05080115 CITY OF CUPERTINO �:
BUILDING DIVISION PERMIT * CONTRACTOR INFORMATION:
..
LONG ADDRESS: JONATHAN GREEN PERMIT 110 5080115
OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
1- in
CHBECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0OLICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nal 1 am dimmed under previsions of Clup¢r 9(commeneing Job Descripvon
Smu forte ane effectDEMO (E) SWIMMING POOL4 License Class L¢.a 4y
n
'ge, Dam Contractor [p/
ARCHITECTS DECLARATION
n< 1 understand my plans Mall W used az public records
sad Licensed Professional
cod OWNER-BUILDER DECLARATION J�
I I hereby affirm that 1 not exempt from Ne Contractors License Law for the
no following rtswn.(Section 703 1.5,Business and Professions Cade:Any city or county
.9
< �i which requires a permit to Construct.eller.improv(,demolish,or repair any stroeture 1 O O O
prior to its issuance.also requima the applicant rorsuch Knott to File a signed summer `
E?0 that he isliccased pursuanuo the provisions of me Contracture Liccnm law(Chapmr9 Sq. Ft. Floor Area 4k'zjwc;.)n :}s Valuation
tt— (commencing with Sce ion?")of Division 3 ofdm Business and Ptolumom Codc)or (/® `"`iii, ",,
y $
that he u exempt therefrom and the basis for the alleged caempuon.An,violation of Ir a.)Cs..
Section 7031.5 by any applicant for a permit subjects the appiicanuo•Civil penalty of anC OCCU Type
not ire Nan Bre hundred dollars(1500). P Y YP
,'s owner of the properly,or my employees with wag".theirsole compensation,
will thework,and Neswnure is nmimmrided or oRerW periodic Dec.7144,Busineu
and Proposal..Cade:The Contractors Lt.law dors Out apply in an ownu of Required Inspections
property who builds or improves thrown,and who docs such work himself or through his
own employees,providcd that such improvements are notimmnded or oQered for sale.If,
however,Ne building or hnprowment is sold within one year of completion.the owner-
builder will ban the bu den of proving Nat he did not build or improve for purport of
sale.).
❑1,as owner of the propeny,am escl.ively contracting with licensed Contractors to
construct the projec,(Sec.7D44.Business and Professions Code)The Contractors Li.
come Law does not apply to an owner of property who builds or improves Merton,and
who contracts for such projects with a conuaetor(s)licensed por mm to the Conunhhors
License Law.
❑Iam"Cut tl See. ,B
Owner
1 off'
Dam
RKER'S COMPENSATION DECLARATION
i rob affirm underpemltY of perjury o.of Nc fallowing dala"uo.:
I hate will maintain a Certificate of Conacnuo xlf-mmm for Worker'sCompcm
Igen, providcd for by Section 37M of the labor Code,for the Perform..of Nc
work for which this permit is issued. -
❑1 have and will maintain Workcri Compensation Insmma,m required by Section
3700 of the Labor Code,for the performance of 0m work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
md,section wed not be compmled lithe permit is For ane hundred dollars(1100)
or lest)
I Cent Nm in me perf o-Mmec of the we !{ which this permit is isswd.I shall not
cmployany'personinanymanwr � aa me mbjecuo cWorkc 'C.m ration
Laws of California.Date
Applicant
NOTICE TO APPLICANT L fier eking this Ccnifl m op mpti.n,you should
become mbjat to Nc W e Compc.ation provisions of the bnr Code.you must
.J z forthwith comply with sp provisions or this permit soon be deemed revoked.
Z'O CONSTRUMON LENDING AGENCY
'Tv I hereby affirm that Here is a construction lending agency lot the Performance of
1' the work for which N¢permit is issued(Sce.3097.Civ.C.)
Qlsndees Name
z Lender's Address
O Q I Certify that 1 have read this application and sale that the above information is
U,;: Correa I agree to Comply with all city and county onlinanns and state laws miming to
OU building construction,and hereby awhoriam rePMmnwives of this city to enter upon Nc
shove-menuuncdprePeny for inspection purposes.
F G (We)agree he save.indemnify and kap harmless 0e Cary of Cupertino against
fA incoomqu rec of t¢costsand exp
ense
w: ch mey in any way same against seed City
t..1z in eonsequenec of the�Rgranting of thisi� '
r. SOURCE REGUL((fl TANDS COMPLY WITH ALL NON INT Issued by. Dale
SignmumofA I nice uacm ,le Re-roofs n '�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wi plicate or(mmuc building occupant mom or hasWlchvaAom motorial
az define the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
AMikode.Sccuon 255J2(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes lfl'f4.
Will the applicant.,rotor(building Occupant use equipment on devices which If a roof is installed without first obtaining an inspection,I agree to remove
On7ouror
dt havardous air contaminants a dc0ncd by 0m Bay Area Air Quality Management all new materials for inspection. '
strict?
�D� ❑vex /amu
I have read the humodi xmamnith requircmcw on&,Chapter 6.95 of the Califon
M&Hcalm&Safety Code,Satinet 5505.35533 and 25534.I understand Net if Ne Wilding
es not cumentl sec a seam.Nat it is my respomihiln,to roil;the occupant of N.
uimmcnts ich umxmetpriortoitsuaweofacemr.amora Signature ofApplicant Dale
Orsto r il eel ,m All roof coverings to be Class"B"or better
r Community Development
10300 Torre Avenue
-zw Cupertino CA 95014
Telephone(408)777-3228
CITY 0, Fax(408)777-3333
UPEkTINO
Building De artment
JOB ADDRESS: PERMIT # i
10/-�q
OWNER'S NAME: oti 2e PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
ignature Date
Please check applicable subcontracto s 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
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile / p-
0 Q
er/Contractor Signature Date
CITY OF CUPERTINO 5
CITY OF DEMO
CUPERTINOPERMIT APPLICATION FORM
APN #
?16 2 3 Date: p I dS
o b
Building Address:
l 0 Q L C
Owner's Name: Phone#: 2-S-4 -7-37,4
Contractor: F License#:
Lld
ct: Phone#:
cant/Contractor: S/
ing Permit Into: ULi TJ p/J OG S ✓ice i�iG c� L
Elect Plumb Mech
Job Description:
Residential: /�/434/1/r7,fiIIi6 670OL Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
f�i
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee Gro
u
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG