03010069 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: NOR—CAL CONSTRUCTION PERMITNO.
10112 SENATE WY 03010069
OWNERS NAME: 5255 STEVENS CREEK BLVD #1'j OPPUCATION SUB DATE
k NINA FELSHTINER 01/10/2003
:HONE: (408) 295-0813 SANITARY NO. CONTROL NO.
ARCHITECIYENGINEEk BUIMING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
width Section 7")of Division 3 of Ne Business and Professions Code,and my license is
Or in full to.And effect. RELOCATE DOORS & CLOSE OPENINGS
z a Ll 4 License Chase—Lic.a
4 fil Dan—CmntNmar_
ARCHITECT'S DECLARATION F=INALELJ
29 1 understand my plans Asir tic used As public records
ro�u
0: Uccnwd Professional
�;Wt OWNER-BUILDER DECLARATION JAN 2 2 2003
12W2
9 �x I hereby affirm that I am exempt from the Contractor's License Law for rise
3:00 following mushon.(Section 70315'Business and Professions Conic:Any city or county
which requires a permit to coriander,site,improve.chermili.h.Or pan any structure BUILDING
Hprior to its issuance,also requires the applicant for such pentrit to file a signed statement
IM
that he is licensed pursuant to IN provisions ofthe Connector's License Law(Chapter 9 Sq.Ft.Floor Area $1WS(D3tion
(commencing with Section 70W)of Division 3 of the Business and Profession&Code)or
that he is exempt therefrom and the basis for the alleged AXAMPLiN.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to.civil Penalty of
not more dam rive hundred dollars(SS(KH. be Occupancy Type
0 I.ea Owner Of the prepell%OF my employees with wages As their earn com,monflon,
will do the work,And the stractme us not intended A,offered for.11(See 70,4,Business
an pmMny who Wilds or teoprons thereon,and who ones such we*himself or through his 102 - PIERS k7eq=uired Inspections
d Pref—imms CNA:The,Contractors 1.1canate,Law does not apply no an Owner of
awn employee,provided that such improvements Are not Intended oroffered for We.If. 103 - UFER
however,the building or improvement is mid within ON year of completion,the owner-
builder will haw the burden of proving man M did not Wild or improve for purpose of 104 - REBAR
sale). 105 - ANCHOR BOLTS
I As Owner of the propuy,Am exclusively contracting with licensed contractors in
con n she project(See.7(1,14.Business and Professions Corm:)The Contractor's U. 106 - SEWER & WATER
cense Law does not apply in an owner of property who Wilds or improm director.and 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contractorm)licensed pursuant to the Combustors
License Law. 203 - UNDERFLOOR MECHANICAL
0 1 Am An. I B&P C to,this madum 204 - UNDERFLOOR FRAME
Owner I.A,41) 0_� 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301
I hereby affired under Penalty of pagm,ON of IN foltoulng clarclarations: 301 - ROUGH PLUMBING
0 1 have and will maintain a Cenificate of consent to self-insur,for Worken'lCompen- 302 - TUB & OR SHOWER
sation,As provided for by Section 37M of the Labor Code,for the Ficirkarmance,of the 303 - ROUGH MECHANICAL
work for which this permit is issued. 304 - ROUGH ELECTRICAL
0 1 have and will maintain Worker's Compensation Insurance,As required by Section
37M of the Labor Code,for IN Performance of the work for which this permit is issued. 305 - FRAME
306 - HOLDOWNS
307 - INSULATION
CERTIFI COMPENSATION INSURANCE 308 - SHEETROCK
or less.)mus=lion need not IN completed irthe,Permit is throne hundred doltars($100) 309 - EXTERIOR LATH
I certify Net the Performance of IN work for which his permit Is issued,I shelf not 310 - INTERIOR LATH
employ any person in my manner an Ad W become subject in the WOrlers!Compensation 311 - SCRATCH COAT
Laws of CAN farrifit.Data
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject 10 IN WaACT'S Compensation Previsions or the Labor code.you most
0z, forthwith Crimpy with such Provisions Or this North"I to chemed minima. 502 - FINAL PLUMBING ENERGY
z 0 oUCOON LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
V) I hereby affirm cl=m is a construction lending agency for the ratrformanc,or 504 - FINAL BUILDING ENERGY
ai the work f which dbis crini[is Anded(Sec.3W7,CO.C.)
Lender's
505 - FINAL ELECTRICAL
Under's Address
� z 506 - GAS TEST
1 certify that I have mail tins application and sum than the above finnisnation is 507 - FINAL PLUMBING
Correct.I agree to comply with all city and county ordinances and some laws rating on
0 U building commuction,and hereby auffiorm,narmusentalives of this city to code, ,on the 5egixx F MECHANICAL
FINAL
Abon-rimAtimourd propeny for intspectim,fourposess. 11
(We)Agree I.save,indemnity and bear,harmless dim City of Cupertino
against FINAG-2RADE
9 LG 9
t A �k 'Z ,
liabilifirs,judgmenuLcosis and expenses which may in my way acene,again idCiiy 5 N
U in consequence ortbe granting of this permit. --G
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by5 1 WORKS Date /Vt
SOURCE GU�NS.
p —11-LP16 rRe-roofs
'WK107 licant/Contrachir -Data
HAZARDOUS MATERIALS DISCLOSURE� Type of Roof
Will IN applicant or future building excupard stoat or handle hazanbous manurial
As defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
erect.Section 25532(a)?
0y. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harambous air contannimanc,as defined by the Bay Area Air Quality Management all new materials for inspection.
Glavin?
❑YeaNn
I have mad dic hammous materials midimmenti underChapwr6.95 olducalifor,
nit Imilth&Samt,Cock,Sections 25N)5.25533 And 35534.1 undersand that lithe Wilding
ones not corm tenant,that it is my responsibility to notify or dic
mqu mine hic Ancipriormismanceof.Ccril a Occup Signature of Applicant Date
Owin, an
All roof coverings to be Class "B" or better
6 • •
CITY OF CUPERTINO p 3 o l o o 6
"T of
CUPEI�TINO PERMIT APPLICATION FORM
•
APN# Date:
C, y (-�
Building Address: C> I/Z
Owner's Name: Phone#k
v I=�Pshfit�r off-was- -P.2/s
Contractor: �Wr W Na I/ License#:
Contact: Phone#:
Applicant/Contractor: Fax #:
1 ermit Info:
Bld Elect Plumb Mech
Job De ption: ,� a / tt-- 11
sidential: 8
Com rcia : 1`V
Sq.Ft.Floor Area: $/Sq t.:
Architect/Engineer: Valuation:
If
Type of Construction: Occupancy Group:
r
Quantity Fee ID Fee Description Fee Group
er
BAPPLOTHER OthA liances MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX &d/Off/Comm/Quasi BUILDING
DCONSTAXBQ 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
BELE 2200 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
BMNEVR ULTI New Multi-Family Res MECHANICAL
BNEWMULTI New Multi-family Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
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(tti set of p:a.s and speafirations MUSS
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gawfut to make any dmnges or afferabortS
rr same wlihcut vritten permissiOR fMM
,e"hm dmg Dcpt., Oty ol Cuperbw.
tte.slawp ^f this ptzo Irrd SpegfIC8U011g
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