02010024a-CTvo
CUPEkTINO
q:iTY OF CUPERTINO
PERMIT APPLICATION FORM
oaoloqa4
APN # Dd
Date: 1 7
Building`,Qiddress
Owner's Name: ,� _o
-do-ntractor.
Phone #:
SZS 7
License #:
Contact:
Phone #:
40`a - 39S - 717 -Z-
'Applicant/Contractor:
1'"t re- L ILT16
Bldg Permitsq. ict
'1 g Permit Info:
Bldg i X(E16ct Z�Plumb) Mech
J escrip #ion:
Residential: I2�HcvbW_ Ei(4 HSTP_ l�D IZ Commercial:
Sq.Ft. Floor Area:
$ /Sq.Ft.:
Architect/Engineer:
Valuation:
fc—) � Q
T f Construction:
Occupancy Group:
2 --
Quantity
Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBLDGFEE
Bldg Permitsq. ict
BUILDING
BBOILERI
Boiler < =100,000 Btu
MECHANICAL
BBOILER2
Boiler > 100K to 500K Btu
MECHANICAL
BBOILER3
Boiler > 500K to 1M Btu
MECHANICAL
13BOILER4
Boiler > 1M to 1.75 M Btu
MECHANICAL
B130ILER5
Boiler > 1.75M Btu
MECHANICAL
BCONSTAX, :, ::..:
Construction Tax
BUILDING
"
' BCONSTAX
'Ind/Off/Comm/Quasi
BUILDING
BCONSTA3B Q
Con. Tax for Bg Zone
BUILDING
BCONSTAXH
Hotel and Motel
BUILDING
13CONSTAXR
Constax – ResilMobile
BUILDING
BELEC1000
Elec 600V c =1000A
ELECTRICAL -
BELEC1001
Elec 600V > 1000A
ELECTRICAL
BELEC200
Elec Svcs 600V <– 200A
ELECTRICAL
BENERGY
Ener
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BIlWESTIGA
Investigation fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUILDING
I of 3
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PE N0.
11497 LINDY PL
MCCOY CONSTRUCTION
02010024
OWNER'S NAME:
PETER & LINDA TONG
193 EAST GISH RD.
APPLTCATION SUB DATE
01/07/2002
?ONE;
(408)395 -7172
SANITARY No. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I—i L__j L _] L_j
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I um licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code- and my license
full force and ✓Y
effyk
REMODEL X I S T MSTR BD RM & BATH
icense class Lic.p S`�SZT9
L'
\tttJ///A /VVVIj��
D AA -in
-
Date I- It77_ Contractor
/7
I
rl' ARCHITECI"5 DECLARATION
I understand my plans shall he used as public records
t•
Licensed Professional
OWNER- BUILDER ��CMTI
1 hereby affirm that I am exempt front ^, ;he Cpntmcl L' a for l
following reason. (Section 703 L5, Business and Professions C ny ci r co
which requires a permit to construct, alter, improve, de 01i It, pair ct
prior to its issuance, also requires the applicant %Eialch LLn l�� gee mtemen[
I - - - -- -- - — -- -
that•)ig i> lic plied puisuaht to the ptocjsitms of a ontractofs d ` Law ( hapter 9
(commencing with Scctiont70(10) of Division 3 Ir the Bus nd _ ess s Code)
or that tie is exempt thertidota and the basis fo ihe�al�egj_�plio n iolarion
of Section 7031:5 by any applicant for a permit h [cant to a civil penalty or not more than.five hundred done s ($5W).
10 LPN ' YOCi DAT I ON
Occupant y e
❑ L as owner of the property, or my employees with wages as their sole compensation,
102 PT RS
will do the work,, Ind the struchire Whotinfended or offered for s0e- (Sec. -7044,
' Businesshnd 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
1.0 4 - RE_ BAR
ar through his own employees. provided that such improvements are not intended or
_ _ _ _
—BOLTS �-
offered for "sale: If, however, the building orimprovemenC is sold within one yeai of
10 5 - ANCHOR Y
completion, the owner - builder will have the burden of proving that he did not build or
improverorpurposeofsale,).
106 - SEWER & WATER
b.I.-as cwner.cf the proficrty, an] exclusivcly contracting with licensed contractors to
202 - -' UNDERFLOOR- PLUMBING- -' _ -
construct the project (see. 7044, Business and Professions Code:) The Contractors
License Law does not apply [o an owner of property who builds or improves thereon,
203 - UNDERFLOOR MECHANICAL l
and who commcts.for, such. projects, with a contractors) licensed pursuant to the.
__-
- - __ 2 O -4 _ r- rnYDER.FLOOR_ FRAME-
U��
Ctrtctods License Law,
on
❑ I am exempt under Sec.' , B. & P C for this reason
205 - UNDERFLOOR 'INSULATION
owner Date
301 - ROUGH PLUMBING
. WORKER'S COMPENSATION DECLARATION
302 - TUB & OR SHOWER
1 hereby offtrm under penalty of perjury one of the following declarations:
303 - ROUGH MECHANICAL
I I have and will maintain a Certificate of Consent to self -insure for Worker's
304 - ROUGH ELECTRICAL
'ornpensation, as ,provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued. ,
305 - FRAME
�phave and will maintain Worker's Compensation Insurance, . as required by Section
306 - HOLDOWNS
37LIO of the Labor Cade, for the performance of the work. for which this permit is
3 0 7 - INSULATION
issued. My Workers Compensation Insurance and Policy mtmber are:,
Carver a � •y ` ` „
3 QQ 8 �- - -SHEETROCK -
.. I
' CERTIFICATION OF,EXEMPT1DNF
. % ' FROM WORFtRS',
-
9 ? == EXTEI�I ORs LATH
- • -- - � --•- �- -- COMI ENSAnON.A`15URANCE-
-`3-10'-,-- - -- "- -- -,_. _.,.- — -- °- -, °, - - - -- --- --
- - ,.INTERI OR
., t ° '(ThiS section need not be cemplei4if the permit is for one hundred dollars
311 - SCRATCH COAT -
I certify that in the performance of the work which this'permit is issued, 1
- - - 313 � ° -' ° -ROOF- NA L_ a.,
[` ,fer
shall not emptoy'any person in any manner so as to become suliject to the Workers'
501 - FINAL ELE'T1�I CAL' ENERGY
pplpcar;� ti °n Laws of California. Date
5 Q 2 FINAL PLUMBING- ENERGY -
NQnCE TO APPLICANT.' If. after making this Certificate of Exemption; you should
become subien to the Worker's Compensation provisions of the Iabor Code. you must
503 - FINAL MECHANICAL ENERGY
rorthwith comply with such provisions or this permit shall be deemed revoked.
.504- - FINAL BUILDING ENERGY
" CONSTRUC)ON LENDING AGENCY'
505 - FINAL ELECTRICAL
I hereby affirm that their is a construction lendimi a jenc) for the pedamtance
of the work fdr which this permit is issued (Sec:'3097, Civ. C.) -'
506 - GAS TEST
Linder's Name'-
Lender red
Lender's Adds'
1 certify that I have read this application and state that the above information is
_ _
567 P
- FINAL LUMBING, ,
5 0 8 - FINAL ME CHANI CAIa
'corMCL I agree to comply with all city and county ordinances and state laws relating
to building constroction, and hereby' authcriserepresedmtives bf this city m enter upon
509 - FINAL GRADE
the above- mentioned property for inspection purposes.- -
510 - FINAL PLANNING ,
(we) agree to save,7ndemn)ry and keep harmless the City of Cupertino against
514 - FINAL PUB I C WORKS
liabilities, judgments, cosls and expenses which may in any way accrue against said
City inconsequence of the'gapting of this permit: ' "
- APPLICANT NDERSTANDS AND WILL CDMPLY�WITH X L NON -PORE '
' -
r
l VC) v
Issued by: Date
E TONS
SSI•n of pplicanvcontractor Date
Re -roofs
HAZARDOUS ACS DISCLOSURE'
Will the applicant or future building ocetipan'slore.br'handle hazardous material
Type_of -Roof .- _ _ •- -- - - - - • _ _ _ _ _ _ _ --- ,
as defined by the Cupenina, Municipal Code, Chapter -9.12. and the Health and Safety
I .
' •." '�-, `, �' .
Code,. Section 25532(a)? r= -
❑Yes
F.
_. ,A1l-roofs_shall1be inspected -prior to -any- roofing material,being installed.
Will.the applicant cr future building occupant use equipment or devices, which
If a roof Is Installed WIthout first obtaining an Inspection; ,f' agree` to remove
lit haiardoirsair contaminants as defined by the Bay'Aiea Air Qualify Management
strict2 .�
all new materials for inspection. Applica_n_t understands_ and will comply_ with.
❑Yes r
_ _
al non -point source regulations., ,
I irate read the hazardous materials requiremt ht 'under Chaplet 6.95 of Elie
_
Calif6mia Health & Safety Cude, Seet(ons•25505, 25533 and 25534.1 understand that
if thkbuilciing does not currently bavea tenant; that it is my responiibiloy to no -lify the
-
occupant of the requirements which'must'be'met prior td issuance of ,a Cenificate of
ancy _
Signature of Applicant Date
All roof coverings to be Class "B" or better
erpra horizedage Da[e
`" OFFICE