02030031-FP 11�Y (DIF CUPERTHN(D C)3
CITY of PIERMIT APP LIICA'll'lION FORM
CUPEK O
APN# b Date: �/O
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B�uil•�ding Address:: (�J {y ,
Owner's Name: Phone#:
Ca" W,, S d1
Contractor: License #:
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Contact: Phone
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Applicant/Contractor: Fax#:
Buildin Permiti Info:
Bldg lect (Plumbech
Job De cription:
esi ntial: o
Sq.Ft. Floor Area: /Sq. t.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Gro p:
nflanta Fee IID Fee Description Fee Groan
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permit sq. foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHA141CAL
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
B1EN ERGY Energy BUI LDIING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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CITY OF CUPERTINO
BUMDINc DMSION1P]E][�1[�T CONTRAC70R III`Y®RLJ` 1:"��
BUILDING ADDRESS: PERMIT NO.
21346 RUMFORD DR 02030031
OWNER'S NAME: APPLICATION SUB DATE
PATT STEVEN L ET AL 03/08/2002
PHONE: SANITARY NO. CONTROL NO.
G ARCHITECT/ENGINEER: BUILDING PERMIT INFO
to
Z BLDG ELECT' PLUMB MECH
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Hlu
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t-? LICENSED CONTRACTOR'S DECLARATION
o y Z
1 hereby affirm that I am licensed under provisions o(Chapter 9(commencing Job Description
HH O with Section 7000)o(Division 3 o(the Busin and Professions Code,and my license KITCHEN & 2 BATHRMS REMODEL.
is in full force and effect.
critL _
i s 4 L' Cly, `-I;1C Lic
O r,v ate o Contra
o.O tri, ARCHITECr'S DEC ATION
LL LL Y 1 understand my plans shall be used as public records
i r
too Licensed Professional
X o�' OWNER-BUILDER DECLARATION
to=ti 1 hereby affirm that I am exempt from the Contractor's License law for the
F'Z Q following reason.(Section 7031.5,Business and Professions Code:Any city or county $100000
f x p which requires a permit to construct,alter,improve,demolish,or repair any structure
to--°4' prior to its issuance,also requires the applicant for such permit to file a signed statement
thzi ha,is licensed pursuant to[he provisions of the Contractor's License law(Chapter 9C1,FIpr.-p,.6a Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code) ((��4 1rj V
or that he is exempt therefrom and the basis for the alleged'exempiioa.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty �7 7,Q,.
of not more than rive hundred dollars(5500). 1 0� PR
PN 1µ AT I ON Occupancy�pe
❑I,as owner of the properly,or my employees with wages as their sole compensation, 1 T 2R
'will-dei the work,and the'struclure isnot intefided or offered for We(Sec-7W, - - -
'Business'and Professions Code:The Contractor's License Law does not apply to an 103 - UFER Required Inspections -
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements are not intended or _ 104 - REBAR
offered for sate.If,however,the building or improvement is sold within one year of 105 - ANCHOR BOLTS '
completion,the owner-builder will have the burden of proving that he did not build or
improve for purpose of sale.). 106. — SEWER & WATER
❑1,as owner of the property,am exclusively contracting with licensed contractors to 202 - UNDERFLOOR PLUMBING
construct[he project(Sec.7044,Business and Professions Code:)The Contractor's
— License Law does not apply loan owner of prcpeny who builds or improves thereon, 203 — UNDERFLOOR M�tiM
E CHUAN I CAL
.and-who contracts for such projecrs-with a.convactor(s)licensed pursuant to.the _ .2 04 - UNDERFLOOR Fi� E -_
Contractor's License raw.
❑I am exempt under Sec. ,B&P C for this reason 205 - UNDERFLOOR 'INSULATION
owper'' Date 301 — ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
I hereby affirm underpenalty of perjury one oche following declarations: 302 - TUB & OR SHOWER
303 — ROUGH MECHANICAL
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's 3 04 — ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued. 3 O rj - FRAME
❑I have and will rnainW6 Worker's Compensation lnsurance,at required by Section 306 - HOLDOWNS
3700 of the Labor C6de,for the performance of the wotk.for which this permit is
issued.My Workers Compensation Insurance'carrierr6,d Policy number are: - 307 - INSULATION
.Policy intiJ.• TL'A'gyal�f 3�7 3.0_8.1 r ,.$ Er.., )�OCK ..
.CERTIFICATION.OFEXEMPT1FROM WORKERS' 305 - EXTERIOR LATH
COMPENSATION INSURANCE`' - -' - -
(Ibis section need'not be completed if the permit is for one hundred dollars 310 -; �Z NTERI'OR`LATH .
(s100)orless.) 311 — SCRATCH COAT
I'ceniiy that in the performance of the.work for which this permit is issued,1 - 313 - -ROOF NAIL
shall'not employ,any person in any manner-so as to'become subject to the Workers 5 01 - FINAL ELECTRICAL ENERGY
Compensation Laws of CaliforKia.Date '
Applicant — 502 — FINAL PLUMBING ENERGY
NOTICE TO APPLICANT:If,after making this Certificate o(Exempti6n,you should
® ® become subject to the Workers Compensatioo'p'rovisions of the Labor Code,you must 503 - FINAL MECHANICAL ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
504 - F I NAL BUILDING ENERGYI . .
f/] CONSTRUCTION LENDING AGENCY'
� ''• I hereby affirm that there is a construction lending'agency for the performance 505 — FINAL ELECTRICAL
the work for'which this pertnil is issued(Sec.3097,Civ.C.) 506 - GAS TEST
�:Q Under s Name.: - _ .. ..
Z Lender'sAddress 507 — FINAL PLUMBING
�. I certify that I'have read this application and state that the above information is 508 - F I NAL MECHANICAL
I+.P correct.I agree to comply with all city and county ordiaapces and state laws relating
509 — FINAL GRADE
OU to building conswction.2nd hereby authorize representativts of this city to enter upon
>;'W the above-mentioned property for inspection purposes.. 510 — FINAL PLANNING
CLA (We)agree to save,indemnify and keep harmless the City of Cupertino against
b.Cn liabilities,judgments,costs and expenses which may in any way accrue against said 514 — F INA P IC WORKS
bCity in consequcnce of the gmpting of this permit. -" 0
APpPIC as s nRp , . tY wITH ALL:NON-Po Issued by: Date
3
re Ap icant)Contract `- a Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building'oecopantstore or handle hazardous material .Type of Root` - - -.
as defined by the Cupeniao Municipal Coda Chapter 9,12,and the Health and Safety .
tone,$ection 2553$(ar?.'
-❑YesI.
All.rggfs shall_be inspected prior to-any roofing material being installed.
w,B the applicant or fate building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,i agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? all new materials for inspection. Applicant understands.and will comply with
°Y-e:s all non-point source regulation's. . ,.
I bsveread the'hairudous matcriali requirements under Chapter 6.95 of the
California Health&Safety Code,-Sections 25505,25533 and 25534.1 understand that
if the,building does not currently vc a tenant,that itis my responsibility to notify the ' •' '
occupant of the togWrmcnmustbe met prior to is enc of a Certificate dfoa°panst b7 Signature of Applicant Date
>040fa ed agent: ,• Date All roof coverings to be Class "B"or better
-:l - - - - OFFICE