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02070035i�VQF CUPEkNO 0 CCETY OF CC�jJrI�E RAZ' HNO FERMHT rr17 641 3 5' APN # � � � Date: Building Address:/ ©S Owner's Name: Phone #: FV6Contractor:License C�'� _ #: 9-/¢/c- Z6,61666 Contact: J.-- V/cp, ROD l v� Phone #: 4-0 9 94-6- 9 3& Applicant/Contractor: ��� e� Fax;;: )RoD916�1��- �� 0 4-6 -�Zf�' Building Permit Info: Bldg ��� Elect �''� Plumb Mech Job Description: l ' Residential: (�6 C� N Commercial: Sq.Ft. Floor Area: $/Sq.Ft.: Architect/Engineer: Dtl?714WV� "— Valuation: Type of Construction: n / Occupancy Group: R, - Quantity Fee ED 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 60.0V <=1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL B EIYIBRGY 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 1 of 3 & 0 MCC uj00 �U~ Q rna OZ tAr�t �J C a X>,u ¢t 3 u t— F��ya(Oy aipO xm� to^v t—zQ �FFC U Cal CITY OF CUPERTIN® BUILDING DIVISION Bul@)1l90@1E�MEADOWV I EW LA PERMIT N92070-035 owRA0REY STANLEY C AND STEPHANIE APPLFCATO)�sP"Tf 2 0 0 2 PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 1 hereby 1 licensed Chapter 9 Job Description affirm that am under provisions of (commencing ADD 400 SQ FT with Section 7000) of Division 3 of the Business and Professions Code, and my license is . . in full force and effect. License Class Lic.# ' Date Contractor ARCHf1ECrS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the $65000 following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 3�6) tSIQ�o3 AEL� Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section by � N Occupancy Type p y yp 7031.5 any applicant for permit subjects the applicant to a civil penalty ofPl�l five hundred dollars not more than ($500).102 — PIERS C]1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of ±63UEPER — Required Inspections ' 10 4 - REBAR property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, 105 — ANCHOR BOLTS however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of 106 - SEWER & WATER sale.). 202 - UNDERFLOOR PLUMBING ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to 203 - UNDERFLOOR ME CHAN I CAL construct the project (Sec. 7044, Business and Professions Cade:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and, 204 - UNDERFLOOR FRAME who contracts for such projectswiLh a contractor(s) licensed pursuant to the Contractor's License Law. - 205 - UNDERFLOOR INSULATION ❑ I am exempt under Sec. , B & P C for this reason 3 01 - ROUGH PLUMBING Owner Date 302 - TUB & OR SHOWER WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL 1 hereby affirm under penalty of perjury one of the following declarations: 304 — ROUGH ELECTRICAL ❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the 3 OS - FRAME work for which this permit is issued. 306 - HO LDOWNS ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 307 - INSULATION 3700 of me tabor Code, for the performance of the work for which this permit is issued. IAY Worker's Compensation Insurance tamer and Policy number are: 308 — SHEETROCK art err: Policy No.: 309 - EXTERIOR LATH CERTIFICATE OF EXEMPf10N FROM WORKERS' COMPENSATION INSURANCE 310 - INTERIOR LATH (rhis section need not be completed if the permit is forone hundred dollars ($100) 311 - SCRATCH COAT or leu') 313 - ROOF NAIL I certify that in the performance of the work for which this permit is issued. 1 shall not mploy any person in any mayaers 'as 6 co spbject to the Workers Compensation 501 - FINAL ELECTRICAL ENERGY Laws o[Califomi . 5 0 2 - F I NAL PLUMBING ENERGY pplicant NOTICE TO NT: If, after making this Certificate of Exemption, you should 5 0 3 - F I NAL MECHANICAL ENERGY become sub' ct to the Worker's Compensation provisions of the tabor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. 5 0 4 - FINAL BUILDING ENERGY 505 - FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of 5 0 6 - GAS TEST the work for which this permit is issued (See. 3097, Civ, C.) Lender's Name 5 077 5 0 8 - FINAL PLUMBING - F I NAL MECHANICAL Lender's Address 1 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 stale laws relating to building construction, and hereby authorise representatives of this city to enter upon the 5 - F I NAL PLANNING above-mentioned property for inspection purposes. 5 4 - FIN C W KS (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the grantin of this permit. APPLICANT UNDE NDS AND WILL COMPLY WITH ALL NON- OINT Issued by: Date RCE RE ONS�HAI Re -roofs Type of Roof Signatu Appctor Dak OUS MATERIALSDISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code. Section 25532(a)? ❑Yea ❑ No All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtainingan inspection, I agree to remove Will thea applicant or future building occupant use pp g p equipment or devices which p g emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes ❑ No I have read the hazardous materials requirements under Chapter 6.95 of thc Califor- niaHealth&SafetyCode,Soctions25505,25533 and 25534, 1 understand that ifthe building s does not currently have a tenant, that it is my responsibility to notify the Occup t of re ast met prior to issuance of a cenificate of Occupan . Sl use O A leant Date All roof coverings to be Class "B" or better o at are