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02060024ec [TY OF CUPERTINO C LJ P 7Y OF PERMIT APPLICATION FORM APN # � ' � � � � Date: Y Building Address: /U z (0 6 =rid' - S �� ems- Owner's Name: /�� % -// /7�� /L Phone #: � s � � �� Contractor: License #: Contact: Phone #: Applicant/Contraptor: Fax #: Bui g Permit Info: Bldg t( Elect Plumb of Mech escription: Residential: Commercial: Sq.Ft. Floor Area: S "u $ /Sq.Ft.: eok . Other Appliances Architect/Engine r: Ll )It Sr' Val on: ' /0� T e of Construction: Occ ancy Group: %) N Quantity Fee ID Fee Description Fee Group APTFEE EACH STORY OVER 3 HOTELFEE EACH STORY OVER 3 OFFICEFEE EACH STORY OVER 3 BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/OffIConun/ uasi 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 gENERGY 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 1 of 3 °�aaa az y < i z r—'- :vrp-•` GGa iOyU i30 d �zd .e W3§ oz O pW„ A a -z Uo CI'II'Y OF CUP ERTIINO j l BUILDING DIVISION ]PERAUT CONTRACTOR INFORMATION: Tb'TWTtRRA STREET GILLEY, MICHAEL AND APRIL PZafrn060024 WMT t, MICHAEL AND APRIL APPLIC1'0V /164A/eZ002 C PHONE: SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION P f hereby affirm thal I am licensed wader previsions of Chapter 9 {commencing 200 S Q . FT . ROOMr Vft r with Section 7000) of Division 3 of the Business and Professions Code, and my license ' is in full force and effect. ` License Class Lic. d 1 Date Contractor ARCHITECTS DECLARATION '.F I understand my plans shall be used as public records Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt fmm the Contractor's License Law for the $19504 following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, 1111M improve, dtmolish, or repahr any aimciure priortoit sissuance, alsarequirestheapplicantforsuchpermit torileasignedstatement - •• 'V1 rAMa - Valuation ' that he is licensed pursuant td the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) Of Division 3 of fhe Business and &ofegsions Code) .- , or that he is exempt therefrom and [he basis for the alleged exemption, Any violation of section 70315 by any applicant for a Permit subjects the applicant to a civil penalty of not more than five hundred dollars ($566). APN Occupancy Type 102 — PIERS ❑ 1, as owner of the property, or my employees with warts as [heir sole compensation, will do the work,'and the ktmqurc is not intended or ofrered for sale (See. 7044, Business and Professions Code: The Contractors License Law does not apply to an — UEPER Required Inspections owner of property Who builds or improves thereon, and who does such work himself 104 — REBAR or through his own employees, provided that such improvements are not intended or 10 5 — ANCHOR BOLTS - _ offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden or proving that he did not build or 106 — SEWER & WATER improve for purpose of sale.). 202 — UNDERFLOOR PLUMBING. ED I; as owner of the property, am exclusively contracting with licensed contractors to 203 3 _ — UNDERFLOOR MECHANICAL " construct the project (Sec, 7044, Business and Professions Code:) The Contractor's License Law does nor apply to an owner of property who builds or improves [hereon, - 2 04 - — UNDERFLOOR FRAME and whtl contracts for such projects with a convanor(s) licensed pursuant to the. - _ Contractor's License Law, 205 - UNDERFLOOR YNSULATI ON XI am,paempt,unde ec , B & P C for this reason 301 — ROUGH PLUMBING wn' e2- wn r 302 TUB & OR SHOWER WORKER'S Oh9PEN5_ANDECLARATION — • 1 It affirm under penalty Of perjury one of the following declarations: 303 — ROUGH MECHANICAL 304 — ROUGH ELECTRICAL ❑ I have and will maintain a Certificate of Consent to self -insure for worker's Compensadon, as provided for by Section 3760 of the hbor Code, for the 305 — FRAME performance orthe work For which [his permit is issued. 306 — HOLDOWNS ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 307 — INSULATION 3700 or the Labor Code, for the per rohmence or the work for which this permit is issued, My Workers Compensation Insurance carrier and Policy number ate: ,r 308 — S HEETROCK Cur cr. ' " '' 'Policy No.:' 309 — EXTERIOR—LATH . ,- CERTIFICATION OF EXEMPTION FROM WORKERS' " COMPENSATIONTNS�RaNCE ' - - _ _ 33 0_ ' - INTERIOR_ LATH (K is 'section need not be completed if the permit is for one hundred dollars 311- '— SCRATCH COAT (3100)orlcss.) 313 — ROOF NAIL 1 certify that in the performance of the work for which this permit is issued, I 501 — FINAL ELECTRICAL ENERGY " -, shall 'not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California, Date 502 — FINAL PLUMBING ENERGY Applicant 503 _ FINAL MECHANICAL ENERGY - 1 NOTICE TO APPLICANT: If, after making this Cenifcate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must 504 FINAL BUILDING ENERGY {k forthwith comply with such provisions or this permit shall be deemed revoked. 505 FINAL -ELECTRICAL CONSTRUC- nON'LENDINGAGENCY' 1 hereby affirm that there is a construction lending agency for the performance 506 _ GAS TEST of the work for which this permit is issued (Sec. 3097, Civ. C:) t'� 507 — FINAL PLUMBING - r Lender's Name Lender'a Aadresr .. 508 — FINAL MECHANICAL I certify that I have read this application and state that the above information is 509 -- FINAL GRADE correct- I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize iepreienladves of this city to enter upon 510 — FINAL PLANNING ' the above-mentioned (We) tigee to proP4ny for inspection purposes. (We) ¢ghee to save, indemnify and keep harmless the City of Cupertino against liabilities; judgments, costs and expenses which may in any way eewe against said ' 514 — FINAL PUBLIC WORKS City' inconsequence of the nting of this permit. N UD T 5 WILL COMPLY WITH ALc1 j�4 -` Issued by: Date Sii- fApplicant1contrac[or Date r Re-roofs • HAZARDOUS TERIALS'DISCLOSURE ull the applicant Or future building occupant store or handle hazardous material Type of Roof as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety Code. Section 25532(a) ?. ° yes ' r ' All roofs shall he inspected prior to.any roofing material being installed... -, Will the applicant or future building occupant use equipment Or devices which If a roof is jn t led 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 to ' s for inspection. Applicant understands and will comply with °Yes "° I hav cad the hazardous materials requirements under Chapter 6.95 OF the all non oin tource regulations. California ealth & Surety Code, Sections 25505, 25533 and 25534. 1 understand that if the but ing does not cunentI�%%have a tenant., that i[ is my responsibility twr�_ fy the occupa of:ihe requ7=/ met prior to issuance ors ate of cc cy 0 � a- gn r o Applicant Date i All roof coverings to be Class "B" or better own -' r a orized aglim 6F Date