04030227 CITY OF CUPERTINO
BUILDING DIVISION PERMIT .�aN`.CRAGTC?R,IN1.'U'
B ILDINGADDRESS: PUROFIRST MIDPENINSULA PERMITNObdo30227 '
OWNER'S NAME: - PERMIYISSUEDATE
ERN
ONE: SANITARY OL NO.
IDa
CHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u LICENSED CONTRACTOR'S DECLARATION
I Manby affirm Nat I am licerocd under viYons ofChepmr 9(ammcncing lob DOSCrIpt100
re Sect 7 )ofDiviaio Sof me Basin dZionsitsm Code.andmy1mmueisull force dem ata � . REMOVE FIRE DAMAGE
m Contncter
a 'CHI CTSD-E^LA ON
a J m am ahel M used m u romme
Cjvu
3 u License sfcssio..I
5p0 OWNE -BUILDER DECLARATION
OU�S 1 here a1Rrm that m exempt from the Contractor's License Law for the
00 following memo. 131.5,Business and Profession Cade:Any city or county
2 E which requires a permit to construct,altar,improve,demolish,or repair my someone
poor It in issuance,also require the applicant for such pmmiuo Glc a signed statement
0 tbut heislicensed pureumttemeprovisiouanftheCo mom'.LkameU.(Chapter9 Sq.Ft.Floor Area u-jiffoYi
o
$ (mmmmming with Section 71100)of Division Sof Ne Businnamd Professions Conic).,
.. that he u exempt therefrom and the basis for the alleged exemption.Any violadon of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of ��fI,,
not more dun few hundred dollen($5007. 3�tl'ero O Occupancy Type
❑I,as owner of the property,or my employees with wags as their ante compensation,
will do the ,"no the structure is not intended or offered for sale(Sec.70/4,Business
and Professions Code:The Character'Liam.Law don not apply to an owner of Required Inspections
property who build..,improves thereon,end who does s tach wank himsel f or through his
own employees,provided that such improvements and not intended oroffmad fnrsak.IL
however,the building orimpmvement is sold within one year of o mpleton,Ne owner.
builder will have the burden of proving Net he did not Wild or improve for purpose of -
.1c.).
❑1,as mvnm of Ne property,am reclusively connecting with licensed contramhas to
construct the pmlect(Sec.7010,Busineaa and Professions Code:)The Contractor's LI-
who Law runnot apply Lean owner of property who buildsorImproves therace. rj
Lummetnen for such projects with acmuacmKs)Ilcenud pursuant he Ne ConumwYa L O•`T[/
Liceom Uw.
❑I em ezempt under Sec. ,B&P C for rule no
Owner Date
WORK ER'g COMPENSATION DECLARATION
1 hereby all.under penalty of perjury one of the following declarations:
ME
Thaw and will far
maintain. 37M of Me Labor Code.for for WoakchCompere
workf r provided for by Section 3]000(du Labor Code.for me performance of the
work for which this permit is Issued.
❑I have and will maintain Worker's Compensation Insurance,an required by Section
3700 of the Labor Code,for the performance of tan work for which this permit is Issued.
My Workefa fCs�'mpensation lnsunna cannier end Policy number am:
Cartier. /1.(91MF Poli No.: Z _
CERTIFIGTE OF %EMPr10 WORKERS' p
COMPENSATION IN ANCB nV 01)b1,6)_
(Ibis section need not he mmplemJ if the permit la forhnc hundred dollen($100)
or lcax3
1 certify that in the performance of the work for which this permit is issued.I shall not -
employ any person in any toment®r as te become subject to me Worked Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject m me Worker's Compensation previsions of the Labor Code.you mum
0Z forthwith comply with such provision or this Permit shell be deemed invoked.
„zi Q CONSTRUCTION LENDING AGENCY
'rr I hereby aRren Nm them is&conswction lending agency for the performance of
CC > me walk for which this permit is issued(Sec.3097,Civ.C.7
IkJ Q Under's Name
z Lcndsr.Address
V Q I certify that I have read this application and sum that the above information is
ty E' ounce.I agree to comply with all city and county ordinances and state laws minting to
QU building construction,and hereby authhdvm mprommadwo of this city to enter upon the (\\
W shove-mentioned propertycosts
for ie penses purpowhich Ms /
gy (We)agree to save,indemnify and kap hasml.n the City of Cupertino against
z in
liabilities,Judgments.cases and expenses permit. may in anyway same against mid City
V Z in consequence of granANDVbiND WILL
APPLICANT D 'STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat "
OUR
UL ' S. Zr
Re-roofs
new afA icamdC.mmet.r Oa
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
c applicant or forum building occupantstom orhandlc harardous material
as defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(a)? � All roofs shall be inspected prior to any roofing material beim installed.
❑res g
If a roof is installed without first obtainingan inspection,I agree to remove
Will the all Itod r or future building by the Bt taw e.Ail u or Mom which P g
mit hasertlnus oil chnuminann vee J fneJ by the Bay Ama Air Quality Menegcmcnt all new materials for inspection.
Disuict7
❑Yes
I hevc mad the hanrdous materials requirements under Chapter 6.95 of the Calder,
niaHeolth&Safcty Code.Seedons25505,25533v 25534.1undemmdthuifthe building
docs not cu oily h a tenM4 Nat it u my msponsihility w notify the mcupant of me
mquircm i abr`metPoor toissumceofaCentimes,o c cy Signature of Applicant Date „
tar ver alllha4scd agent Dr.. All roof coverings to be Class"B"or better -
Community Development
*00F
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
�UPERTINO
Building Department
JOB ADDRE
5 5 L PERMIT# Gr�O3 O ZZ -7
OWNER'S N PHO � ) TL Y - 3 z
GENERAL CONTRALTO -s(/ # >)
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
j Glass / Glazing
Heating
Insulation
Landscaping s'
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
\� 3 LS o
ntiactor Signature Date
CITY OF CUPERTINO
DEMO
CUPEKTINO PERMIT APPLICATION FORM
APN#
Building Address:
Owner's Name: Phone#:
6&) 36�� z
Contractor: J License#:
Contact: Phone#:
Applicant/Contractor:rt Info:
;'Building
lect Plumb Mech
Description: r—
Residential: Commer al.
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: P
rDa
Type of Construction: Occupancy Group:
y. if
A 1' ab e Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business LicenseBUILIDNG
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