03090090 l CITY OF CUPEWrINO
BUILDING DIVISION
PERMIT CONTRACTOR4NFORMATION
BUI LDING ADDRESS: KNOLL SYSTEM CORP PERMIT N1b3090090
034 LA.URRTTA MR
OWNER'S NAME: 5375 CLAYTON RD PERMIT ISSUE DATE
NE:
(925) 787-5626 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
i0Z, LICENSED CONTRACTOR'S DECLARATION'
10 F I hereby at frm the,I am been,ed under provisions of Chapter q(commencing Job DeseriptlOn
n?1 with Section 7000)of Division J of NC Business and Pr ms Cndo,a dray' uia
<„ mrunroreeand�Hgm.Z0 CE FURNACE & ASC 'A r*
ALE®
tnZ Lilco 1 Lm'#
Dale �>P`��1 GamraeCL SEP 2
ARCHITECTS DECLARATION C ^003
I� flaw
I undersand my plain shall W uxd u public accord; 1a C
>yV
a.t; Licensed Professional
3 OWNER BUILDER DECLARATION ���'
a f 1 hereby affirm that 1 am exempt from the Contractor's License Law fur the NG
COD D following reason.(Section 7031.5,Busiucas and Prufcuiuna Code:Any city or county
<i which acquires a permit to construct,eller,improve,demolish,or repair any structure
"iy Poor to its issuance.also requires the applicant for such Permit to file a signed sat men
s
M- � that he is licenud pursuant to the provisions o
visiof the Contractors License law(Chapter Sq. Ft. Floor Area Valuation
(commencing with Section 7000)of Division 1 of the Business and Professions Code)or
3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of 32654033 . 00
Section 7071.5 by any applicant for a Permit subjects the applicantto a civil Penalty of _ APN Number Occu ane T e
not marc than Eve hundred dollars(6500). - - - —-- - - P y YP -----
0 1,u 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.7014,B us!less 3 0 1 — xUUIJ 1-1
PSC Ions
and Pmlesaions Code:The Contractors License law does not apply to an owner of 3 0 3 .- ROUGH f:1.
property who builds or improves themon,and who does such work himself or through his
own employees,provided that such Improvements we not intended or offered for asle.If. 304 - ROUGH ELECTRICAL
however,the building or improvement is sold within one year of completion,the owner.
ve
builder will have the burden ofprevingthat hedid hot wild orimprofor purpouof 505 - FINAL ELECTRICAL
al`)' 507 - FINAL PLUMBING
❑ h as owner of the property.am exclusively contracting with licensed contractors to -- —
construct the pmjea Isec.7044,Business and Profession;Code:)The Contractor Li. 508 - FINAL MECHANICAL
come law does not apply to an owner of property who Wilds or improves Oemon,and
who Contracts for such projects with a co imcmr(s)licensed pursuant to the Con ado's
License law.
❑I am exempt under Sec. ,B k P C for this reason _
Owner Date _
WORKER'S COMPENSATION DECLARATION ..
thereby affirm under penalty of perjury one of the fallowing declanitimme .. . .
Ihaw and will maintain Cenifeau u
of Consent self-insure Worker'sfurWorker's Cumpcn- „
,arson,u provided for by Section 17W of the Labor Code,for the performance of the
work for which this permit is issued.
hats and will maintain Wurkefs Compensation Insurance,u required by Section
700 of de IoW,Cade,for the penfarmance al the work for which this permit:,issued
y Worker's Compensation ins1y m eartierand Policy number am;
Cartier. �' L /�. Policy No.:./-U 1)
CE�FICATEOFEXEMPfION FROM WORKERS'
COMPENSATION INSURANCE
171tH section need not becompleud ifthe ratrmit is for one hundred dollars(SIM)
or Icss)
. 1 certify that in the performance of the work for which this permit is timed.l shill not -.
employ any Person in any mannerm oto become subject to the Wortera'Compesatlon „
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenifeau of Exemption,you;liquid
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this farm it shall bin deemed revoked.
Z .~N.. CONSTRUCTION LENDING AGENCY
I hereby affirm that dere is a commiefln,lending agency,for the Performance of
Z 7 de work for which this permit is issued(sec.7(197.Civ C.)
11 o Under',Name
3 z Lender's Address
J Q I codify that I have read this application and sato that the dhow oforrnuiun i;
Fcorrect.I agree to comply with all city and county ordinances and state laws relating to
7(J above-mentionedng sot and hcacbYauthimprposes ati roe of this city rocnmrupon the
above-mentioned to save forimnify aPurposes.
ti (We)agree l.live,indemnify and keep hay in an the City accrue
Cupertino against
V) lioconsa'denc mcnn,coats and expenses which may in any way accmc against said City
J z in conuyucncc he granting n!suis inn.
�. SOURICANT OTgSTA S WILL C PLY:WITH ALL NON-POINT Issued by: Date �, 3
9f )e IQ Re-roofs
HAZARDOUS
SiSignatureof ApplicaDem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum bonding e.occupant handle Head,
and
As defined by the Cupertino Municipal Code.Chapter 9.12,and the Heald and Safety
Code,Section 25512(a)'❑rax ( ' All roofs shall be inspected prior to any roofing material being installed.
will me apps ant nr Tatem Wilding occupant u equipment or devices whish If a roof is installed without first obtaining an inspection,I agree to remove
it heaardnua air contaminants as defined by the Bay Ama Air Quality Management all new materials for inspection.
;trio? t/
OYca ONu
1 have mail the hanoc ous mtudals requirements under Chapter 6.95 of the Califon
.in Health @ Safety Coto,Sections]55115,85]1 and 25514.1 understand Not it the Wilding
dam not currently hove a tenant,that it is t y rcaPonsihiliry to notiI the mcupant of do
oc immcns;C
ustWmc o anccoh nifica of c
?`�" �, '� �If,"y�o Signature of Applicant Date
Owner lir thorived egcm t nD„e All roof coverings to be Class •'B'• or better
CITY OF CUPERTINO o3 7O
FURNACE/AC o 'o
• CUPERTINO PERMIT APPLICATION FORM
APN# r G O Date: / k,3
Building Addres ,-103q
/O 3 q J �
Owner's Name: lin /j .L Phone#: >39 -2-6 Z /7
Contractor: hone: License#:
a 9�5 68/-04177 4/3 V
Contact:
P one: Cupertino Business License#:
Building Permit'Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech
Job Description:
Residential Commercial ❑
For Residential Installations:
Attic ❑ I" floor ❑ 2nd floor❑
. Adhere to min set back re uirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction: Occupancy group:
0-0
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Re lacementIK"
Qt
A rc le Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
EPERMITFEE Elec Permit Issuance ELECTRICAL
1
PERM FEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING