03110143 (4) CITY OF CUPERTINO /-�/� "�+�yr,s�7'x". may I�Tp. a"`� }s�� k rs�. .fit
BUILDING DIVISION PERMIT CON A..R\kiftOR INVOR1Y.RATION
BUILDING ADDRESS: DRAEGER CONSTRUCTION INC PERMIT N003110143
1147 STAFFORD DR
OWNER'S NAME: PERMIT ISSUE DATE
ROL PARK 605 COMMERCIAL ST 11/24/2003
IE: SANITARY NO. CONTROL N0.
(408) 536-0420
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
O O LICENSED CONTRACTOR'S DECLARATION
u 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing - Job Description
with Section 7")of Division 3 of the Businaus 9,d Professions Code,and my license is
mmn tore n. 3 Lie.�r^ b f;741 V REPLACE DECK DAMAGE .& BROKEN CHIMNEY
: z u.ena.a
7 CTmctor C(� hf'+
A 3CCHHITEC11 D ATIO
a dcrsunJ my plana shallheused.4 lieretards
a0e G� LiccnscJ Professional
S OWNER-BUILDER DECLARATION
��M i hereby ofOrm that 1 am exempt from the Contractors License Low for the
M0 following rearm.(Section 703 IS,Business and Professions Code:Any city or county _
<m which requires a permit to construct,alter,improve,demolish,or repair any structure 1 O O O 0
oar
prior toiisissuance.also requires the applicant for such permit m File a signed statement
o mat he is licensed pursuant tothe provisions ofthe Contractor,License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
N
.. at he is exempt therefrom and the basis for the alleged exemption.Any Acted,on of
Scdion 7031.5 by any applicant for apermh subjects me applicant to a civil penalty of 0 Occupancy Type
not mom lean five hundred dollars WOOL P Y YP
❑L a the work,
rhe pmpent',m my intended
wages a mei(Sec.
7044,B be�as
will dothework,ands: amuaumisoats Livens Law
for sale Business j��
end Professions Code:The astheman,License law docs or apply to an owner of Required InSV VALE®
own
em who builds iimprovesthereon,and who are hot
.,offered
imugh his
own employees,lding Or improvement th imprw ld within
it are not intended mplefimd the o e.r.
builder the buil thebrenofproving that
mi not year ofimproeiforon.theowner.of
builder will haw the Horden.f proving mat he did not Wild or improve paryose of JAN 1 5 2004
axle).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
consumer meproject(Sec.n an Business and nywhobui Code:)The es beacon,LI- BUILDING
cerise Law tices not apply m an owner or property who builds or improves d Coes,and
whonseLow. for such projects wiseaconvactor(s)Licensed pursuant mthe Contestant's
License Law.
❑I am exempt under Sec. .B&P C for this reason '
Owner —Date—
WORKER'S
ateWORKER'S COMPENSATION DECLARATION
I hereby effirm under penalty of pe jury One of the following declarations:
have ono will remain a Certificate of Consent to calf-insum for Woollen'sComped
soden,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑I haus and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which mil permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
a 'y: 4JZL'_!'# (nl.$. CO. PolicyC'yWe—
CERTIFICATE OF EXEMPTIdNM WORKERS'
COMPENSATION INSURANCE t-T'F yyOV
(ThH section need not bec.mplcied if the permit Is for one hundred dollars(SIOJ)
or last.)
1 certify that in the parroodenca of the work for which this permit is issued,I shall not
employ any Foram in any mannerso as in become subject to the Workers'Compensation
Laws of California,Dau
Applicant
NOTICE TO APPLICANT:IL after making this CCOMCB.of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
'z forthwith comply with such provisions or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constmeion lending agency forme performance of
x the work fur which this permit la issued(Sec.3097,Co,C.)
MW Q Lenders Nam.
z Lenders Address
U 0 1 cenify that I have read this application and amt that the above information is
Irw N correct.I agree to comply with all city and county ordinances and state laws relating m
O V building construction,and hereby authorise representatives of Its city to cnuromm the
U above-mentioned property far inspection purposes.
(We)agree to save,indemnify end keep harmless the City of Cupertino against {
ft'rn liabilisles,Juogmenla,costa andexpensea which may in anyway accmc agains"m City
fJ7 seeonuquen of the granting of this permit.
r� APPLICA UNDERSTANDS AND WILL CgMPLY WITH ALL NON-POINT Issued by: Date
SOURCE EGULATIONS.
y ° Re-roofs
t gheruor,ofApplicaHAZA,..to,
BOOUS MATERALDISCLOSURE Date' Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
as dented by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Sectio
r s 25532N)? 44'n All roofs shall be inspected prior to any roofing material being installed.
Will the applicant Or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t int?hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
ta
❑Yes eNit
I have mail the han dous materials mquircmenu under Chapter 6.95 of the Calirm,
nix Hcalm&Safety Cont,Sections 25505,25533 and 25534.1 understand meti(thc building
does not cu oily have a tenant drat it is my responsibility m til'y the
occupant orm.
requiremen wM'chmuaC metpOur
toissuanccTfacertiFica nrarepaneSignature of Applicant - Date
ton .r amhmi,sJ agent Date All roof coverings to be Class "B" or better
so(vw CITY OF CUPERTINO ` a ��
CITY Of PERMIT APPLICATION FORM 0
CUPEkTINO
Z Date: 10
Building Address:
V S A - FU/Z 02iUE 15 T(iv0 Cs L7SU1
Owner's Name: Phone#:
c470-L__ q()8 - a0 ;z-7-I
Contractor: License#:
to E2 c.azv STez cT/o�j AJL• Co 13 ce / 0
Contact: Cupertino Business License#:
S G- // ��A2O /N
Building Permit Info:
Bldg e Elect ❑ Plumb ❑ Mech ❑
Job Descriptions
Residential
Sq.Ft. Floor Area:
/v Al
Cost of Pro' t: ccupancy Group:
Type of Construction
uanti Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu 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
z3 �
Iof3
18 so I
CITY OF CUPERTINO
CUP TYOF O PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM StonwRain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREN20LE Pole/Platform Fixture ELECTRICAL
•
2of3
L' CITY OF CUPERTINO
CIrY0 PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
3 of 3
1 w:
I
`�'-Fret f @ "-'-`.a^ - -�. -•`�ri'�"�• /a- - r 7 t
(`<G 1 R _ •1. ice._ -_ } I � �� � �`.
-'..Y
�.-...�,u a,- ��. '-:�`_'r�. -1" .._ '� .^r •�>+.d�r�.1"„ V > .-ms's- ,
'µ C
- i
: a ISI .. •
i
I •
I 1.
r 1 1
r
r
I
_ I
• I
1
I _
I I 1
1 1
I r VI.
CITY Or CUPERTINO
BUILDING DIVISION PERMITCONTRAC-TORINFORM06
BUILDING ADDRESS: DRAEGER CONSTRUCTION INC PERMIT NOfl 3 110 14 3
1147 STAFFORD DR
OWNER'S NAME: PERMIT ISSUE DATE
ROL PARK 605 COMMERCIAL ST 11/24/2003
f E: SANITARY NO. CONTROL NO.
(408) 536-0420
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
!00 LICENSED CONTRACTOR'S DECLARATION
Lw I hereby affirm that I am licensed under provisions of Chapter 9(commencing .lob Description
SZ with Section 70(l of Division 3 of the Business a dPmfiCCaom,CndC.endmy1iCCmsCls
nm -(-"y/erml,k D o /-74fU REPLACE DECK DAMAGE .& BROKEN CHIMNEY
j License C17r J Lic.
;H0
t-0 Dam y A O Contractor�2QEG EN KIUMrI
eQQmj n CHlTECTS°ECLgAt F ALE
e 2'�' rynucfstand my plans shall he used as{m(ic records 1N v
pats
s LLo Licensed Pmfcssinnel
S Oat I am
DECLARATION JAN '1 5 2004
i E I hereby affirm int 1 ore cxcmpt from the Contractor's e:Any
Law for the
po following reason. permit 703LS,Business endw,dcsini Code:Any city orcounty
which its issuance,
s ea a permit re construct,alter,applicant
improve,h Permit t fire a Sir anygned structure $10000
uZ that heor sslcensece,elsarequires the
Provisions
visio sof for suchPctor's cense Law statement
x`e (embrOmmirigsedpuntion70o)ofDiairm3teGnnwounn.nccrsclsw(Gbapter9 Sq.FL Floor Area on -
s- that he is xempth Secdominion
and the
Division 3 theof al Busaged exempt Profusions Code)ion or
of
rhes he is exempt thcmfrom and Ne tools for the alleged exemption.Any vinlmimn of
Section 70313 by any applicant for a Permit subjects the applicant to a civil Penalty of4i "00 Occupancy
not more Nan five hundred dollars(S500). Pane Y Type
0,I,as owner of she pmpcny,or my employees with wages as their sole compensation.
win do the walk,and the awctm is nos intended or offered for sale(See.7044,Business
and Profusions Code:The Contractor's License Law does at apply to an owner of Required Inspections
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 o Wned for sale.IL
however,the building or improvement is sold witin one year of completion,the owner- _
builder will have Ne burden of proving that he did not build or improve for purpose of -
.[aL
0 I.as owner of to properly,am exclusively convecting with licensed contractors to
cnnswct Be project(Sec.7044,Business and Profusions Code:)The Convector's Li
cense Law does not apply to an owner of Property who Wilds or improves themon,and
who contracts for such pmjects with a conwetor(s)licensed pursuanuo Be Contractor's
Lt...Law.
0 1 am exempt under Sec. .B&P C for this reason
Owner Dote
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury,one of Ne fallowing declarations:
have and will maintain a Certificate of Consent to selginsum for Worker's Compen-
Satlon,as provided for by Section 37W of the Labor Code,for the Performance of the
work for which this Permit is issued.
0 1 have and will maintain Workers Compensation lnsunnce,as required by Section
Pull of Ne Labor Code.for the performance of the work for which this peon it is issued,
My Workers Compensation Insurance Cartier and Policy number am:
a it ARCH (n/.5. CO. Policy��YYtil� GV(UG 10t'O�.
CERTIFICATE OF EKEMPTI&FPOM W ORKERS'
COMPENSATION INSURANCE t�'P F40V
(IMS¢conn need not he completed little pewit Is for one hundred dollars($IW)
micas.)
1 comfy that in the performance of the work for which this permit is issued,I shall not
employ any Person in any manner so as m become subject to the Workere Compereatimi
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Become subject to the Wodcr's Compensation provisions of the Labor Code,you must -
Oforthwith comply with such provisions or this Permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency I'or the performance of
the work far which this pumas is issued(Sec.307,Civ.C.)
QLender's Name
= z Lender's Address
U Q 1 ccnify that 1 haw mad this application and scam that the above information is
cannot.I agree to comply wit all city and county ordinances and suite laws relating to
pts building construction,and hereby announce representatives of tis city to enter upon the '
,tea above mentioned prapeny for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgments.costs and expenses which may in any way social,against Said City
Inconsequen ofill gran ting ofthispermit.
tr APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE IfEGULATION .
° Re-roofs
l gra urc ofApplic HAZARDOUS
MATERIAL DISCLOSURE DataType of Roof
Will the applicant or future building uccup m store or handle hazardous material
as defined by the Cupertino Municipal,Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(a)? // All roofs shall be inspected prior to an roofing material beim
❑Yea �Na P P Y g g installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ha'ehrdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict? J
❑Yes „yl Nir -
I have mad Be haaardous materials tequimmcnts under Chapter 6.95 of the Califer-
nia Health&Safety Code,Sections 255115,25533 and 25534.1 umderswd that if the building
docs not cu rely have a mnan4 tat it is my responsibility m otily the Occupant of the
requimmcn whicmm�sC mu pnonuissuanccofaCcnihca rtxeaanc /3 Signature of Applicant Date
2/ G
'Owl nrapmorhedagent Dmo All roof coverings to be Class "B" or better