02100033 (2) yr
CITY OF CUPERTINO
BUILDING DIVISION PEI IRIT C0NTRACTOR3NF0'iR 'LION:k
Buu-1] *EsVENDERGAST AVE ADRIENNE HARBER PERMITN(02100033
owAIIDRAPE'NNE HARBER 18900 PENDERGAST AVE APPLICATITJYggf 2002
ONE: SANITARY NO. 77 �� CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION O�l¢Ss Op �® O
es to
F I hereby alums that 1 am licensed under provisions of Chapter 9(commencing
O es [IOD/— I�`�d�lar
W with Section 7")of Division 3 of Ne Business and Profamomcolk,and my license is ADD GARAGE 25 t' 2 .
n in full force and effect.
le Liecns,Cled Lie" NOV 2 0 2002
Fh F❑ Dau Contractor
pp ARCHITECTS DECLARATION
�0o ude IondcrsunJ my glom skllkuudu public rccoNs
BUILDING
yU
- LkcecJ Professional `
OWNER-BUILDER DECLARATION
c.`v I hereby r(Sect that 11. exempt from the Cssion, a License taw for the $6500
i_p o following rico..(Saito]031.5,Business and Profcmions h.or Any city or county
x„� which inquire a Permit to cnnsVuck alter.improve,demnlah.or repair any swnum
Fly prior to its issuance.also requires the applicant for such permit to Rlc a signed suument
< that he is licensed pursuant mtbe provisions of the Contractor's License Law(Chapter 9 3id�5FS.3%b2A10A Valuation
mFg (cbmmcncing with Section 7M))of Qivision 3 of the Business and Pmfcssions Code)or
a 3$ that he IS exempt therefrom and the brio for due alleged esemptian.Any violation of
Section 7031.5 by any applicant for i permit Subjects the applicant to a civil penalty of PN'N Occupancy e
of more man five hundred dollars(5500). P Y TyP
102 — PIERS
1.e thaw
ownerof tie property,or is employees with cagesatic(sole compensation.
tut dock work.and the structureunot intended orolfertd formic(Sec.70m,Business'and Prefecuo Cudc:The Convacmrs License law docs not apply to an owner of 104 - REBAR Required Inspections
progeny who builds or improves ummon,and who docs such work himself or through his
own employee,provided that such improvements are not intended oroffered forsude.If. 105 — ANCHOR BOLTS
however.the bonding or improvement is Sold within one yard of completion.the owner- 106 — SEWER & WATER
builder will have the burden of proving that k did not build or improve for purpose of
Sale). 202 - UNDERFLOOR PLUMBING
❑L as owrmr of dm propeny.am excluaively contracting with licensed contractors to 203 — UNDERFLOOR MECHANICAL
consumer the project(Sec.]Obs.Business and Proesuodu Code:)The Comnctofs Li-
censeLaw does not apply toanowner ofproperty who Wil&orimprovmmemonand 204 — UNDERFLOOR FRAME
Licensa�Wu for Such projects withaconvacmr(q licensed pursuant to me Comrsn°`a 205 — UNDERFLOOR INSULATION
O 1 am exempt ugder Sec. or this reason
1y� � g� 301 — ROUGH PLUMBING
1 ownn",IL/ � Data 302 — TUB & OR SHOWER
YTD WOKE ' OhPNSAIONDECLRATION 303 — ROUGH MECHANICAL
I hereby ofimt under penalty of perjury one of tk urinating declarations: 304 — ROUGH ELECTRICAL
l
have and will maintain a CeniOcau of Consent to self-insum for Worker;Compcm 305 — FRAME
tion.aa provided for by Section 3]00 of helabor Code,for the performance of me
work for whim this permit is issued. 306 — HOLDOWNS
❑ I have and will maintain Worker's Compensation Insurance,Sa inquired by Section 307 — INSULATION
37M of the Labor Code,for ftpefformutce of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are: 308 — SHEETROCK
Carrier: PolicyNo.: 309 — EXTERIOR LATH
CERTIFICATECOM PENSATON INSURANCE [Rs' 310 — INTERIOR LATH
mrs Semon need not the completed if permit is for one hundred dollars(slm) 311 — SCRATCH COAT
"ries,') 313 — ROOF NAIL
I certify that in the performance of the work for which this permit is issued.I shall not 501 — FINAL ELECTRICAL ENERGY
employ any person in any man `m kWME-Sidla Date We ers'Com ns o
Laws of Cali r a. arc • W l� 502 — FINAL PLUMBING ENERGY
Applicant ,
'NOTICE Td A ICA :ILSmrmaking Ccniftcamof pti .youshnulJ 503 — FINAL MECHANICAL ENERGY
become Subject o the Worker;Compcovtion provisions of tk labor Cale.you must 504 — FINAL BUILDING ENERGY
zO forthwith comply with such provisions or this permit Shan be deemed n:voked. 505 — FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
CSE14 IberebyaMr.chat dim.isaconswepcmance
Nonlendingtiger,forth ,firof 506 - GAS TEST
> the work(or which this pc.it isissued(So,.3W].Ci,C.) 507 - FINAL PLUMBING
Lenders No
w z Lender;Address 508 - FINAL MECHANICAL
U O 1 certify the I pave read thirty and c un and dune that ak above information is 509 — FINAL GRADE
correct,I agree ct comply with all city and roomy ordinances of and sac t laws t opro Inco
WOU building coniwnion.and hereby aushorimrcpresenutivesofthis city tocnurup�n5 FINAL PLANNING
} W above-menionedpri for inspection purposes- 14 FIN I WORKS
F+ a (We)agree to save,indemnify and keep harmless me City of Cupertino against
V) liabilities judgments,costs and expenses which may in any way ammo against said City
U Z in consequence of the granting of this permit,
r. APP ICANT UNDERSTANDS D WIJL COMPLY WITH LL NON-POINT Issued by: Date l
SO ECILATIONS.
u-f- Re-roofs
SikniLurc7bI7AppIicarVCmummtdr 1. Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle bma dour material
as defmcJ by me Cupertino Municipal Cour,Chaptcr 9.13,and the Health and Safety
Code,section 35533(.)+ v� All roofs shall be inspected prior to any roofing material being installed.
❑Ye pl No
Will the applicant future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit haaardous air conuminam as defined by the Bay Area Air Quality Management all new materials for inspection.
District? `
Cl yes t Nu
1have read the MmousmateialsmquimmenuundoChapar6.95crtheCalifor-
niaHcalo&S4fety Code,sectin 505.35533W25536.1wulersnmthuifthe Wilding
does not currently have a tenant,that it is my responsibility ofy doe wxupanI of me
req ementswl}iehmoStbemetpBr rirspan raceme torr a Signature of Applicant Date
1� 1 ro «� 2 All roof coverings to be Class rrB” or better
O nr or amborixcd agent Do.Da¢
I
CITY OF CUPERTINO p ?
CITY
CUPEI�TT INO PERMIT APPLICATION FORINT
!.APN# . 37 —_ 3 ? O ,J Date:
Building Address: J 7 ���0�� oz—
Owner's Name: � Phone#: r &
Contractor: License#:
Contact: n r �C J� Phone#:
Applicant/Contractor:
1
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: \
Residential: ✓-1-TTA(--f\P� AXA(gOE. Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: ' 5 7 Valuation: v 0 o
�( S C H J s;2
Type of Construction: wonOccupancy Group:
o Fume_
l-.1 001)< OT') C-6-
Quantity Fee ID Fee Description Fee Group
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
q. 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
BNUCOMME I New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP I New Comm Plumb PLUMBING
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