08110038 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .'�1RkLTR"Il ''0;} M:�T�.I01v ,
BUILDING ADDRESS: PERMIT NO.
22241 .MC CLELLAN RD TBD — TO BE D
OWNER'S NAME: PERMIT ISSUE DATE
17T3DPATTNQ r"TTV I1P
NE: A CONTROL NO.
ARCHIIECT(ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
Boa LICENSED CONTRACTORS DECLARATION Job Description
CvF 1 hmeby affirm Nat 1 an lixnsed under pmvisisv of Chaplu 9(commencing
`Z umridt Section 70M).[Division 3 of ds Busts.aed Profestioru Code.and my license is
+,„ mm0force arWertec. REPLC GALVNZED PIPE IN WATER SUPPLY SVC
.yz License a.a Lle.d
Dale Co toneor
p ARCHITECTS DECLARATION
W U I understand my pWu shall be used u public wcmds
g G Licensed Profcsdonal
3 OWNER-BUILDER DECLARATION
f 1 hereby afrna that I am exempt Isom the Communes License Law for the
HO OO following moon.(salon 7031.5,Business and Profcssiou Code:Any city or county
which require a Permit to construct,altar,improve,demolish,or.,an any suuttum
y Prior m its issuance,also inquiresflue applicant forsuch permit to file.signed elakmam
<
that he is licensed pursuant to the provisions oflhcComment's 4ccocLaw(Chapter 9 Sq.Ft. Floor Area Valuation
E5o
IF-$ (commencing with Section 70W)of Division Sof the Business and Pramssinns Code)or 5500
'51
Nat he u exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy
onsmore Nan five hundred dollars(S5001 35706014 . 00 ZYpe,
0 1,u owns of Ne pmpmny,ar my wploym wu wager u theta mk compcmdon,
will do tine woh and thesuacture u East Intended oroRered ersale(Sec.] .Business
and Prore�ov Cade:The Contracmra License Law dm East apply m an owner of Required Inspections
property who builds or imps e.darcon,and who does such work himself ter through his
own employm.provided that such improvements are not intended oroRered forsale.If.
however.the building or improvement is sold within ane Inca of complefian,the owner- -
builder will have this bmdcn of proving Nat rte did Out build or Improve for purpose of
sale.).
L u owner of nk property am exclusively contracting wins licensed cantrvcmrs N
construct the project(Sec.7044.Business and professions Code:)The Coouurofs U.
cove Law dm not appy m an owner Of propenY whe latilds or improve themon.and
who conmcu for such projects wins aeonvuNr(a)Iie6msed purmann m the Convectors
License Law.
❑Ian te(e�/ppt/andp\Sec B&Pcf Ends o
Ownv^ (n JR
WORKEERS RICO CO PENSATION DECLARATION
411 hereby a0'vm under Ey.f perjury one olds(allowing declwions:
1Is and will maintain•Cmifiestaof Consent m self-inureforWr1oe.Compen-
an.as Provided for by Section 3700 of the Labor Code.for thin performsnm of the
ware for which this permit is Wood.
0 I have and will maintain Worke/a CompeoNme Nunn.,u wired by Section
3700 a Ne Labor Code.roc rhe pcf.mEmccof the wart for which Nu permit is issued.
My W.k .C..,.fion Insennm carrier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(Thessection need not de completed If the permit Isforone hundmeddollass($100)
or tesa)
I cenify Nat in Ne performance of the work for which this Permit is issued,I shall not
employ any personIrany mannerm tabc oLnpauj mthe Worken'Compmmuon
Laws
OTC aI famia.
AppDaW
uaant
NOTICE TO APPLJ A .If,aMs makmjoaCSnificate of Exempts...ysu.houM
become subject be the Workers Compensation provisions of Ne Labor Cade,you masa
0 z forthwith comply with such provisions or this permit shall be decreed revoked.
? O CONSTRUCTION LENDING AGENCY
HI hereby affirm that there is nsw
a coction lending agency for the Performance of
a> Os wort for which this permit b issued(Sec.3097.Civ.C.)
C0 Undies Nano ,
]z LsndersAddreu
U O 1 Carry that I have mad this application and scale Na the wove information is
E' const 1 agrec an comply with all city and county Ordinances and sere laws mlating to
.0Ubuilding camunw:do.,and hereby mNonm representatives of Ncc u
Nu city to mpon the
r Cn abivc-mentioned property for iopeetion purposes.
4 (Wer)agree to taw,indemnify and keep harmless the City of Cupertino agil
H can liabilities.judgments,costsaml..w.which may in any way awns against said Cit
t.),Z, in cooet,mnte of de,grutrng of Nu permit
^ APPLICANT UNDERSTANDS AND WILL C LY WITH ALL'NON-POINT Issued by: Date
. ////e Re-roofs /
Sigwuro Applical4AZARDOU Das
xnznaoou ATERLAIS DISCLOSURE
Type of Roof
Will y t e Cuont or mum wading e.Chart team 2.haMk lurvdov mooed
u de0ncd by the Cupenins Municipal Cade.Chapter 9.11.and the Health and Safety
Code.Section 15531(.)] ^ All roofs shall be inspected prior to any roofing material being installed.
❑Y �NO
Will the applicant or future building aaapant use equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
con haeardov air contamimants as defined by flue Bay Area Air Quality Management all new materials for inspection.
strict]
DYcs y
I have mad the heaaNsus materials requirements under Chapur695 of Ne Califor-
oiaHcalth h Safety Cols,sections 25505.25533 and25534.I undencened thaifNe building
dm not currently have•tenant that It b to 'Oi ty m no ily Ne occupant of Ne
mga; /Bwhlgnmmwxmapnor r oisCenmcaaf Panay Signature of Applicant Date
�l (J //�i owdp All roof coverings to be Class'J{"or better
Owner or autbonmd agent T Dam
o?// 0 0.3?
O CITY OF CUPERTINO
Q- 1 REPIPE/SEWERIMAIN SERVICE
IF
CUPEkTiNO - PERMIT APPLICATION FORM
APN # D
357o o / y, ate:
Building Address: 2 :2 2 y/ M, /el'IV,
Owner's Name: Phone #:
Contractor: Phone #:
CA2/oak P M 6 . �� SOPL"/rc- 41op•- 3 > 7 - 3017
Fax #: .35 9 -3 S'OS-
Contact: 2o5e1 C/i Phone#:y _ 20S — 36
Fax #: —
Contractor License#: 1441 6/o 7
Cupertino Business License#:
Job Description:
Rep4re-
Sv/lp�y SPRuick '
Residential Commercial ❑
Valuation:
SSoa
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit Type
Group
iPCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
IBPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BSEISMICOM Seismic Commercial P
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
a-,
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEkTiNO - FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
IPPRSEWG Private Sewage Disposal System P
1PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
IPLMBLNCK Plumbing Plan Check P •
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1BUSLIC Business License B
Revised 6-16-08
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