04020019 CILADDR�S
ER'I'INO .3•' -:-z �^cvmt >�
ISION PERMIT ICO NTRACTO] INFM� A.TIQN�,'
BUILRANCHO SAN ANTONIO HOUSING TdItO04020019
ER'S NAME: PERMIT ISSUE DATE
2,10 2
,NE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG • ELECT PLUMB MECH
300
LICENSED CONTRACTOR'S DECLARATION m fj1N
a / \�d 1 ion? affirm Nat 1 em if didBa under provisins of CWpur 9(commencing JOb DeSCrILwith Section]0087 of DivisionJof Ne Business end Profnssians Code,and mylicense is
in full fmceand effect.LicenreClass Lae.0 38 LIN. FT WALL HEALTH CR
Da¢ commclar �1
ARCHITECT'S DECLARATION NOV01�
I undersunJ my plans shell be used a public meuNV .�Is Y T
JyU
ir Pinhea
o Licensed encu affirm
I ®I
OWNER-BUILDER DECLARATION.
1 hereby affirm that 11. exempt from Ne Colon o License law for the
O O following return, etch t Aonstr Business And in.demolish.
Code,:Any city of county BU
$ which requires a permit inquires
construct.epee impmw,h permit t or erepair anygned tnumum g^-—
_iy
prior itsrcesed e,r art qui ms thovisiosof for sucCommrmiuocense Law(Chapter
mem —
30 (comeucing with
pSectiot it]ft of Diviomnfof the Bsimesnd Professors
Cok)or Sq. Ft. Floor Area "Valuation
$ thammcscingwi flumfoa and di Division r the
the B ed exempt on.An iana Cadc)or
..
that he is comp(thcmfmm end Ne basis for Ne objects
do, exemption,Any violation of
S.not
loan by any hundred
permitsubjccuNeapplicanuoacivil pcnvpyof 342144Ima)L£er00 ecupane .,Type
oat mart Nan five mundrtd dollen(SSW).
❑I:u owner ,the p e stra a my cmployeea with wegea u that sale compenu0on, 4}wL^--�'
will do Ne work.and the swewrt is not imm�ded or affertd fonek(Sec.]DW,Businua _
and Professions Code:The Contractor's License Law does not apply to an owner of Requl d'I S'pe0 IOns
pmpeny who builds or improve theroom,And who doesauch work himself ortho ugh his
own employees,provided that such improvements Am not intended aroRemd ferule.If.
however,Ne building or irepmwmem I,sold within wee year of completion,Ne owner
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑h As owner of Be property,am exclusively convecting with licensed contractors to
consvuci the pmjem(Sec.701,Business and Pmfeaziona Couri The Contractor,Li.
cense law dots not apply to an owner of property who Wilds or improve Neuron,and
who contracts for such projects with a comnmor(s)licensed pursuant to the Convector's
Lease law.
am exempt undo Sea. ,B A POC for thio von
'r ue
D ,,?
KKER'S COMPEN51O70 DE ARATION
j Ihemby-Rom under penalty of ped.r,,Qpy he fallowing decluations:
I have and will maintain A Cenificoeaf Consent to self-insum for Warlides Compen- -
sation,u provided for by Section J]W of the labor Code.for We performance of the
work for which this Permit is iuucd.
Q I have and will maintain Warkar's Compensation WmNee,ea acquired by Section
3710 of thc labor Code,for Ne perfarmancc of the work for which this permit is issued.
My Workers Compensation Insurance canicr and Policy number art:
Cartier. Policy No.: _
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
or les")(1'hls section need not becomplevd If tbe permit is for one hundred dollars IS 100)
I certify that in the performance of the work for which this permit by Y;bad,I shell not
employanypetsny man era azo eco subjecn IhEWorken'Compemellon
Applic Califo m
ApPlic m
NOTIC AP I: ANT: ,i mr making Nu Centfica a of Exem9 ion,you NsmIJ
beco c0 to the Wpr ri Compensation pmvisiom of tW Labdr Cnde,you muse
.JO forthwith comply with sec pmvisiom aphis permit shall W deemed revoked.
'z y CONSTRUCTION LENDING AGENCY
[+ Ibertby Affirm that Nem is A Constmninn lending Agnrcy for the sormounic of
W7 the work fur which this permit is issued(Sec.3097,Civ.C.)
Wti fender's Name
J z Leader's Add.
U 0 1 certify Nat I base road this application and sat¢No the above information is
W Fcorrect 1 agree to comply with all city and county ordinances and state laws relating to
0 U building Constaction,and hereby auNorix,mpmmmatives of Nig city to enter upon the
4
.hove-mentioned property rot Inspection purposes
t„t (We)Agree to saw,indemnify And kap harmleu the City or Cup of against
h liabilitiea,judgments,cants And expenses which may in any.way accrue,against said City
U 7 in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WI L-COMPLY ITH ALL N DINT Issued by: Date
SOU REGULATIONS. r
Re-roofs
ignmukaf PitheantlConvacmr '
HAZARDOUS MATERIALS DISCLOSURE Ie, Type of Roof
Will the applicant or future building occupant atom or handle havamous material
As defined by Ne Cupertino Municiipa Code.Chapter 9.13,and the Health and Safety
C.SectionzssJzpn All roofs shall be inspected prior to any roofing material being installed,
❑Yea
If a roof is installed without first obtainingan inspection,I agree to remove
.Will the applicant or Towns building occupant um equipment at devices which P g
d0 haaard0us air conuminams u d fined by the Bay Arco Air Quality Management all new materials for inspection.
crier?
❑Yes
10aw rtaJ Ne hvardtwsmaurials rtyuimmcnu under Chapter 6.95 of the`Glifnr.
ria HcalN&SafcOy Coda SeeNms25N15,35533md255J4.lund wdNufrNc Wilding
does not Cunard,have Amrnnt that it is my maponsihility m rush h cecupan0 of do.mquimmcnts which most
W met prior to issuance of Zr.f Oe, array. Signature of Applicant - Date
n (
nor or au00orizcJ a All roof coverings to be Class "B"or better
CITY OF CUPERTINO °'<, " ---_.-. _ _
BUILDINGDIVISION PERMITCONTRACTOR ORR A' 7 .
BUILDING ADDRESS:
RANCHO SAN. ANTONIO HOUSING tMN004020019
23600 VIA FRPIENDOR
DNER'SNAME: PERMIT ISSUE DATE - - '
RANCHO SAN ANTONIO HOUSING CORTT4F. FOR
PHONE: SANITARY.NO. CONTROL NO. -
(925) 273-0100
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
ELECT PLUMB MECH.
fop
LICENSEDMetIam ONRIACn)R'S DECLARATION
of ON AL_ E D
I hereby amrIC met 1 am licensed under DEC A ACTep¢r 9(rnmmeroc(nt Job D¢_SCrlp[I /
a� with Snetion 701a1)of Division 3 of lM Business attd Prelccions Codc.md my license is
S� intuition e.nd arras'• 38 LIN. FT WALL (HEALTH CEN E
i5 License Class Lk.M
j Dam Camraetor 8UBCON. :OLIVER.'PLASTERING
ARCHITECTS DECLARATION JUL O`' 2(pII
I understand my plans dull Mused u public records JUL
Licensed Professional I ®I /�
OWNER-BUILDER DECLARATION \(V�
q I hcrehy.('firm on 11. exempt from the Cssionso License Lew for the '
0o following reason.(Section]1131.5,Business and Professions Calc:Anycily or courtly -
3:0
$K which requires a permit M rnuuvel,alma improve,demalkh.Or repo!,any slruaum
of prior In i%issuance.also requires me applicant for such permit m rile a signed statement -~ -
& IhuMislittnsad pursuant the ISIONnf 1I1C C0nnNmfY ll CnC hW(CM1. ¢r9 Sq.-Ft:-Floor Area --- - — --,Valua
p pm: p $10.00_-___
�FF� (commencing with Section 70BD)of Division 3 of me Business and Pmfueians Code)or ' - - - " - - --- -- -_
3— that he is exempt themfmm and me basis for Ve alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjttta mo applicant to a civil penalty of APN Number Occupancy
...mare than 11.w hundred dollars(M). 34254016 : 00 Type
' ❑I,as owner of 0u pmpeny,or my employcu wise weguuthe'v mleeompanwdon, '
will do the workand meuroenum isnot intended oroEened forese(Sec.7W.Business .. _ ,
and Pmfudons Cade:The Convectors Licence,Law does Out apply to an owner of *'-- ---- = Required npecuons
s
pmperrywho bund,odmproses thereon.mr!whodoessuch Work himaHormmugh his
howeer.theu,pmvidedmu anchtmprowmantaare oat inundadoroeened fmule.If. -
builder will haw
ing thebrimpmvement issold hatlo,idnone Wild
of mproefor
a.
builder will Mw the burden of proving that he did not build or Improve far Purpose of
ask.). - . ..
❑1,as Owner of the progeny,am exclusively contracting with licensed contractors to -- _
consumer the project(Sea.7014.Business and Professions Code:)The Contractor's Li. -
emse law does not apply to an aWher of property who builds or improve thereon.and
who contracts for such pmpN with a ch,,Okumr(q liaised pursuant to the Contractors'
Like.Law.
❑Tun exempt under Sec. ,B&PC for this moon
en Dem
WORKER'S COMPENSATION DECLARATION
1 hereby alarm under ptamy of perjury One of the following declarations:
1 hew and will maintain a Cenilicatoof Consem m ulf-ircum for Workers Compen.
sation,an provided for by Section 3700 of the labor Calc.for me performance of the _ -
work for which this permit is issued. - - -
❑1 have and will to.mi n Worker's Compensation Insurance,an required by Section
3700ofine labor Code,for on performance of the work for which this permit is issued. - -
My Workers Compensation Insurance carrier and Policy number use:
Carrier. Policy No.:
CERTIFICATE OF EXEM PITON FROM WORKERS'
COMPENSATION INSURANCE
(This section need nothe completed if the permit is Intone hundred dollars(SIM)
carless.)
I certify that in the performance of the work for which this permit is issued.I.ball out
employ any person in try manncrw as to horome subject to the Worker!Compcuation
Laws Of California.Dam
Applicant
NOTICE TO APPLICANT.IL after making this Ccnifmaa of Exemption,you should
become subject to the Workers Compensation provisions Of the Labor Codo,you must
.J w forthwith comply with such provisions or this Permit shall be deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
1herehy.Mrm that there is a consumminn lending agency for theform
puantt of
Qi me work for
which this permit u wad(Sec.3097,Civ.C.)
4 0 Undoes Name
Z Lender's Add.
V Q 1 comfy that 1 have read this application and sum that the show Information Is '
D, f•' corRCL I agme to comply with all city and county ordinances and utak lawn relating to
O V building convection,and hereby authorise mpruenudvra of this city to enter upon the
{1.1 above-mentioned pmpcny for inspection purposes
y (We)ague to saw,indemnify and kap harmless de City of Cupx�rflnoagmun
In Imbilincajudgmenla.co its and expenses which may in try Way accrue,t¢tlnsl said City
V z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of Applicant/Con RDD Dau Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
N911the Applicant or future buildingkauputnorc .andth Health and
u do,Sod by the Cupertino Municipal Code,,Chaplet 9.11.and the Health tad Safety
oJc.Schon 15532(¢)?
❑Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant an equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haeardnus air contaminants u darned by the Bay Arca Air Qumlly Management all new materials for inspection.
Disuia?
❑Yea ❑Nu
I he.mad me nominees materials requirements under Chapter 6.95 of the Califon.
-I.Heuidt&Safely Calc,Sumo.25505.15533 and 25534.1 understand thus if Be,building
does not curmmly hew a¢roans met it is my na raihility W notify the Occupant of no
requirements which menu be mel prior w iasuana of a CcNRcau of Occupancy. Signature Of Applicant Date
GWnet or omhodmd agent Dam - All roof coverings to be Class oBo or better
Nov 17 2004 11 : 05AM THE#FORUM#AT#RANCHO#SRN#A 6509035920 p. 2
i
CITY OF CUPERTINO
BUILDIN G DIVISION PERMIT ' , ri-.RR 6D,
,p
'I"O2"9"0 VIA ESPLENDOR RANCHO SAN ANTONIO HOUSING P6aC'/PiN004020019
OWN R`5WMCHO SAN ANTONIO HOUSIN CORTH FORUM 'P0iT1�IE�Bl° 3/2004
. .
PHONE 6509440100 CUPERTINO, CA' 5014 SANITARY 14D. CONTROL NO.
ARC ITECTIEN0INEER: PHONEN. 38 LIN. FT WALL (HEALTH CE TqW BUILDTNOPERM(T1NFO'
EL PLUMB MEC"
TOARRANGEBVSPECTION JOB DESCRIPTION
}� v
CALL 777-3279 MONDAY-FRIDAY 24 HOURS RTc[DPa'PI.Lr--
BEFORE REQUIRED INSPECHON.JOB ADDRESS O SFDWL O KITCHEN REMODEL
u y . .� AND PERMIT R ARE NEEDED WHEN PHONING. 1-1ADDITION [2PLUMBING
RE-PIPE
S !� FOUNDAC ❑MULTI-UNIT ❑sTRucruRAL
IIJFER GROOUUN/PIERS/HND .DPMODIFICATION
5 PAD/SET BACK-CERT RESIDENTIAL_COMMERCJA _OTHER_ ❑ INTERIOR ❑CHIMNEY REPAIR
!�K+ GARAGE SLA3S/PREGUNITE IMPRO�MMENT ❑ SWIMMING POOLS
`O� HA7ARDOIJS FIRE kREA ❑BATH REMODEL/REPAIR Q DEMOLITION
❑ OTHER UNDERGROUND(SLAB 0Y It les-I aadcrzwd Wast a0 A"ressc;nMr Is ocalrcd.
o UNDERGROUND PLUMBING
L' $ UNDERGROUND ELECTRICAL D n0 Imarl Ic.B;o.r
COMMFRCIAT
AIR Tl�w. ' OUSTIN •R OF COVFRTNG C NEW BLDG/ADDITION ❑ DEMOLITION
UNDERFLOOR PLUMBING' I Numher of eaiuing covarings ❑ IMPROVEMENT TBtIANT 0FOOD SERVICE
UNDERFLOOR MECHANICAL, ❑OTHER
UNDERFLOOR ELECTRICAL Toberemoved Tob stained
UNDERFLOOR FRAMING VENTS I .
UNDERFLOOR INSULATION
TYPE orROOF COVERING
t - Fn nN - PROPOSED.•
ROOF SHEATWDIAPHRAG7.7 0 Bulli-Up Roof ❑ Built-Up Rod
PLUMBING
TUBS @ SHOWER PAN ❑ Asphalt Shingles O Asphalt Shingle,
ECHANICAL ❑Wood$Mkts ❑Wood Shakes
CTRICAUPOOL BOND ❑ Wood Shingles ❑ Wood Shinglea
MING/STAIRS/E.EGRESS2—/qs-Ar
❑ Ota(Sexily] Q Other(SpIecily)
S5IaaNSULATIOMIVENTILATION —/ Provide I.C.B.O.Report No.
Provide Mfgr.Installation Specs.
EXTERIOR SHEARMOLD DOWN
INTERIOR SHEAR/HOLD DOWN
SHEE'TROCK/SHEETROCKSHEAR INSPECTION SPECIAL INSPECTION REQUIRED [3DATE INSP
EXTERIOR LATFDW.SCREED
SHOWER LATH
,;., ASP110
SCRATCH COAT $�
SEWER/WATER
TEMPORARY APPROVALS
OCCUPANCY
I,
Z PLANNING 777-3309v
GAS TEST
I11✓IPORTANT
GRADE P.W.777.3354
J RE-CALL(409)378-4010 7,1 When a permit has 4pired, a charge totaling one-half
r HANDICAP the fees to obtain a new permit must be paid to
ELECTRICAL reactivate the permit. —
'r p, PLUMBING .
- U Z MECHANICAL
ENERGY If a permit has bee t♦ expired for more than one year,a
VISUAL FINAL ONLY charge totaling the I fees to obtain a new permit
BUILDING must be paid to rea
ta ,;5,„Pp> j73ty,rrR �_ t p 1
x• y�' r ivate the permit.t
B4
i
Initials
CERTIFICATE OF OCCUPAIJ Y
RE-INSPENON: ,PLYWOOD: IN'-PROGRESS:
,
IN SP. DATE MSP. DATE INSP. DAT[
TEAR OFF INSPECTION: BATTENS: FINAL
S INSP. DATE INSP. DATE _�_ INSP. CATE
,NATE: OSHA APPROVED,ACCES,STO ROA.F §If BE PROVIDED.FOR INSPECTION
--!
CITY OF CUPERTINO '
BUILDING DIVISION p)C+ �Cd'�1�?TR .CTQR gyp'b yam'.
BUILDING ADDRESS: RANCHO SAN ANTONIO HOUSIN TntfQ04020019
OWNER'S NAME: PERMIT ISSUE DATE
ONE:
SANITARY N0, CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
. BLDG ELECT PLUMB MECH
t�
o o LICENSED CONTRACTOR'S DECLARATION lob Descriptio
i I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing -
n< with Section 7").r Division Sof Ne Burbossand Pruressiuns Codc,and an,license is
-_ in full mreeondeffent' 38 LIN. FT WALL (HEALTH CENTER)
Data Contractor-
Lieu. NOV 17 2004
^ Date C S DELL
e ARCHITECTS DECLARATION
y � 1 understand my plain shall W used as public records
g BUILDING
u, Licensed Profatowasl
OWNER-BUILDER DECLARATION..
9 f 1 hereby.(Set that 1 rein exempt from the Conon.Co License Law for the
0 o following vires a Permit
t ]onstr Rosiness borrow,
w,demob Code:Any city or county -
Km whichrequiresitsiscanpermit requires tealter.imfor sudemolish,ore a sig any Structure — "'4,;;`(J:—tr,
y2�, prim at its issuance,also requires the appheanl for such perm1110 RIea3igneJChaptstatement
p a
that to is licensed pursuant the provisions of the Contractors License lsw
(Chapter Sq.Ft. Floor Area ValUBI100
y $ (commencing with Section 7M)of Division 3 of the Business and Professions Code)or
y Nat he is exempt therefrom and In,basis for the alleged exemption.Any violation of I
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 348I9"VS-r00eeupane -Type
not more than Eve hundred delta.(3500).
" ❑i:u owner Of the property,or my employees with wagssss their sole compensedon, - /'-' --- —
wiil do the work,and the structure is not intended or offered tonal.(So..7044,Business _...�n��'—'
and Pmfessions Cade:The Contncmes License Law does not apply to an owner of Requi 'd=Inspec OnU S
properly who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improv meat 1s sold within one year of contributor,the owner.
builder will have the Some.of roving that he did not build or improve for puRose of
askJ.
❑1,as owner of the properly,am exclusively contracting wit licensed contractors to
construct the project(Sec.7(144.Business and Profession Code:)The Cc onctors Li.
come Law docs not apply to an owner of property who Wilda or improves thereon,and
who contracts for such projects with a contracter(s)licensed pursuanuo the Comm ictor'a
aL' se Lew
.
am exempt under SeeB$PC for Nh azon
Ow cp r C ) 'r'/ WteZ 7 r� -
/� RKER'S COMPENSATIO OEC RATION
I m penal hereby affirunder penaof perjury following d.clamions:
❑Ihaveend will moimain eCenificamof Comes,mulGinaum for Workers Compere -
sation,as provided for by Sermon 37W of to Labor Code,far the performance of the
work for which this Permit is issued.
I have and will maintain Workers 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 Insumna carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed it the Permit 1s for one hundred dollars(SI W)
or less.)
I certify that in the performance of the work for which this perm.1.1la and,I shell not
employ any pars ray man era vin ec .bjec.the Workers Compensadon
Laws of Callo to
Applin int
NOfiC AP L ANT amr makin this Ccmificac of Exampion,you should
.bcco net to the W., re Comp rmation pmvisiona of the La14 code.you must
,JO forthwith comply with sue provisions of this permit shall W deemed ranked.
ti vCONSTRUCTION LENDING AGENCY
{r I heohyaffirm Nat Nitreiso construction le.0 ingageney for the performance of
fin 7 the work for which this permit is bound(Sec 3097,Ci,C.)
W� Q fender's Name
a z lender's Address
V Q 1 certify that I have read this application and stns,that the above infomta0un is _
w correct.l agree to comply with all city and county ordinances and suite laws palating to
O V building Conduction,and hereby auNorim representatives of this city to enter upon the
(1.1 above-ommu ncd property for inspection purposes.
(We)ago.to save,indemnify and keep harmless the City or Cupertino against'
aj Hadlitieajudgments.costs end expenses which may in any way accmc againstsaid City
U in consequence of the granting of this rermit. (� �rs
r� APPLICANT UNDERSTANDS AND WILL'COMPLY WITH ALL JON)POINT Issued by: Date -/
SO BOE REGULATIONS. .t �, I/ � Ik_
\ p Re-roofs
ignawo of Re-roofs
MATERIALS DISC./OSURE 1C Type of Roof
Will the applicant or future building Occurrent store or handle hazardous material
as defined by the Cupertino Municigo Code.Chapter 9.12.and the Health and Safety
Codc.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Y
Will The applicant or future building occupant ore equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
amit handout nip cnnbscrim s es rlcdnW by the Bay Arca Air Qmlity Management all new materials for inspection.
District?
❑Yes
I have read the hmardnus materials requirements under Chapter 6.95 of the Calif sr. -
ronHealth$Safely Code,Sections 25505,15533 and 25534.1 understand that if Ne building -
docs not currently hove a tenant,that it is my responsibility to fury Ih oecvpentM the
equiroments which most be nutrition.issuance ofa Certificate of ( uunity. Signature Of Applicant Date
All roof coverings to be Class "B"or better
ncr ser authorircd aFgp a W� 4 / 4'N. Dam g