02070020 CITY OF CUPERTINO
a BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BIfILp1yY(jf0 RDE ANZA BLVD SUN RESTORATION (MANDER IN P�RMrr 02070020
LJA E 635 UNIVERSITY AVE APPLICA7P 78712002
I'-
:8�z
HONE: L`"� (408) 358-6454 SANITARY NO. CONTROL NO.
RCIi1TECT/FSGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C-1 L-I
LICENSED CONTRACTOR'S DECLARATION ription
iZu 1hertby aRrm hat licenxd under pryvislons of Chapter 9lcommencing TI- 'VEHICULQA L,''
._t withSmion]o007 of Division3 of the Buxine✓xuf�tja Professions Code.era mylicenx
m is inn full fort an C f /� p(1 (}� j ^ EDj
� Lir nuLice l' JJV -']
3 i u Date comm',f�r L.__J 1J
ARCHITECT'S D[(/I,ARATION
QCs ondersmm!my plans slmll he used r., blie records "'b
r
Licensed Professional
e-o OWNER-BUILDER DECLARATION .,,�
t= I hereby.(firm thin]am exempt sun Nc sionsC Contractor,License I:Ww for the -
' Za followingaimson.(Section]malmBusinessend Professions Cadc:Any cityor.Dome,
i F O which tits a permit re constsun,oher,improve,tle Permit
1.
,or repair any xwcturt
3� pdoheislcense pursuant
toregrrts p—i,iedelippl..f roc Conpetoinaicense Law
harne9
mommencamedpursuion700).J`Divi,mm3xeamtmcm usniulxlewonsCed9 . 3Sy2180r vp.®d$a .. 5 , a , Valuation
or that a is exempt with Secerefro and tDi Writ o t the legthened ss and ion.ProAn vi Cade) ) 1 I''. s .n _ _ _ t
of Shot he is31.5btnerefrom'and the basis for the alleged exemption.Any violation -
-of not mo than by airy hundred
run for a permit subjects the applianno a civil penalty,
ornntmortmanrvenunareaaonanaslw). 10]ARN1P'OLINr)ATION - Occupancy Type
O l,tvmvmrnf the pmpenyo my employees with wage.as theirsole minme nsaumn, 102 - PIERS
will do the work,and the structure is not intended or offered for sale(Sec.]614, 1 0 3 - UFER
Business and Professions Code:The Cnntmnor's Lkense Law does not apply man Required Inspections
a' r of property Who builds or improves thereon,and who docs such work himself 104 - REBAR
or throwss r his own employees.provided thin such improvements art no,intended m
offend fOr sale.IL however.the building or improvement is sold within one year of 105 - ANCHOR BOLTS
completion,the owner-builder will have the Wreen of Proving thin he aid not build or 106 - SEWER & WATER
improve for purpou of sale.).
- 01,al owmr of me mpeny,am exclusively contracting with licensed contmemss m
202 -- - UNDERFLOOR PLUMBING---
p
construct the project(Sec.7044,Business and Professions Codc:)The Co.rutin. 2 0 3 - UNDERFLOOR MECHANI CAL.
License Law does not apply to an owner of property who builds or improves thereon,
and who contracts for such projects with.. tmctons)licensed pursuant conm the 204 . — UNDERFLOOR..FRAME
CaIs.mis License 205 - UNDERFLOORI INSULATION
01 am exempt under Sec, .B&P C for this reason
)woes ' Dot= 301 - ROUGH PLUMBING
WORKERS COMPENSATION DECLARATION 302 - TUB & OR SHOWER
ntcmby.ffirm..aerpenalty.fNrjurymmmthe following deelamtmm: 303 - ROUGH MECHANICAL
0 1 heve and will emblem a Certificate ofConsent to xlf-Instue sof Weaker', 304 - ROUGH ELECTRICAL
compensation. as provided for by section 37M of the Leiser Cade, for the 305 - FRAME
_ perfomrance of She work for which this permit is issued.
01 have and will maintain Worker's Compensation Insurance,m required by Section 306 - HOLDOWNS
3]00 of the Labor Code.for the performance of the work for which this Permit is 307 - INSULATION
issued.My Wwke/s Compensation nsumnce a mer and Policy.amber am: - - 308 - SHEETROCK
caYeR'T�C' 7"_'Pa30.9 4 !EXTERrIOR LATH
ON CE IF1C M W
COMPENSATION NSUFROKERS'I
31.0- -. .;INTERIOR. LATH
'(This xctionneed nisi b<rompined inne perms is for one hunetee amlem 311 ' — SCRATCH COAT
aloo)aneaa.)_ 313 - ROOF_NAIL
"i artily that in the pertormance or the work ter winch mis pemdt is issued,)
501 — FINAL ELECTRICAL"ENERGY
shall not employ any person in any manner so as to become subject to the Worsen
Compensation lswaorca0romm.Dine 502 - FINAL PLUMBING ENERGY
Connected.
Applicant - -
NOTICE TOAPPLICANT.If,after making this Certificate ofExemption,you should 503 - FINAL MECHANICAL 'ENERGY `
become subject to She Workers Compensation previsions of the Labor Code,you must
Z O forth wehcomply with such provisions or.
this Permit shall Wdeemed revoked. 504 - FINAL BUILDING ENERGY
505 - FINAL ELECTRICAL
f^ i CONSTRUCTION LENDING AGENCY '
I h by 0i' Sha,there s a nsostiu li n lending agency for the performance
s > 506 - GAS TEST
v Lethe work f which ims perm.i issued IS 7097,Civ.C)
y.p 'L=der Nme'' - 507 - FINAL PLUMBING -
U C L`�d"`Aearta 508 - FINAL MECHANICAL
Immfy that i have read dialipplicni mul mm that dmidove infornmion is 509 - FINAL GRADE
lL.Es .Direct.1 agree to comply with all city and county ordinances and state laws relmin{
to Wilding construction:and hereby authmire mpaxmadva of Nis city to enter upon 510 - FINAL PLANNING a
}y (g] She shave-mentioned pmpcny for inspection purposes.
L pe (We)agree tbsave,indemnifyandkeepharmlessNeCity ofCuperinoagainst 514 - FINAL PUBLIC WORKS
FFnn Vl liabilities,judgments,cents
me expenses which may in any way accrue against said
U'.Z., City in con equrnce of She grandtg of Wisp, Cs
_ APPL7C TUNDERSTAND. j' WILLCOh1 WITH ALL NON'-PO(hT Is
AFFIX Dale
SOUR E(i'CATIONS. g'1- _n+) Y•
mcf APpli ,/ cmc. ,. / DamlL. . Re-roofs
AZARDOUS h1ATERIALS DISCLOSURE, 1.
'' Will'thea icanforfutua tidilEingoccupam stow of handle heraraous material Type Of Roof ..
es defined Cupmino l funicipel Cade.Chep¢r 9.12.end the Health mtl Sofety
Ctde;Sectiomnr 25 25532(e)] = •- ', r, • ) '.
°Y All.roofs_shall bi,ins ected, .onto any roofin material being Installed.
WinmeaPPhea�,m future Wilding ocyupam use equipment or devices which If a roof is installed without first obtaining an inspection;I agree to remove
,nit hvzNous air conmmimnn m defined by the Bay Area Air Quality Management
thrum? �— all new materi
°Yr als for inspection. Applicant understands and will comply with
., . all non-point source regulations.
t--�
'I have}cad dm,haiallous m lethals 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 have a tenant,that it is my responsibility to notify She - "
occupant of t equirements which he met prior m issu ce of a Certificate
Occupancy.
"2-04 Signature of Applicant Dateliel „
r unit...de age ate All roof coverings to be Class"B" or better
- - OFFICE
` CITY OF CUPERTINO 2, D
#CUPEQJINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
d � S
Owner's Name•bcn-ult Phone#:
I ]Ah
Contractor: (n� -` License#: p
do.rL1�� 1—LL '4 '9i� 7 C 0
Contact: Phone#:
Applicant/Contracto Fax (Ai
ol3 '
•Building Permit Info:
Bld El Plumb Mech
-Tob Description:
Residential: Commercial:
Sq.Ft.Floor Area: $/Sq.Ft.:
chitect/Bngineer: Valu on:
Ito,
ype of Construction:
Occ'up anc Gro
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances 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 Comm. Housing Mit. Fee BUILDING
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BNEWMULTI New Multi-family Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
�et7
1 of 3
3W3