02110002 i
CITY OF CUPERTINO '•nb°.' C
BUILDING DIVISION PE TI C,ONTT6ItACINFOR ION:
'. .
BUll1f 0301sRODRIGUES AVE 7C WALDRON CONSTRUCTION COMP M+ITN®2110002
owL IQFEBILTMORE APARTMENTS P 0 BOX 598 arrucangNls 01 2002
ONE: (408) 377-8186 SANITARY NO. CONTROL NO.
ARCIII'IECT/ENGINEER: BUILDING P12RMIT INFO
BLDG ELECT PLUMB MUCH
0 0 0 0
{n�90p LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thm l on licensed coder provisionsnf Chapmr 9(urmmeneing REMODEL-KI
9�fff' "1VALL A C UNIT FLOOR
� 8 with Section no0)onDivision JonW Business and Professions Inde,nnumr license
is r r
nrmllnreeandeffect. AND WASHER/DRYER. ®
~�2 License Class Lo.x WALE
o Z-O Dau Contractor
1pt- ARCHITECTS DECLARATION. t
Iunderstand myplans shallthe used anpublic rccnras JAN 0 2 2003
LLO< Licensed Pmfesm
snal
OWNER-BUILDER DECLARATION BUILDING
Y herebyreason.
.Ilion that 11, cacmpt from the Comment's o License Lawl for the !
o which ng reason.(Section mnmor Buslness and ve.fessln li Code;any city nr"'Only
$ which myuscs a perost re ttmmrthe aluc impnmc,h per demolish,or mash any soucmre $34660
Fz< Oat hei licensed
e.pursuant
to resthe thecant lie SucContramriuolife a censesigned emmmenl
Oat neishcewit vection mthe ofDivisio of the conusinc rsnd Professions
Code)Or Sy. Ft. Floor Area Valuation
�$ (pont a is exe pt therefrom and the osis f r the al eged mss and Pnl(Any vi lotion or 3 6 9 0 3 0 08 . 00
., at Section
is exempt tang ap ii and the basis far the alleged exemption.Any l violation of
not m]OSlsbyaundredcantrorspm,nasubiectameappucanttn.ci.Rpena¢rof APN Number Occupancy Type
not more than five thforpany,or yem(S500p. �� 101 - FOUNDATION
P Y YP
❑1,as owner of the pmla+ny,or my employees with wages u their wk comparealion,
fill do the wok,and the swaure is not intended or offered for sale(Sec.7D44,Business
and Professions Code The Contractor's License Law does not apply to as Owner of 103 - UFER Required Inspections
property who builds or improves thereon,and who docs such work himself or through his
own employees,provided that such i mprovemen¢are not intended or offered for sale.If, 104 - REBAR
however,the building or improvement is sold within one year of completion,the owner- 105 - ANCHOR BOLTS
builder will have the burden of proving Nat he did not Wild or improve for purpose of
K.sale : 1 106 - SEWER & WATER
Las owner of the property,am exclusively contracting with licensed contme ms'In 202 - UNDERFLOOR PLUMBING
el the project(Sec.]044,Business and Professions Code:)The Contractor's Li-
censelawdoesnotapplytoanownerofpropeny who builds or improves thereon,and.
203 - UNDERFLOOR MECHANICAL
whocontmcis forace pnj CUWuhaconoacter(s)Ilcen.¢dpurwanuothe Contracwr's204 - UNDERFLOOR FRAME
License Law.
❑ lam exa t t er Sec. ,B&P C B'rdas reason 205 - UNDERFLOOR INSULATION
OwnerI Dau /� 301 - ROUGH PLUMBING
KEIT SATION DECLARATION 302 - TUB & OR SHOWER
I hereby affirm under penalty of perjury one of The following declarations: 303 - ROUGH MECHANICAL
❑ [haw and wilmaintain acemrcamofConsent toself-insure for Wntker'sComPeo 304 - ROUGH ELECTRICAL
moon,u provided for by Section J91k1 of Ne labor Code,for Ne performance of the
work for which this Permit is issued. 305 - FRAME
❑1 have and will maintain Worker's eof
Compensation work for
h his Pertl bgSssued. 3 06 - HOEDOWNS
My of the Labor Code,for the performanceof d work forwbichmis permit is issued.
My Worker's Compensation Insurance canner and Policy number am: 307 - INSULATION i
Carrier: policy No: 308 - SHEETROCK
CERTIFICATE OF EXEMPTION FROM WOR KERS' t
COMPENSATION INSURANCE 309 - EXTERIOR LATH
(This scetian need not he completed if the rcrmit is boom,hundred dollso I$IIs)) 1 310 - INTERIOR LATH
"r'css) I :I 1 311 - SCRATCH COAT
I 1 certify mat in the peancp of the work for which this rrmit finished,1 shall not l 313 - ROOF NAIL
empinyany perm ny Mlru,as ty MCBmestm the Wnrkcri Cnmpcnsalinn
Laws of Celf a
D /' O/^/�^i501 - FINAL ELECTRICAL ENERGY
Ann1B�a��k{{�� G&,,k iJ
1 NOTIpf1p'0APPLICA :Il,atlet ski agthisCeni;iehmofExemption,youshould 502 - FINAL PLUMBING ENERGY
ter or subject o the Winter's Compensmion provisions of the Labor Code you must 503 - FINAL MECHANICAL ENERGY
fmOwi th comply with such provisions Or this permit ya shall the deemed reacted. 504 -
FINAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY
[-th themby 1 505 - FINAL ELECTRICAL
'he workforwhichthis pcmtnisissucd(Scc31y9],Civ.CJI 506 - GAS TEST
W
7l; t<ndcr's Name
IsndcrS Address 507 - FINAL PLUMBING
UO 1 certify mat 1 have read this opNmminn and ante that he above imnrm lion is 508 - FINAL MECHANICAL
W (-' cones.I agree to comply with all city and county ordinances and state laws relating m t
O U building construction.and hembyamhmimreprescmadverOfthlsCity tocnmrupmtbc 5 FINAL GRADE'
W alovcmentioned propertyfor inspection purposes. 10 FIN PLANNI G
(We)agree m save,indemnify and keep harmless the City Of Cupertino against
h liabilities,ludgmcnks,cons and expcnres which may in any way accmc against salol CllY 5 F N LI WORKS
U z In cnnsaµcneAL
ming ofthis permit. /I
APPLICANTP TANDS AND WILL COMPLY WITII ALL NON-POINT Issued by: Date I'
SOURCE �d //I� � Re-roofsSil,come of AppIicanVComeachn / Dare
IIAY.ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haaardous material
as defined by the Cupenum Muni`pal Code.chapter 9.12.and the health and Safety
Cale,Section 255J2(a'f All roofs shall be inspected nor[o an roofing material bein
• ❑Yes No P P Y g g ins[alle .
1 If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building by the B use equipment or devices which
emitict? ousairnmmminantsasdefinedbytheBayAreaAirQualityMawgcmcm all new materials for inspection.
District? *11 o
❑Yes
I Imvc read theft....ous m ourn.1s mquimments underCOpmr h.95 of the Cthiftss
his Nealth&Safe Code.Sections 259)5,25533md255J4.lundernandmatiflM ilding
does not cunt y sc s unapt,ynI it is my OrNosi bili,,or tit,the occupant of me
requirements sic m rurissumceoracenmcerrJ�c�,1 Signature of Applicant Date
ownermaat ori,dagem // Date All roof coverings to be Class "B" or better
• •CITY OF CUPERTINO D �� ��
BUILDING PERMIT APPLICATION FORM
Building Address: 40030 //, &45,&4 5 /1_., # -7L,
Owner's Name: `'5 i'PVhhoone No: c-,c16_ 53 0
LAICr✓ ILTMORE pPA2'f-M�-rl5 G50
Contractor: License No:
C0NS7WAG71orj nlc.
Contact Phone No: Sgb-53o8
5 WEav�2 P207r ACR G
Architect/Engineer License No:
9TAuem I SINCtAiR. K55
Applicant/Contractor:
026 APAQrMt-Nrf�
Building Permit Info: (circle one
Bldg Ele Plumb Mech
Description: lwMo¢ iW VA-InD4 tN RG-MODeL D 14 BA
NEW WA6AM/DeYEe , NEW tuott_Ala , NVW Ftoee Coin#)&
Residential: MiALTI-FANU01 Commercial:
Sq. Ft. Floor Area: 1000 Sr_ $/Sq. Ft.:
APN # (Must provide): Valuation
3rd-D3-00 re 3�F Gbo
Type of Construction: Occupancy Group: R 1
• Qty. if Fee ID Fee Description Fee Group
Applicable
BTEMPPERM Temporary Bldg Permit BUILDING
BCONSTAX Construction Tax BUILDING
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BOVERTIME Inspection Overtime BUILDING
BPERMFEE Bldg Permit Fees BUILDING
BMITIGAT Housing Mitigation Fee BUILDING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BREINSPECT Reinspection Fee BUILDING
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
ZADDCHG Address Change BUILDING
i • 4z,Pz77