02100110 CITY OF CUPERTINO
BUILDING DIVISION PERIM COWRACTORINFORMAT ,
BUlqi8(89DRN0RMANDY WY TROJAN REMODELING & DESIG PE9A3 @02100110
owQUT,FVR KHUNDHAR 681 ELDEN DR APPLICATIQ103YRPgrry'2002
ONE: - (408) 371-9179 SANITARY NO. 77 CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMTTINFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION
I hertby eflipn Net I em licenxd under pmvisiom of Chapter 9(commencing
with Section AglOof Division 3 of Rusinese epd;Protexiom Code.end my license if REPLACE SUB FLJO/R K SEAT
rn in full scree an a .J` AT F I L ' '` '�='
Z6Ppb Licnne Cl I\
P, Cuntncmr W. II
F= ARCHmECT`S DECTZPRfflON Vt
I understand my plana shall he used as public records '
u0
3 u.
Licensed Professional
" OWNER-BUILDER m Ce Contractors
ON
I hereby affirm Net I t. exempt from the ossom, License Law for the _
_OO following exon.permit
703t.5.Business and Professionsh.or Any tiny or county
$� which requires a permit m mmswct,tltec improve,dcmoluR or repair any structure $2800
prior to its issuance.alta requires the applicant for such permit to Ole a signed statement
Net he if licensed pursuer,w me provisions of the Contracmts Licevc Law(Chapter9 Sq. Ft.Floor Area Valuation
e(FO (commencing with Section 7")of ivision lofthe Businessand ProfessionsCode)or
W R_ man bu If exempt therefrom and the�bssis for the alleged exemption.Any violation of 36611167 . 00
Secum.7031.5 by any applicant to,a permit subjects the applicant&•civil penalty of APN Number Occupancy
me more man five honored dollars(s500). 101 - FOUNDATION p y�'Pe
❑I.ms roftheprop.ny.mmyemployenwimwageantx4wtcwmpe on,
±82 PiERS
willdo Ne work,wd the avucwre urwt intendW oroRertd fmssk(Sec.]ON,Bwinnsa
and Professions code:The Contactor.Liana Law Area Ann apply in an owner of 103 — UFE R Required Inspections
property who builds or improv&thereon,and who dce..uch wart himself m through his
own employees.provided thatsuch improvements art notin¢nGA mourned fursam.If. 104 — REBAR
however.me building or improvements sold within can Year ofcnmpletion,the owner. 1OS — ANCHOR BOLTS
builder will have ft burden of proving met he did not build w improve for purpose of
106 - SEWER & WATER
❑1,as owner of the property.am eaclusively contracting with licensed contraction in 202 - UNDERFLOOR PLUMBING
construct the project(Sec.7W,Staines.and Professions Code)The Contractors Li.
cons law time not apply to an owner of property who buil&or improves thereon,and, 203 — UNDERFLOOR MECHANICAL
who contracts for such projects with a coomenorm)licensed pursuant to me Contractor.
License Law. 204 - UNDERFLOOR FRAME
❑ 1Amesemptunder Seo. .B&PCfor this mmon 205 - UNDERFLOOR INSULATION
Owner Data 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
Ithereby afnninunder penalty ofperjury on,ofinefollowing declarations: 303 - ROUGH MECHANICAL
l hem and will maintain a Cenirce¢ofconxm mxlf-insure mrwmke&Compen- 304 — ROUGH ELECTRICAL
codon.n provided for by Section 3]00 of the labor Code.for me performance of me
work for which this permit is issmd. 305 — FRAME
❑1 ben and will maintain Worked Compensation Imminence,As required by Section 306 — HOLDOWN.S
3TWof the labor Code,for the performance of me work for which mis permit is issued
My Workers Comparison..[resource cacti.,end Poli number art. 307 - INSULATION
�e er: Po / -w - G 308 - SHEETROCK
CER]IFI COMPENSATI50N INSURANCE ITIWFROM ORKERS' 309 — EXTERIOR LATH
(This xenon need not be completed ifine perms is forone hundreddunan(S1a)) 310 — INTERIOR LATH
" Iass') 311 - SCRATCH COAT
1 sonify met in the perfmmenee of the work for which this permit is W.A.I shall nut 313 - ROOF NAIL
employ any person in any manner an as In nature subjeeuo me workers'Compensation
Laws of California.Dale 501 - FINAL ELECTRICAL ENERGY
Applicant
NOTICE TO APPLICANT:It,am,ntaking this Certificate,of Exemption,you should 502 - FINAL PLUMBING ENERGY
bmome subject to the Worker's Court attention provisions of the labor Code,you must 503 - FINAL MECHANICAL ENERGY
Forthwith comply with such provisions or Ns pmmin shall be deemed revoked.
� z a 5
CONSTRUCTION LENDING AGENCY 04 - FINAL BUILDING ENERGY
(hereby e0irm that mem its consnaction lending agency lis,the perfurmmcc of 505 - FINAL ELECTRICAL
ai
the work ddreashmi.permitisissucd(Se<.309],Civ.C.) 506 - GAS TEST n
W Q
Lattice Name,
� Lenders Address 507 - FINAL PLUMBING f
U O 1 cenlfy Nen 1 have reed thio application end sate that the ab0m brimmed..1. 508 - FINAL MECHANICAL
D. F contact.1 agree to comply with all city and county ordinances and some laws belong m
C) building conswction,and herebyeushodxrepresentatives ofthisCity toenter
upon me 5 FINAL GRADE
W ,above-mentioned property for inspection purposes. 10 FIN PLANNI G
t.3, (We)agree n0 cove,Indemnify and keep harmless the Cllr of &Saint against
Tq inconiequenc ofth,costs and expenses mit, may in any way emroe against aid City 5 N U LI WORKS
U ",� in consequence of the g,entind of this permit.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOWT Issued by: Date
-SOUR GULATIONS. o
�'A` Re-roofs
Si of onwctor '
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant orfuwx building pa IT%rhaMlehnallom mexried
As defined by is Cupertino Munkipd CMpmr 9.12,and the Health and Safety
Coda Se.fion 255321.)] All roofs shall be inspected prior to any roofing material being installed.
❑Ya ❑
17
Will the applicanl,orrumre building pant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants a dch y the Bay Area Air Quality Management all new materials for inspection.
Dialficl7
❑Yes
I hem reW the mrdnuamaterialsmqulremens under .Chapter6.95ofthc Califon
nice Hcsithd, At c,S 6om25N15,25533md25534.1undcnundthmifine building
dmf non torte he a xnann.Net It is my msponsibility m notify ti¢mcupxt of me
requirements hic fat he met prior to issuance ofe CcniBcale of Occupancy. Signature of Applicant Date
Z All roof coverings to be Class"B"or better
nor m te
�. . � CITY OF CUPERTINO
CUPEIZo PERMIT APPLICATION FORM o u
lei APN# Date:
is /
Building Address: /
7 (-kT- /VdrM4wDI � w. �
Owner's-Name: Phone#:
G Gi u r ti� ti 799= S1 7 9
o tractor: _ License#:
I-u wr. XPe i ^ 013 - 9 6.O 9-2
Contact: Phone#:
Applicant/Contractor: Fax#:
'� 6k65 Y,C3
Builg Permit Info:
BldRI Elect Plumb Mech
JDescription:
Residential: Ri . o 7-,t- Commercial:
Sq.Ft.Floor Area: �o So /_--e,7 . $/Sq.Ft.:
. / Z
Architect/Engineer: Valuation:
2
Type of Construction: Occupancy Group:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
13CONSTAX Construction Tax BUILDING
BCONSTAX -Ind/Off/Comm/Quasi BUILDING
BCONSTA)MQ 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
BNUCOMMPI New Comm Plumb ( PLUMBING
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