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07010061 CITY OF CUPERTINO 'BUILDING DIVISION PERMIT e� TiT� IRMATIf3N PERMIT NO. BUILDING ADDRESS: nlzoi 0061 22426 MC CLELLAN RD STORM Eh& PERMIT ISSUE DATE OWNER'S NAME: JEFFERY & VIVIAN WIGMAN 16770 IvLkGNESON LOOP 01/09/2007 SANITARY NO. CONTROL NO. 'NE: (408) 35 -)-8677 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH O p LICENSED CONTRACTOR'S DECLARATION Job Description .:"I F I hereby affirm that I am licensed under provisions of Chapter 9(commencing NEW 1 0 0.SMP PANEL =u w withScction 7000)of Division 3 of the Business and Professions Cods,t)nd luensC is y in full force and eft til 7 vn Z License ass Lic.A Date Conttacwr C. A CHITECrS DECLA 0 coe< t understand my plans shall be used as public records U `a H Licensed Professional n 01 OWNER-BUILDER DECLARATION 2<z 1 hereby affirm that I am exempt from the Contractor's License Law for the r p o following reason.(Section 7031.5,Business and Professions Code:Any city or county t which requires a permit to construct,alter,improve,demolish,or repair any structure Z r prior w its issuance,also require the applicant for such permit to file a signed statement S Ft.Floor Area Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 fl' $1800 Ytz-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of p Number Occupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 35604 0 2 3 :L'Plt not more than five hundred dollars(5500) ❑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 Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of 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, 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(wild or improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. F1I am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insurc for worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker Compens uon In!y:n ca 'er and Polirynumber Cartier •Y Policy No.. o v CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) 1 certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date— Applicant NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J'Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY F.t I hereby affirm that there is a construction(ending agency for the performance of p!> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name �a Lender's Address 1 certify that 1 have read this application and state that the above information is LUL correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorize rcpresentativcs of this city to enter upon the above-mentioned properly for inspection purposes. >4 a (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 g of this perm' Date G V Z APPLICANT UN T D L PLY WITH ALL NON-POINT Issued ty: SOU ' Re-roof; Signal App cart ontactor Date Z of Roof HAZARDOUS MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material as defined by the building occupant use equipment or devices which Cupertino Muni' 1 Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All rooms shall be inspected prior to any roofing material being installed. ❑Yes No If a zoo-is installed without first obtaining an inspection, agree to remove Will the applicant r future 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&rials mquimmcnts under apter 6.95 of the Califor- nia Health&Safety Code,Se� 25505-2.5533 and 25534, dcrsrand that if the building does not currently haypa" t.out itis my nsi ' y to notify the occupant of the reynlrc wniflr reef tt e 'fteateofoce � Signature of Applicant Date All roof coverings to be Class"B"or better Ownc authory agent Date CITY OF CUPERTINO I'D 0 Lo I %TWYOF PERMIT APPLI CATION FORM CUPS TINO _LPN# 3� A Date: i I� ��J✓tJr - o�- 023V � Build* Addres :Mailing Address (if different from building address): z� IMS � 1e1��► Omer' ame: Phone#: Contractor: y License #: --� C ntact: Phone: G �f 5-7-7 Cupertino Business License#: c�rJ4-7P/t5C4�-(f_ Fax: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Job Description: ) Residential j� Commercial ElSq.Ft. Floor Area: q. t.: Cost of Project: G� C �� (, Occupancy Group:- I Type of Construction: Please check this box if the project is a �- second-story addition: Project Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Dther Appliances MECHANICAL BBOILERI Bciler<= 100,000 Btu MECHANICAL BBOILER2 Boilcr> l OOK to 500K Btu MECHANICAL BBOILER3 Boi:er> 500K to 1M Btu MECHANICAL BBOILER4 Boil(;r> IM to 1.75 M Btu MECHANICAL BBOILER5 Doiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ir,d/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V<= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 ElezSvcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 F CITY OF CUPERTINO PERMIT APPLICATION FORM CUPERTINO �Quanti Fee ID Fee Description Fee Group BREMSIGNAD Rm3l Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Th,;atrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS V,-ntilation Systems MECHANICAL BSCBLVD 36 Specific Plan BUILDING BSEISMICOM SEismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Y umbing Fee sq foot PLUMBING PLLONGRNGC Planning, LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning;Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3