any violation
t e
' of Section H131.5 by any applicant for a permit subjects he Applicant to a civil penalty
,ofna most than five hundred dollars(S501)y
1 U IAPN
Occupancy Type
01, as owner of the propcoy. or my employ res with wages as their sant cmnpensatloa
102 -
PIERS
wdrari the work: ad thd-Itrucare'is nm intended orofferedsale (See. Tad,"
Businessand Professions Code: The Contractor's License Law docs not apply m an
-ERRequired
Inspections 10' • ., - :r.
owner of property Who builds or improves thereon, and who does such work himself
104 -
REBAR
that .mph improvements mems ore not intended m
or throw r M1A] own hervoemployees.th Wilding
art�ree�rsal<:Ir;naweser.mebnoamgaeimpra..cmentissaid wiminone year of'
._... "1-05--
ANCHOR' BOLTS._.._..._.__. _. ..._._....-...-,- --.._..._
meawaer
106 -
SEWER & WATER
improveCompletion,
saleerwdInAvemenabenarpm,•ingmath<eieiwtbodeo`
improve for puryase of sale).
_. __
_ . -...202-- -
PLUMBING
UNDERFLOOR -PLUMBING--
sit.
1: as owner of the property. 1 ively < uammg who of n c Co arrors to
consumer
comswct the pro3en ISe< 7a4, Baskets ria Rafesuons Coee.) The Contnnor'a
203 -
UNDERFLOOR MECHANICAEI
License Law does not Apply to vn owner of property who builds car improves thereon,
2O4_...-.
-
UNDERFLOOR- FRAME
..and who commets.far. such. pmjemS.wim A eoinmmogs) licensed puranam to thA.
Couaia.ea License Law.,, ;,_ _•
_.-._____...
205 -
UNDERFLOOR-INSULATION
R-
❑lam<aemptumder Sec. BPCforthisowwn
301 -
ROUGH PLUMBING"
Ower WORKER' S COMPENSATION DECLARATION
302 -
TUB & OR SHOWER
Ihereby arctmund.rv<twit,ofkrju;yanepr,mgrmlowingdecla a.mrs:
03"1
303 -
ROUGH MECHANICAL
hacc'and will mmmdin'la 6itircate of Consent to self-insure for Workers
304 -
ROUGH ELECTRICAL
Compensation. As provided for by Section 37M of the Labor Crude. for the
305 -
FRAME
performance of the work for which this permit is issued,,
306 -
HOEDOWNS,
❑ 1 have and will maintain Workers Compensation InsumbEe, as requited by Section
307 -
INSULATION
37W of the labor Code, for the performance of m< work for which this permit is
issued MyW kers Co penvton lmonnce carrier and Policy her Are; -
r
308 -
SHEETROCK
57/-:iii a ;r
c.m 57N'rG°'F✓w19 �' noyo�✓�!
`.
!•-' • O'9
t•L`TiTH��
�i l CERTIFICATION OF E NFROMWOR
COMPENSATION INSURANCE:'
"--EXTER-TOR
.; c'3
'='rthi: scmiom'oeca noix�ompieied it me permbis far one nanema aonam
311'''-
'SCRATCH COAT - " •" `I^.' j'iir
(sloo)ar rata.)
313 -
ROOF NAIL
'sI{miry that in me,perfarmarice or ire work for which this pertNi is issued;1
501 -'
_
FINAL ELECTRTCAL-',ENERGY--,'' `-
shall.net employ any person in any manner an as to become subject to the WorkcK
Compensation Laws ofCaliifornia.Date "
502 -
FINAL PLUMBING ENERGY
NOTICE
503 -
FINAL MECHANI CAL: ENERGY' —7,"7---"
1
TO APPLICANT If..fic, main, this cnt➢cam of E.<.,Som. you should
heloma subject to the Worker's Compensation provisions of the Labor Code. you must
504 -
FINAL BUILDING ENERGY
forthwith comply with such provisions or this permit shall W deemed ro k d.
1
' CONSTRUCTION LENDING AGENCY
505-.-.'FINAL
ELECTRICAL
'• thatp.ar..r.
'of
[ending g c.y.f.
im.t.n.._tm.:
506
TEST `
work egthpermit d( 97 ov Cd
Uraer s Neme —A.p .-i,<
.GAS
_._- 507._FINAL-PLUMBING-
_._.... .-,....... _.._ ...
INAL-PLUMBING_.508
.,Ih.
,�.m"which
, ,I.construction..:,. .. ...c;p ..
508-
FINAL MECHANICAL-,
1 canny that 1 have mail this application and state mat me Above information is
509 -
FINAL GRADE
connect. 1 Agree to comply with All city and county ardinmeas and slate laws miming
to Wilding construction. and hemtiy euthonm representatives of this city to enter upon
510 -
FINAL PLANNING ,
the above-mentioned property for inspection purposes.
(We)Agree to sa.<: indemnify and keep hamd<ssihcCity of Cupcninoejaimt
514 -
FINAL PUBLIC WORKS
liabilities, judgments, tutu and expenses which may in any way acerae Against said
Cnyiri consequence of the granting of thi's'perrnis.:;; "' """•"'
w
.: ..
ICE`T U`DERS SNDS AND WILL COMPLY` TINALE'NOV.PoRT'
Issued by:
(Jt.
Date14
SAO
ig Mol'Applicav ° or'- ', r"; " Dte:':I;'
'
Re-roofs
,HAZARDOUS MATERIALS DISCLOSURE
&.0dicamorfram. Wldn ora die orhandl fiva now.rial
g iia
Wnyt
Type of Roof
__ .. .. __.. .-
•- _
mdef d b 'the Cupertino Municipal Code. Chapter 9.12.and the Health and Safety
'S
s 3
, ,:,4, „' .
Cod t 45532(.7 is t �. t _..
is s r-
All roofs, shall. be
` •. i,' . •.
Inspected prior to any. roofing material being installed..._.___....
Will the applicant or future building occupant use equipment ordevices which
If a roof is installed without first obtaining an inspection, I'agree.to`ieinove
ran haaardoos air conmmmanta ns del by the Bay Area Air Quality Management
rt�cn" •"'
all new materials
,
for inspection._ Applicant_ understands and, will Corry y_with,
F .' ; , ., :
all non-point source regulations ; ,;,.
':Ilhe4e readld,e�heieidous'ma¢riolirequiremenduntler Chapter 6.1i5 'd Ne
CaliforniaHedlm & Safcry Code, Scdtiam 25505. 25533 and 5534. 1 understand that
if die building docs na curcndY haveamnnet. Thai it ii mYrmpomibiliiY t°-notify the
occupem of me rego;rements,which must be met room Issuavice of a C'mro ate of
«ups y . ,. .,.
s"-, •�a�
Signature of Applicant
,. Date
_ .. _ ...-. _
All roof coverings to be Class "B" or better ..
lir ar .amarie<a p e �; Dac
lig r. r.'. 1•
..- - <:•."r "a- ,...�.,.. .i.
..--OFFICE.
...... _. ...... _