02060021aUT-
CITY OF
CUPERTINO
%-,ITY OF CUPERTINO
PERMIT APPLICATION FORM DaO4w�+
APN #
Date:
1
Building Address: �
` 11161- 1�7fevevr, Creei--
Owner's Name:
Phone #:
Contractor:.
License #: ,
Contact:
Phone #:
-�02 2
Applicant/Contraptor:Fax
p( V) V)eyDs . (OOS
#:
252 DC7
g Permit Info:
rld
g�\ Eect Plumb Mech
escriptiom �' , e
Residential: S6?(t4( r�[merlo
Sq.Ft. Floor Area:
/Sq.Ft.:
Architect/Engineer:
Valuation*f'
Type of Construction:
Occupanc Group:
Quantity Fee ID
Fee Description
Fee Group
APTFEE
EACH STORY OVER 3
HOTELFEE
EACH STORY OVER 3
OFFICEFEE
EACH STORY OVER 3
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,
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
BMNEWMULTI
New Multi -Family Res
MECHANICAL
BNEWMULTI
New Multi -family Res
ELECTRICAL
1 of 3
CITY OF CUPERTINO q s F
BUILDING DIVISION PERMIT
BUILDING ADDRESS: RS CONS TRUCTIO UMMITNO.
19929/99 STEVENS CRK 02060021
OWNER'S NAME: 1475 SARATOGA AVE PERMIT ISSUE DATE
PINN BROS CONSTRUCTION 02/28/2003
PHONE: k 4 U d 2 b 2-'13 1 SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER: I I BLDG BUILDING
LECT PERMITPLUMB MECH !
O O LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
7�U, with Section 7000) of Division 3 of the Business and Professions Code, and my license Is
a y in full force and effect.
� y Z License Class Lic. it
±t-- Date Contractor
rz
ARCHITECTS DECLARATION
a I understand my plans shall be used as public records
5aU
z WO � Licensed Professional
= ti OWNER -BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i Ci O following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to ennalrthet, alter. Improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
4 that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
$ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y .. 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 penalty of
not more than five hundred dollars ($500).
❑ t, as owner of the property, or my employees with wages as their We compensation,
will do the work and the structure is not intended or offered for We (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 doessuch work himself 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 completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
1, as owner of the property, am exclusively contracting with licensed contractors to
wct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects th a contracior(s) licensed pursuant to the Contractors
License Law.
[1 1 am exWpunder Sec. , B & P C for this an
n
Owner. Dale
ORKER'S COMPENSATION D ON
I hereby afrrm under penalty of perjury one of hirfollowing declarations:
❑ 1 have and will mainudn a Certificate of Consent to self -insure for Worker's Com pen-
sation, as provided for by Section 3700 of rhe Labor Code, for the performance of the
work for which this permit Is Issued.
❑ 1 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 issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars ($100)
or es&)
I certify that In the performance of the work for which this permit is Issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: if, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
'Z V) CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a concoction lending agency for the performu ce of
the work for which this permit is Issued (Sec. 3097, Civ. C.)
W Q Lender's Name
aLender's Ad dress
V 0 1 certify that 1 have read this application and state that the above information Is
LI~ — correct 1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
HLL (We) agree to save, indemnify and keep harmless the City of Cupertino against
,.., liabilities, judgments, cos expenses which may in any way accrue against said City
() r�- inconsequence of the g ling this permit
APPLIC UNDERS7 ND ND WILL COMPLYyJ
WITH ALL NON -POINT
SOUR 1 1L � p � 1 h
athrc of Ptilicant/Contraclor l/ Date
!!�� HAZARDOUS MATERIALS DI LOSURE
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, Section 25532(a)?
❑ Yes p0 No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants u defined by the Bay Arca Air Quality Management
District?//
El Yes
No
I have read the hazardous materials requirements undcrChapter 6.95 of the Califor-
nia Heal th&Safety Code, ti s25505.25533and25534.1understandthatifthebuilding
docs not gently have rpm that it is my reseonsibility to nodfy the occupant of the
rcyulrcmcn which must c' riar taissuanc of a CcniOca�vhf Occunnw
Job Description
GATE LOOP/DECTOR SYSTEM
Sq. Ft. Floor
501 - FINAL P8 (!Y
505 - FINAL ELECTRICAL
on
Occupancy
v V
Issued by: 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.
Signature of Applicant Date
All roof coverings to be Class "B" or better