02080100CITY OF
CUPEkTINO
CITY OF CUPERTINO 6
V#'ERMIT APPLICATION FORM
APN #
Date.
Fee Group
mygymmag �
/9
-02-
Building Address:
N OW
BCONSTAX
lndOWCO
/PIT� �uasi
Wil
Ovwnerls'garne:
Phone #:
37
License #:
j - /eC21
Contractor:
Constax — Resi[Mobile
2-98
-2-3 7i;�t
Contact:
Phone #:
BELEC1001
ifflec 606V > I OOOA
ELECTRICAL
Applican IC ntra tor:
Fax #:
Diego) ,Tft"
111.3
BENERGYADD
4uil . ng P it Info:
BINVESTIGA
!
Bldg i�m Elect Plumb
Mech
,jo�bscription:
.V
Residential: 12fP1-WJ-?, BFWAA�6!KAIZAI CkgM�ommercial:
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W b9it
-35111112 AMUM
Sq.Ft. Floor Area:
$/Sq.Ft.:
a 13,91 W31 S t1j a
Architect/Engineer:
Valuat*
New Comm Electric
ELECTRICAL
Type of Construction;
C cc
lof3
,�
Fee Group
mygymmag �
=l Other A liances
MECHANICAL
IBCONSTAX•its
N OW
BCONSTAX
lndOWCO
/PIT� �uasi
Wil
p
I' Con. Tax fo rpQ Zqn�
Hotel and Motel
I...Lue LIN WWI
Constax — Resi[Mobile
BELEC1000
Elec 600V <= 1000A
ELECTRICAL
BELEC1001
ifflec 606V > I OOOA
ELECTRICAL
600V <= 200A
ELECTRICAL
Diego) ,Tft"
111.3
BENERGYADD
Ene
_p �r Add Multi
BINVESTIGA
Investigation fee
BMITIGATC
Comm. Housing Mit. Fee
.V
Res. Housi�g Mit Fee
■
W b9it
-35111112 AMUM
Lnw Multi -Family Res
MECHANICAL
a 13,91 W31 S t1j a
New Multi -f
New Comm Electric
ELECTRICAL
Mech c
NOW
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r-,
r—APE
CITY OF CUPERTINO
BUILDENG DTMION
PE HT
" k�j
PERMIT NO.
02080100
BUILDING ADDRESS:
10455 GLENVIEW AV
M VA�YENSEN
APPLICATION
0 8 7Y?A/TE2 0 0 2
PHONE:
SANITARY NO. CONTROL NO,
ARCHrIECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L= L_J C -L-1 U__3
LICENSED CONTRACTOR'S DECLARATION
x5rim
I hereby that I am licensed under provisions of Chapter 9 (commencing
t,
Descngion
REPAIR PERIM FN IN ARAGE
with Section 7000) of Division 3 of the Business Professions Code, and my license
is in full fir0l elb,,,
p
Licen C1.pLic.#, Z7e
D, Contra
ARCHITECT' S DEC
I understand my plans shall be used as public records
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
$1950
which requires a permit to consumer, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Valuation
that Ini 6 licensed p0suarit t6.ffe provisions of the Contractoes License Law (Chapter 9
(commencing with Section 79PO) of Division 3 of the Business and Prpfe
,ssions Code)
or that he Is ;iempi therefibm'apil the basis for the alleged exemption. Any violation
of Section 7031.5 by any applicalit Inert permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).
101APNMMATION
Occupancy Type
0 L as owner of the property, - my employees with wages as their sole 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 _....q
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 impnevernent is sold within one year of
'completion,
105
ANCHOR'BOLTS
the owner -builder will have the burden of proving that he did not build or
improve for purpose of sale.).
106
SEWER & WATER
C] I, aiap'wner,of the property, am exclusivelyI - contractingI with licensed con . tractors to
202
T_JNDERF`LOOR 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 projectswith a contractors) licensed pursuant to the
204 .-UNDERFLOOR
--FRAME-
Contractor's License Law,
2AT am e t d Se B & P C for this reason
205 -
UNDERFLOOR INSULATION
301 -
ROUGH PLUMBING
OR R'S COYIPENSATION DECLARATION
302 -
TUB & OR SHOWER
l hereby affirm under penalty of pe4jury one of the following declarations:
303 -
ROUGH MECHANICAL
11 1 halve 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 of the work for which this permit is issued305
"`
FRAME
0 1 have and will maintain Worker's Com pensation Insura I ace, as required by Section
306 -
HOLDOWNS
3700 of the Labor Code, for the performance of the work for which this permit is
"Worker's
307 -
INSULATION
issued. My Compensation Insuraticicarrier and Policy number are:
308
SHEETROCK
Carrier: Policy No,:
CERTIFICATION OF EXEMPTION FROM WQRKrRS'%
30
tk`±-ItRIOR': LATH-:
COMPENSATION INSURANCE
INTERIOR -LATH
(This section need not be completed if the permit is for one hundred dollars
311
8CkATCH COAT
313
ROOF - NAIL
I certify that in the performance of the work for which this permit is issued, I
shall not employ any person I,, a ma er •o a c Itect to the Workers'
501
FINAL ELECTRICAL ENERGY
Compensation Laws o California
Ap ties
N5;k T:
502 7 -FINAL
PLUMBING ENERGY
, fter making this Certificate of Exemption, you should
503 -
FINAL MECHANICAL ENERGY
become $ e,,t to the Worker's Compensation provisions of the Labor Code, you must
fogthTi amply with such provisions or this permit shall be deemed revoked.
504 -
FINAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY
505 -
FINAL ELECTRICAL
I hereby 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
..J07...-
FINAL PLUMBING
.
50 8,,-
FINAL MECHANICAL
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 ordinances and state laws relating
5
5
INAL GRADE
10
to building construction, and hereby authorize representatives of this city to enter upon
5 0
INAL NG
the above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
1
51:
INAL B RKS
liabilitie& judgments, costs and expenses which may in any way accrue against said
City in consequence of the granting of this permit.
APPLICANT ER�WST!DS AND WILL COMP 11
LY WITH ALLYN-POII _T
SO R G ATI
� ffG- I
CE�
A by:
Issued by;t
Date
—
'tic! trarior�
S na of Applica ntractor Dat e
4�j _
Re -roofs
HAZARDOUS
OUS MATERIALS DISdLOSURE'
ill the applicant or futurebuilding occupant store or handle hazardous materiatType
of Roof
as defined by the Cupertino Municipal Code, Chapter 5i. 12, and the Health and Safety
Code, Section 25532(a)?
No
All roofs shall be. inspected prior to any roofing material being installed.
Will the applicant or future building butlding occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
If a roof is installed
without first obtaining an inspection, I agree to rertiove
District?
0yes,
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
I have read the h.2.1:N:
C dussm terial2s,,requirements under Chapter 6.95 of the
California Health &Safety Codc, Sections , 25533 and 25534. 1 understand that
ifthe building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requ' 'mems which must be met prior to issuance of a Certificate of
Occupranc 7e 1
�er �authri
Signature of Applicant
Date
All roof coverings to be Class "B" or better
or ed agent Date
OFFICE
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j 14
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS:
10455 GLENVIEW AV
1ffjTj k'A'ENS EN
I V..f'T. A
q Q ZD ARCHITECTIENGINEER: y
U
6
6a
Z y = LICENSED CONTRACTOR'S DECLARATION
I hereby eeirm thio I am lianxd under provisions of Chapter 9 (commencing
1-„ C
with Senior]0001 of Division 3 of the Business Nft Professions Codc,and my license
ae sait is m ran roreynd err t J'
z s$a z Licens CIasS I,ia N �Z�
a.
E, 0 %n D ARCHITECT'S D C r A N
i ej 1 understand my plans shall be used u public records /r
yO O Licensed Professional
°J o OWNER -BUILDER DECLARATION
ui 1 hereby affirm that 1 am exempt from the Conti License Law for the
F ? < following reason. (Section 7031.5, Business and Professions Code: Any city or county
F F O which requires a pcmut to construct, alter, improve, demolish, or repair any structure
u�3Cm-primtoitsis.... se. also requmxNeapplicam for such permit to file a signed statement
(commencing witt%semion 001 "of Div
i..04-Of
the Business anJ PryfessionsCWc) i�
or Nat he is exempt therefrom and Ne hasis for Ne alleged exempthn. Any violation
of Section 703 L5 by any applicant fore pcmdt subjects Ne applicant m a civil pemlry
of not more Nan by
hundred dollars is")
PERMIT N0.
020800100
sS
APPLICAff 1 PA/2002
2
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REPAIR PERIM FNDN
Des"Fl�AAGE
FINALED
AUG 2 3 2002
BUILDItir_ $1950
101APNMIliWATION
01. as owner ofine property. or my employees with wages as their sale compensation. 102 - PIERS
--win do the work,-aud-the suuemre'Is-act intended or uRcred'for sale'(Sec 70WT I O3 - UFER 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 arc am intended or
-�oflrered for stheowe - N will
avec pofproynsurdwithin idone otyearor ANCHOR BOLTS'-
' improve o the use build r ill have the burden of prov ng that he did not build or - ' -
impmver.rparpoxorxme). 106 - SEWER & WATER
ac,.____ licen_..._fo -
O Las owner of Ne property, am exclusively a comroding with licensed contractors to ' n+ : •.'�❑ I '•3%1
construcnhr Project (sea. ]two, easiness and Profusions Codes The Comrecmr's 203
- UNDERFLOOR MECHANICAL- f
License Law does not apply to an owner of property who builds m improves thereon,
- ; _.ane who.commcss for such animus with a.contractodsl licensee pursoam m.the- ..... _ _._- _204- ----UNDERFLOOR--FRAME -- --- -- -- -------- - ---
veer ra Ue<nu La
(l me empts ee s °n
6'&Pcfmrhx 205 - UNDERFLOOR.:,INSULATION
301 - ROUGH PLUMBING
ORK RS COMPENSATION DECLARATION 302 - TUB & OR SHOWER
Ihereby f.under phaltyofp,rjpry.6 of rhem0owingdeelamdons: 303 - ROUGH MECHANICAL
:
❑ 1 have and will maintain'a Ceniecaie ofConsent to self -insure (nr Worker's 304 - ROUGH ELECTRICAL
- - _ compensation, as provided far by Section 3700 of he labor Coda far the 305 - FRAME
'pert n of the wo k f which Nis period d. , ,
❑ 1 In'a and will amt n worker's Co pe tin Insurance, as required by Section 306 - HOEDOWNS
3700 or: the labor Cod far the pc:rcimancc of the work for which this Permit is 3 07 - INSULATION
f
issued,My WorkcexCornpemvdima luxurstrice'carrier and Policy nnrrnlar ere
30,8
c r Io_, Gi to IONOFFEMMo' -'J%. ; 3.09�14};EXT'ERIOR°=Hn;
[s ., _iCERTIFlCACOM OF COMPENSATION
INS RANCE O1K515':•
COMPENSATION INSURANCE —
(Ibis sermon need not be'completcrl if the permit is for one hundred dollars 311-' - S CRP:TCH COAT � r
(5100) I )
„r 1 c rt fy Jtat'in the Performance of the work for which this --
shallnotemlotip P`ctto!!heWissued,1 501 - FINAL ELECTRICAL'ENERGY '
employ Y Person in ma c tin', W�'ect to the Workers
Co pdnxiionLaws Califbmia `r °' !// -502_ - FINAL PLUMBING ENERGY
=N PP flermaking this Certificate ofExemption, you should 503 - FINAL MECHANICAL'`ENERGY
z tiecome s t to Ne Wo ke C mpensauon p otthe labor Code, you must
Ofohh i omplywith chprovisionsthn permit shall he ked _ 504 - FINAL BUILDING ENERGY__
EZO___ _ _ __ .
� CONSTRUCTIONLENDING AGENCY " 50 _ _
5 - FINAL ELECTRICAL ' " _i>
a c 1 herebYSfflrm that the s e daexwnton lending agency for Ne performance - .
of the rkf which this penmt 506 GAS TEST 1
tsaaee (Sec 3097. civ. c I �
Larr Name - = .. .� -...._50.7_._-.FINAli"'PLUMBING
L;;); Z e fAaaea 50 - FINAL MECHANICAL'("'
- U -O I nify that I have read this application and state that the above information is 5 - I NAL GRADE
comes. 1 agree to comply with all city and county ordinances and stem laws relating '
to building construction. and hereby audience representatives of this city to enter upon
Ne .bm
ole-entioned pmK.y for inspection purposes 5 0 - I NALNG
^. 4:
(We) agree to save indemnify and keep harmless the City of Cupertino against 51 - INA BRKS
U'
-VII liabilities, judgments, casts and expenses which may in any way same against said
7 li,;.,..e...._..nw_....,......._rth.
'mit hazardous vi coniam
D rim?
�-❑vas -
- tithe building does nocurrentil
"oecupsin of he,requ}'�em<mxw
Occk'pal ' .7 9" ':,
permit. ^ /
WILL COMPLY WITH ALL N-Pom'r' [slued by; Date o l/
-e-- '.
": nate Re -roofs
\TERIALS DIS&/'SUR
ling pant store or handl hexardou makenal . Type of Roof
Cade, 9 1; and the Health and Safety _
,.!°eIl`.,a,..,`P. l; "_s{:''74)3.-Itr"aTI`1.'+' ,
_All roofs shall.be inspected poor -to any roofing material being installed.. _.-- ......
dingoreuparduse gaiPm nrmdevices which If a roof is insialledwith'out first obtaininganlins ection, Pa ree tri remove
s
ined by the Bay Aa Air Quality Management) P g
all new materials for inspection., Applicant understands and will comply. with ,
all non -point source regulation's:: -•, ; , ,• ,
be mit prior to
of
Signature of Applicant -
All ft b CI s "B" 6 a
:e: agenn- , Data I too coverings o e as or a er .
'----OFFICE-