03100077CITY OF CUPERTINO
L , ' , ` -
Co] TR_, CTORINFORMATION:
BUILDINGDIVISION PERMIT
--,
BUILDING ADORM:
PERMIT N0.03100077
R'S NAME:
PERMIT ISSUE DATE
SNE:
-
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby of on that I am licensed under provisions of Chapter 9 (commencing
P
with Section ]OW) of Division 3 of the Business and Professions Code, and my liana is
in Licenlforce se Class d affect. Lic.g
DEMO WALLS/HVAC (1500 SQ.FT.)
Dore Comment
ARCHITECTS DECLARATION
1 undersand my plans shall be used as public records
nod Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
reaso
followwhichrgm a SecuPonca Tonstr Business and Professions Code: Any city
permit m alar, improve, or repair any sbunme
which mount e
Is
an
prim m its Issuance. p also rcquireuhe applicant for such permit to Ela License signed s hapten r
its ams the h permits
purmunt 7000) of theConoanssanProfessions
thatbe ending
Sq. Ft. Floor Area Valuation
(commencing with Section
it of Divisio Code) or
of Division3 o(the Businessantl Professions CnM) or
a rd alleged exemption, Any violation of
li and the basis for
Natio u sumps tang
35907005.00
be
by any dollarorapemiitsubjects Ne apPhcanuo acivil penalty of
ap
Sectnot
APN Number
Occupancy Type
P
MM MLS
not more Nan Eve hundred dollars ($300).
Y YP
El I, as owner of the property, or my employees with wages as their tele compensation,
will do Ne work, and the structure is not intended or offered for sale (sec. 7044. Business
end Professions Cade: The Contractor's Liana Law docs
- DEMO Required Inspections
not apply to an owner of
properlywho builds orimproves thereon,and who such his
himselfed
We
amended Threats.
tl or for le
own employees, provided that such improvements are not ear
mpleered
however, Ne building m improvement is halt within one year of r-
of the nose
builder will have the burden of proving that he did not build or improve for purpose of
improv for of
soled.
r�
❑ I, as owner of the property, am exclusively contracting with liermaed con(recmrs I.
� ']
consumer the project (Sec. 7W, Business and Professions Code:) The Contractors Li.
cense law docs not apply to an owner of property who builds or improves themon, and
- V!
who contracts for uch projects with a comractor(s) licensed pursuanuo the Contractors
t}s
en 0L
Iam e e pr ticr see. P C for remora
�,B&
ER'S COMPENSATION DECLARATION
I hereby aRtm under Penalty of perjury one of Ne following declarations:
1 have and will maintain a CettiOcate of Consent to self-insure for Worker's Compen-
aation, as provitled far by Senian 7]W of the Labor Code. far Ne performance of the
work for which this permit is issued.
.
1 have and will maintain Worker's Compensation Insurance, as required by Section
3]W of the labor Code. for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hecomplcted if the Permit is for one hundred dollars (Sisk])
ass.)
I certify that in the performance of the work for which this permit is Issued. I shall not
employ any person in any mannerso sent become subject o the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Comficare of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed mvnkcd.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a construction lending agency fm the Performance of
Ne work fur which this Permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Leader's Address
I certify that 1 have read this application and aunt that Ne above information is
correct,) agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorize repmsentatives of this city to enter upon the
above-mentioned properly for Inspection Purposes.
(Wc) e6 cc to save, indemnify and keep harmless the City of Cupertino against
'had coke uses
expenses which may in anywayscene against said City
in
incon n gratsing of this Permit.
NDERST
APP C UNDERST DS AND WILL COMPLY WITH ALL NON-POINT
issued by: Dale
SO fsIJL-AT
Re-roofs
Type of Roof
100-
um ¢anUContractor ati
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or fume building occupant store nr banJlc hezutlous mucrial
az defined by the Cupertino Municipal Code, Chapter 9,12, and the Health and Safety
e. secties 25532(01,All
❑Yes k Na
roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant am equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
it havardom air conaminants a5 dcfnad by the Bay Area Air Quality Management
all new materials for inspection.
islricl? /f
F-1 yea a
I have redme vaNnus materials requirements under Chapter 6.95 of the Cali foo-
malrealth& y ,Somm¢255(I5, Sand 25534.1 undersand date if the building
-
does not cur n y a Icnant s responsibility m nosily Ne Occupant of the
R
requiremgn a be e ssuance of a Campeau, of Occupancy,
i'
Signature of Applicant Date
f r aa
All roof coverings to be Class "B" or better
0. arborized agent Dam
CITY OF
CUPEkTINO
.JTY OF CUPERTINO
PERMIT APPLICATION FORM
� c) (-,) c�) 77
APN # e'
i
Date:
BBOILERI
Boiler <= 100,000 Btu
MECHANICAL
Building Address:
Boiler > 100K to 500K Btu
MECHANICAL
-mmoc
Boiler > 50CIK to 1M Btu
a o
Owner's Name:
Boiler > 1M to 1.75 M Btu
Phone #:
I ..
Boiler > 1.75M Btu
44 -58
Contractor:
Construction Tax
License #:
Contact:
Ind/Off/Comm/Quasi
Cupertino Business License#:
i Permit Info:
Con. Tax for BQ Zone
BUILDING
Bldg Elect
Plum
�) Mech ❑
escri tion:
�
BUILDING
Residential ❑
"' `C41rcial
d
Sq.Ft. Floor Area:
Elec 600V > 1000A
$/Sq.Ft.:
BELEC200
M� h
ELECTRICAL
Cost of Project:
Energy
Occupancy Group:
Type of Construction:
Energy Add Multi
BUILDING
Quantity I Fee ID I Fee Description Fee Group
BAPPLOTHER I Other Annliances MECHANICAL
BBLDGFEE
Bldg Permit sq. foot
BUILDING
BBOILERI
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler > 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 50CIK 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 I
Comm. Housing Mit. Fee
BUILDING
1 of 3 2. .,% �..
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CITY OF CUPERTINO
BUILDING DIVISION PERA
CONTRACTOR INFORM. ON:
BUILDING ADDRESS:
PERMIT NO.
03100077
OWNER'S NAME:
TMWALTE/STEGNER
PERMIT ISSUE DATE
110/1)
PHONE:
SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions or Chapter 9 (commencing
with Sac tion 7000) of Division 3 of the Business and Professions Code, and my license is
in full effect.
DEMO WALLS /HVAC (15 0 0 SQ FT )
LicenseorceClassnd
Lic. N
. .
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans shall he used as public records
nscd Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to Glc a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant 10 the provisions M the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division J of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
35907005.00
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
704 - DEMO Required Inspections
will do the work, and the structure is not intended oroffered for sale (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 does such work himself or through his
own employees, provided that such improvements arc 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
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
.
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for uch projects with a contractor(s) licensed pursuant to the Contractors
L' ens,
I am e e pt der Sec. . BB& P C for this reason
�.ER'S COMPENSATION DECLARkTION
t// 1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance or 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. 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 less.)
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
forthwith comply with such provisions or this permit shall be deemed revoked.
� CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructinn lending agency for the perfurmance of
the work for which this permit is issued (Set:. 3097, Civ. C.)
Lender's Name
Lender's Address
/ I
t.
j 1 certify that I have read this application and state that the above information is
' correct. I agree to comply with all city and county ordinances and state laws relating to"��
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabiliti 'ud cots, costs and expenses which may in any way accrue against said City
' in con q an or the granting of this permit.
' APP C UNDERST DS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SO�iUL-AT
Re -roofs
Type of Roof
00 1 urcicanUComracmr /Date
HAZARDOUS MATERIALS DISCLOSURE
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 255J2(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes XNu
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
E] Yes py Nu
I have read the zarduus materials requirements under Chapter 6.95 of the Califor-
niaHealth& y , Sccdons 255(15.2 Sand 25534. 1 understand that ifthc building
docs not cu n y a Ienan .' a responsibility to notify the occupant or the
rcgwmmen u be a ssuance of a Ccruficate of Occupancy.
�""
Signature of Applicant Date
D�
All roof coverings to be Class "B" or better
Ow
r uthorizedagcnt Date