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07010066 CITE'OF CUPERTINO BUILD. D,v,s,oN PERMIT � �� RM AT BUILDING ADDRESS: PERMIT NO. 28 STAFFORD DR REB ZZ- __ CQ IST QW9i9Q66_ OWNER'S NAME: PERMIT ISSUE DATE DON FERRIE 5765 W: NNFIELD BLVD 01/11/2007 3NE: SANITARY NO. CONTROL NO. (408) 229-9689 A RCH17'ECT/ENGI NEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 40 p LICENSED CONTRACTOR'S DECLARATION Job Description tui r- 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing awith Section 7000)of Division 3 of the Business and Professions Code,and my license is UPGRADE� 1 0 0 AM P TO 2 0 0 AM P 0, in full force and effect �2 2 License Class Lic.# t p Date Contractor ARCHITECTS DECLARATION rC U I understand my plans shall be used as public records a VQ y Licensed Professional m OWNER-BUILDER DECLARATION +�< I hereby affirm that 1 am exempt from the Contractor's License Law for the y 00 following reason.(Section 703 1.5,Business and Professions Code:Any city or county e i4 IXZ which requires a permit to construct,alter.improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such permit to rile a signed statement F=C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $2500 y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of 36207013 . Number Occupancy Type not more than rive 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 dos not apply to an owner of q P 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 build or improve for purpose of sale.). as owner of the property,am exclusively contracting with licensed contractors to trust 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. ❑1 am exem under Sec. B&P C for this ason Owner 4 L/l12 PMa_�Due WORKER'S COMPENSA71ON DECLARATION I hereby affirm under penalty of perjury one of the following declarations: �]I Itsve and will maintain a Certificate of Consent to self-insure 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's Compensation Insurance carrier and Policy number are: Carrier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner sp as be optesu .ct to the Workers'Compensation Laws of Calif a Dim—I Applicant 2n(/4!—^ - it I)C3 - NOTICE TO Al3PLICANT.If,after makf4 his Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY [.-t►- I hereby affirm that there is a construction lending agency for the performance of p(> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name � Z Lenders Address U O 1 certify that I have read this application and state that the above information is LL" correct.I agree to comply with all city and county ordinances and state laws relating to 0 U building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. (We)agree to save•indemnify and keep harmless the City of Cupertino against rA liabilities•judgments•costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. �" LICA UNDERSTANDS AND WI L 9OMPLY WITH ALL NON-POINT Issued bJ: Date SO CE GU TIONS., 1/11�U Re-roofs Sig�applicant or Date US MATERIALS DISCLOSURE Type Of hoof re building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? ❑Yes P1. All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove .mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r iaterials for inspection. District? Q �r]' / Yes lm(yJ, I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building docs not currently have a tcnan4 that it is my responsibility to notify the occupant of the 2uirc not hick must be met prix ficate of Occupancy. S1 nature of Applicant Date g PP c oraulhorizedagent Dai c All roof coverings to be Class"B"or better Community Development 5,.•, . 10300 Torre Avenue r ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408Y777-3333 rUPEkTINO Building Department JOB ADDRESS: PERMIT# 11 2,A 0-7 OWNER'S NAME: 7 1 er✓ PHONE # GENERAL CONTRACTOR: FAX # J r I am not using any subcontractors: 5� J E ignature Date Please check applicable subcontractors d complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF C'UPERTINO 0UI0100W CITY OF PERMIT APPLICATION FORM CUPEkTINO ,PN# Date: Building Address: Mailing Address (if different from building address): I f� 46(6 ,-f`v r Owner's Name: Phone#: `h0 �e 33c�- � 3v Contractor: I License#: —� L47 4 ? J �bv , Contact: Phone: (.9(� - 3'yU 736 Cupertino Business License#: ,40,_ n rMa f+ax: Building Permit Info: Bldg ❑ Elect J'lumb ❑ Mech ❑ Job Description: Residential EA e ,Oe-) Sommercial ❑ Sq.Ft. Floor Area: I USq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ roject Size: Standard ❑ Large ❑ Major ❑ Quanti Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Bc iler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boi.er> 500K to 1M Btu MECHANICAL BBOILER4 Boilo;r> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX In d/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Cc nstax—Resi/Mobile BUILDING BELEC 1000 E 1ec 600V<= 1000A ELECTRICAL BELEC1001 Iaec 600V> 1000A ELECTRICAL BELEC200 Elei-- Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA I_J__nvestigation fee BUILDING I of 3 CITY OF CTPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rnidl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR TY:eatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM S�ismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Tem orar Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE E lee Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE M Bch Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Plannin g, LR Comme/Multi-Fam PLANNING PLLONGRNGR Plannin j Long Range Residential PLANNING ZADDCHG Address Change BUILDING 3 of 3