04110133 1
CITY OF CUPERTINO
BUILDING DIVISION PERI& ®NTRACTnR INF®RM,ION 4 -
N.A x"rzs bt�a.F.u.spffi;;;:ey4t„s;? rouxx<e^3 -..�iata�.a
BUILDING ADDRESS: PERMITN'0 4 1101 3 3
10581 CASTINE AV
OWNER'S NAME: PERMITLSSUEDATE
KANNE LLC 11/22/2004
TONG:
SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER: _ BUILDING PERMIT INTO
BLDG ELECT 'PLUMB MECH
C7 I�
auk LICENSED CONTRACTOR'S DECLARATION
°p JobDescri ti{I'n���p
<�F I hereby affirm that l am licensed under provisions of Chapter 9(commencing p �" Ada .
�b with Section)DnU)nf Division JoftM Businc end Profcsnum Code.and mylittnu is
� mmllr... acrreat DEMO (E) POOL
�z License Class Lic.g
. =p Dam Contractor
Z� ARCHITECTS DECLARATION • N /cl �rsOr
1 understand my plans shall W used as public records N T IJ 5
`LLu
Licensed Pndcssional �f a pB yy�,,,
°g OWNER-BUILDER DECLARATION t 1�ft fl p •,{ t(7�
y Lhcmhy affirm slim 1 am exempt from the Contractors License Law for the 1lSrl����J<D ICpli9Nn BgUUON�
O° following motion.(Section II01.5,Business and Professium Code:Any city nr county C
I.,
m which round.a ycrmit to cnmtrucs.arm,,improve.dcmnlLsh,m repair any strucmrc '2
Fib prior to its issuance,also mquims the applicant for such permit to rile a signed statement
2�° that he is licensed pursuanuo the inwiliuns of the Contractor's License Law(Charter 9 Sq. Ft. Floor Area Valuation
be (commencing with Section 7")of Division of the Business and Professions Code)or '
y Nat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of0t O Occupancy Type
- not more than five hundred dollars(5500).
❑I,as owner of the property,or my employe"with wages as their sole comp Semon,
will do to work,and the Someone is not intended or offered for Sale(Sec.1064,Business
and Professions Code:The Connector's Lienee Law does not apply to an owner of Required Inspections
property who buildsor improv"thereon:andwhodoes such work himself orthmugh his
Own employees,provided that such improvements arc not inm Wed oroffced for sale.If.
how er,the building or improvement is sold within am year of completion,the owner-
builder will have the burden or proving that he did nos Wild or improve for purpose of
sale.).
�{1,as owner of the property,am exclusively contracting wit licensed contractors to v
constmet the project(Sec.7W.Business and Professions Codc:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improv"Braman.and
who contracts for such p x rets with a canwanins)licensed 1.11mum to the comseamr's ..
Lice se Law.
Sam❑1 exempt under Sec. ,t .B&P C rot this Season
rte 1�}c�( - ENSA ION DE � i( ,L
V�OR 'SGCOMPENSATION DECLARAT N
I hereby affirm under penalty or p"jury one of the loll wing deelemtiov: -
1 haw and will maintain a Cenifeate of Consent to scl f-insum for Worker's Compcn-
on,u provided for by Section 3100 of the Labor Code,for the performance of slit
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u required by Section
37W of the labor Code,for the pedmmanee of the work for which this permit is issued.
My Worker's Compensation Insurance tamer and Policy number ate:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu""ion need notbreompleted Bthe fermis is forme hundred dollars($lip)
of less.)
1 unify Nat in the pedmmanee of the work for which this permit is issued.I shall not
employ any person in any manner u az 10 become Subject o the WorkersCompensation
Laws or California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ccnificale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall he deemed evoked.
z CONSTRUCTION LENDING AGENCY
(r I hereby affirm that there is a construction lending agency for the performance of -
a> the work for which this permit is issued(Sec.3891,Civ.C.)
Is-1 tenders Name
6.n Lender's Address
D
U 0 1 certify that 1 have mad this application and sure Nat the about information is
u,- Contact,l agree to comply with all city and county anfinances and state laws mlating to
OWilding conxwnion,and hereby authorim representatives or Nis city to chief upon lite
U &dove-mentioned properly for Inspection purrases.
IL (We)agree to save,indemnify and keep harmless the City or Cupertino against
by liabilides.judgments.costs and expenses which may in any way accme against said City
V z APPLICANTUNDERSTANDS Cof OC groaning LAND WILL COMPLY WITH ALL NON-POINT Issued by:his Permit. Dale �( /
SOURCE REGULATIONS.
-) < (( Z ,Re-roofs
Sight eornpp1iwmV n ed, - m
♦{ ARDOUS MATERIALS DISCLOSURE / Type of Roof
Will the applicant or future building occupant store or handle hadNous material
as refined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sccfion oy;25532(a)l \J- All roofs shall be inspected prior to any roofing material being installed.
N.
Willma apNfuture or turre building eeaapant ase quipme,ordcvia:which If a roof is installed without first obtaining an inspection,I agree to remove
fit haiardous air cmerainah6 as defined by the Bay Area Air Quality Management all new materials for inspection.
lett
Oyer,
Hitvc adthchmar nusmamrialsmquimm nuundcrChapmrb.95ofthcCalifor-
niaHcalth&SafctyCo ,Sc..25505,25533and25534.1understandthuifslit Iuilding
does Trot currently haw a tenant.Nat it is my resPernlhllity m notify the occupant of Oc
requirements which most he met Her to issuance of a Ccnfcaue of Occup ar' Signature of Applicant Date
�.� (/ LL - All roof coverings to be Class "B"or better
Otvncr ton tharircJ gent Dam
CITY OF CUPERTINO
�em l of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32644033 . 00
DATE ISSUED. . . . . . . : 11/22/2004
RECEIPT # . . . . . . . . . 27833
REFERENCE ID # . . . : 04110133
SITE ADDRESS . . . . . : 10581 CASTINE AV
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER KANNE LLC
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95015-0712
RECEIVED FROM . . . . : JOSHI ANNE
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
- -------- ---------- --- ---------- - --------- - - - - ---------- -
BPERMFEE VALUATION 3 , 000 . 00 83 . 16 0 . 00 83 . 16 0 . 00
BPLANCHK PERMIT FEE 83 . 16 110 . 98 0 . 00 110 . 98 0 . 00
BSEISMICRE VALUATION 2 , 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
----- ----- ---------- --- -- - - -- - ------- - - -
TOTAL PERMIT 194 . 64 0 . 00 194 . 64 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - --------------- ------------ - - - ---------- -- - - -
CHECK 194 . 64 6916
TOTAL RECEIPT 194 . 64
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
---------
___ ___-------__----------------
704 DEMO
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ON= MTH NOV � 2 4
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q0�QiD AND tDINA BY:
Wt
TVc plan b specifications MUST.
DA kit wa ne job a alltimesand ft is urt, � cop
avatut to make an hon es or, alterations
ran some without wr tzer (ermission from
the building Dept., C D Cupertino,
Phe stamping of this Ian and specifications
!HALL NOT be held Jo permit or,to be aC
#pproval of the violation of any pmmijana
�f anv City Ordmanc� oc kala Lars.
CITY OF CUPERTI T
DEMO
OF
CUPERTINO PERMIT APPLICATION FORM
APN# � Date:2 � - y- y- -� 33
Building Address:
toS� I cPtS-rI Al v�
Owner's Name: Kky` SSL LLC Phone#:
kvS(j Nj ) o R -X33
Contrac'or: J f (-14J\-A 6-/ec—w, - License#:
Q - S axj
Contact: ��5}{) A ,mF Phone#:
7
Applicant/Contractor: T054 1 k /lJAJE
Building Permit Info: L �I L !N G� W I T-1 k S o )L
Bldg Elect Plumb ech
Job Description:
Residential: Qoo i II_L I N �� o
Sq.Ft. Floor Area: $/Sq.Ft.`
Architect/Engineer: Valuation:
Type of Construction: Occ pancy Gr
Qty. if
AFOpiable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK. Plan Check Fee BUII.IDNG
BUSLIC Business License BUILIDNG