04090292 (3) CITY OF CUPERTINOkW1�. . l. rd � k'�� Qa - -.
BUI LDING DIVISION PER 1T .," 1,.t a,,. ayt�", ;•.. 3C,✓ -w. '-"„.3J =- ..
PERMIT NO.
BUILDING ADDRESS: WASHBURN CONSTRUCTION 04090292
PERMITLSSUBDATE
�NER'S NAME:
-ONE:JON SANITARY OL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0 0 0
Z
0 0 LICENSED CONTRACT'OR'S DECLARATION Job Description
1 hereby of.that 1 em liesrned u r vssrons of Chapmr 9(commencing
Z ',it7l See"*. (BfIB)roff lDonsian3of NCB 'n, dProfcs ns Code.and my license is - - -- - - - _--
iMf dRfaw'�pif
qIo Lice I.. Lim.x GAS LINE TO 2ND FL. 'LUNDRY ROOM
jn p Data �..� v ContractH- `{
ty ndARCHITECTS DELL
M 1 understand my pis.shall M used as public reenrds
Y6U
Licensed Pmressianal -
S OWNER-BUILDER DECLARATION
aI 1 hereby affirm Out I am exempt fru.the Contractor's License Law for in,
_p o following reason.(Section 7031.5,Busiaru and Profeasioaa Code:Any city or cloudy
which rcquires a permit 10 construct,alma impmm.demolish,or repair any mucro. 690
_jam prior to its issuance.also requires tmapplicant for such permit mfile asignedstatement Valuatio
lh
xxa Nm he is licensedpnamonuahcprovisionsofamConnector''sLicenseU.(Chapter9 Sq.F[.Floor Area
F$^(commencing with Section 7008)or Division 3 of the Business and Profamimr Code)or _
y
that he is exempt therefrom and are basis for the alleged exemption.Any viomficoal
Section 7031.5 by any applicant for a permit subjecoo the applicant to a civil penalty of 3.%TVefr0 0 Occupancy Type
not mom Nan five handled delta.(5500).
_0 1.as owner of fl a properly,un my employcea with wages u heir sole compensation,
will da the work.and construct..is amintended oroffeRd far sale(Sec.7W,Business Re^pC,��k lred Inspections
and Professions Code:The Contractor's License Law does not apply h an owner of wI 0 !
propenywho buiidsor improves thereon,and who doesssehworkhimulforthrough his ^ 7
own employ..provided dansuch implavemeam are notinmaded at offered for sold. ' ^ �t.0
boeven the building or impowerend is sold within one year ofco.pletion,the owner. oral
Wilds'
will have the Wades of proving that he did not build or improve far purpose or
aam).
❑I,as owner of he properly,am exclusively contracting with licensed tonvacwrs to
e0roun etthe project(Sec.7W,Business and Professions Code:)The Conlracmr's Li• -
cense Law does not apply to an owner of property who builds or improves Ihemon,and
who contrms for such projects with a contracmKs)licensed pursuant to he Contractors
License Law.
1 am exempt under Sec. .B h P C far his...a
ner Date
WORKER'S COMPENSATION DECLARATION
t I hereby aB)rn under penally of perjury an of the following declermions:
❑I ham and will maintain a CerOficate of Consent to self-insure for WorkersCompel-
sation,u provided for by Sutton 3700 of he Labor Code,for 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 Codc,far he performance of the work far which this Permit is issued.
My Work lis Cam ensaI lnsumnce c urbo to ciPolicy number a.:
Came} Policy No.-
Cut
t// CFRTIFIPTION h W CERS'
COMPENSATION IN ANCE y��. fLot> �
(This section need not he completed if he permit is foraiffc hand dol ars(SIM)
or less.) -
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any mannerm as m become subject.he Workere'Compensmlon
Laws of California.Dam
Apblicant - .. ..__._..._ ....
NOTICETO APPLICANT'.If,atoolmaking his Ccnifice¢of Exemption,you should
become subject m the Worker's Compensation provisions of the Labor Code.you muss
Oforthwith comply with such provisions or 019 permit shall W deemed mmked.
CONSTRUCTION LENDING AGENCY
[-i Ihereby affirm Wt there is a construction lending agency for the performance of
y' the walk for which this permit is issued(Sec.3091.Civ.Q
aQ Lenders Name
z 12nders AaaRsa
V 0 1 ccnify hat I have read his application and seam that he above information is
ly correct 1 agree to comply with all city and county motionless and soon laws acting to .
DV building conswee toandbercbyauthonmeepumaiws ss the this city toenter
rtino.upon the
L>) shave-mentioned pmpeny rte inspection poTases.
G (We)agree to wm,indemnify and kith hay in an the City of Cupertino against
..y r/i liabilities.jV Is and expertsrs which may in any way accrue against said City
V'F7j in conic{ircnce f Ne orating of this permiL Date
APPLICA NDERSTANDS AND W L COMPLY WITH ALL NON-PDI Issued by:
SOUR GUKATI�o�� J-�J�r ♦;I
~'�1 — /1 j` Re-roofs
,iialumure of ApplicaHAZARDOUS MATERIALS DISCLOSURE Dan Type of Roof r
WIII the applicant or future building occupant store or handle hamrdous material
as defined by the Cupefteo Municipa -ode,Chapter 9.12,aad the Health and Safety
Code,Section 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will he applicant or future building occupant use egldpma t or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaentnus air contaminants.defined by he Bay Arca Air Quality Management all new materials for inspection.
District?
s Nu
I ac ad he havanam mandate requirements under Chapel 6.95 or the Cabroa
ria cal etyma ,Seaiy.2550,35533 and 25534.1 ndersmnd Nati rhe Wilding
does uncndy ha a moa L that is y respmuibility n notify the occupant a me
.qtr endow term at m tprior ssuance ncenif an orOcapanry. Signature of Applicant Date`
l�
Dam All roof coverings to be Class"B" or better
wnc'r—or aamorivsa agent
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CITY OF CUPERTINO•
•CUPEIILTINO PERMIT APPLICATION FORM v `�o Z Z
APN# -2 r / 0 Date: �� G
,` h q
Building Address: Mailing Address (if different from building address):
0 0 11 M i 'r e� Sbly
Owner's Name: Phone#:
JM C I 64v-(_
ontractor: License#:
E vv,/ Coo 31dvJj ,,") -7 4
Contact: Phone: Cupertino Business License#:
Fax:
BuilAiaR Permit Info:
Bld Elect ❑ Plu b Mech ❑
Tob caption: / ,
esidential El (� o ercial Ef
Sq.Ft. Floor Area: /Sq.Ft.:
Cost of Project: d-U Occupancy Group:,
ype of Construction: I Please check thi x if th 4froject is a
second-story addition: ❑
Project Size: Standar Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> LOOK 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 MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/OfVComm/ uasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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