07010122 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � ��IEQ] MANIN
—'— PERMIT NO.
BUILDING ADDRESS:
21130 rAT\TVDT\T ()AK WAY
nw UE DATE
OWNER'S NAME:
ANETTE SILVER 1860 ALMADEN RD 01/19/2007
SANITARY NO. CONTROL NO.
.ONE:
(408) 267-9330
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
apo LICENSED CONTRACTOR'S DECLARATION Job Description
4 V P 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
z 8 with Section 7000)of Division 3 of thc Business and Professions Code,and my license is REPLACE GAS LINE FROM HOUSE TO BBQ I S LAND
a 0- in full force and ejte
j Z License Class Lam•
F p Dare Contractor
ARCHiTECI S DECLA V ION
a< 1 understand my plans shall he used as pub c records
�aU
k
U.y Licensed Professional
OWNER-BUILDER DECLARATION
} i hereby affirm that 1 am exempt from the Contractor's License Law for the
E 0 O following reason.(Section 7031.5,Business and Professions Code:Any city or county
t m� which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z y prior u)its issuance.also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area $17 0 0
xH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
J1 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 34260002 . bN Number Occupancy Type
not more than five hundred dollars($500).
❑I,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(See.7044,Businesa Required Inspections
and Professions Code:The Contractor's License Law does 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 We.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.).
❑I,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 docs 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.
C]I 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:
CB�l have 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.
g 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 Workers Compo allon�insurannce carrier and Policy no ber arc:
Carrier.Y L4L� Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for enc 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 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
�Z forthwith comply with such provisions or this permit shall be deemed revoked.
0
z, CONSTRUCTION LENDING AGENCY
Fr rA I hereby aiLrm that there is a construction lending agency for the performance of
(� the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
jz Lender's Address
V C) I certify that 1 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 o[Cupertino against
liabilities,judgment,�,posts and expenses which may in any way accrue against said City
V z in con3RW
is permit. Date
APPLAND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR
/-&-ci Re-roofs
Sig re of cant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Loof
Will the applicant or future 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)? _ All roofs shall be inspected prior to any roofing material being installed.
C3m/Yes V(No/ If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&safetyCodc;�kctions 255Q5 25533 and 25534.1 understand that if the building
does not currently have tenant, my responsibility to notify the occupant of the
requirements which be rw issuance of a Certificate of occupancy. SignaturE of Applicant Date
`"7 All roof coverings to be Class"B" or better
Owner auth0riacd a nt Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI71(Of Fax(408)777-3333
"'UPEkTiNO
Building Department
JOB ADDRESS: PERMIT #
U Oral-
OWNER'S NAME: 5 5)`/ PHONE #
GENERAL CONTRACTOR: 0-) -� �,� ,,,,��, FAX#
I am not using any subcontractors:
1pature Date
i
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
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 CUPERTINO
0g010
_ _ l22
CIT of PERMIT APPLICATION FORM
CUPEkTINO
APN # '3 �z-u000-�_ Date: / ,
l &�
BuildinAddr s: Mailing Address (if different from building address):
Own% 's Name: Phone#: / n�� o/ _ A
Cffont�acto : /' - License#: 20 Jam- D
Contact: Phone.1 U 2 ,C/ o Cupertino Business License#:
�(it rL ,f�k e Fax: Vtlk� �,2 3 j
Buildin ermit o: l I
Bldg ❑ Elect ❑ I'lumb Dgr Mech ❑
Job Description-
Residential
t
Residential lnstt. ��►rC- " `�`O Se—Commercial ❑
Sq.Ft. Floor Area: -tcj q.Ft.:
Cost of Project: D 00 Occupancy Grow:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
?roject Size: Standard 0 Large ❑ Ma or ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER ether Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3. Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM to L75 M Btu MECHANICAL
BBOILER5 E oiler> 1.75M Btu MECHANICAL
BCONSTAX construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Cc n. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax-Resi/Mobile BUILDING
BELEC 1000 El ec 600V<-- 1000A ELECTRICAL
BELEC1001 E lec 600V > 1000A ELECTRICAL
BELEC200 Elec. Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD .-nergy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
of 3
SIN CITY OF CUPERTINO
CinOF PERMIT APPLIC-1ATION FORM
CUPEf�TiNO
Quant Fee ID Fie Descri tion Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Ven t Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Si-.b Specific Plan BUILDING
BSEISMICOM Seb mic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL S )ecial Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Tc mporary Power ELECTRICAL
KNBTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Tem Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electricals foot ELECTRICAL
PERNIITFEE Elec Permit IssuanceELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
PERMITFEE 112ech Permit Issuance MECHANICAL
PERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Pliunbing Fee sq foot PLUMBING
PLLONGRNGC Plann!!Ig LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Ran a Residential PLANNING
ZADDCHG Address Change BUILDING
3 of 3