07010185 .--7777777777777.11,
CITY OF CUPERTINO
BUILDING DIVISION PERMIT e� � TR IFORMATI€)N«
BUILDING ADDRESS'� t ' PERMIT NO.
-7 O
1 0 11813
PRMATE
OWNER'S E: u1o Vfn Rd O&4J l QLX q1L1 VD hifi
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BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB ML_E_CHH
p LICENSED CONTRACTOR'S DECLARATION Job Description
v 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z with Section 7000)of Division 3 of the Business and Professions Cade,and my license is
H in full force and a Gest
v�z License CI Lon A
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Date /' Contractor
a ARCHITECTS DECL.AR ON ^ �
aa 1 understand my plans shall be used as public records /
iaU
4 tol- Licensed Professional
o
a W OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K$ which requires a permit to construct,alter,improve,demolish,or repair any structure
a~y prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. O C O
xF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or r[n, J
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of PN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500). f i
❑I,as owner of the property,or my employees with wages as their sole compensation, T-
willdothework,and the structure is not intended or offered for sale(Sec.7044,Business 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.).
n 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 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.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of the following declarations:
Q I 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.
N_Loavc and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compefnsation Insurance and Policy number are:
Carrier.1 in � �� Ig'
CERTI CATS FEXEMPTI0 OM WORKERS'
COMPENS&IO,I URANCE
(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 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.
z CA O CONSTRUCTION LENDING AGENCY
[.r I hereby affirm that there is a construction lending agency for the performance of
Q(�✓ the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Z Lender's Address
1 certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
.� 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
"c/) liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AN ILL COMPLY WITH AL NON-POINT Issued b r:
SO CE`EGUL ONS. C r tT�
Re-roofs
Sin re of Applic Mractor tc
HAZARDOUS MATERIALS DI LOSURE Type of Zoof
Will the applicant or future building occupant or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof:;shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicantfuwre building occupant use equipment or devices which
emit hazardous air con nants as defined by the Bay Area Air Quality Management all new I naterials for inspection.
District?
Yes u
I have read the ardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
rc uircmcnts which met prior t iss c of a Certificate of oc pan Y. Signatur'of Applicant Date
O v All roof coverings to be Class"B or better
O ncr or authorize it 7 ate
k.1
CITY OF CUPERTINO
0010l85
FURN.�-&E/AC:
:UPER,TINO PERMIT APPLICATION FORM
APN# �2� 00 Date:
Building Address:-
Owner's Name: V Phone #:
to-r2r- 40
Contractor. Phone: License#:
r -c9,9 3 - W317q.
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect P lumb Mech m
Job Description: `���'►� ;-�
Residential Commercial ❑
For Residential In tallations:
Attic ❑ Is' floor 2nd floor❑
Adhere to min set back requirements
Ar Commercial Installations:
Replacement same weight ❑ Additional weight (st:-uctural calcs)
Structural Calculations required for new installation
New installation Planning Approval Required
Cost of Project: Type of Construction: Occupancy grou .
Strapped n Platform Bonded C9� Sq.Ft. Floor Area:
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Furnace EJMECHANICAL
BREMACOVER AJC Unit> 10,000 cfm MECHANICAL
BREMAIRHAN AJC Units<= 10, 000 cfm MECHANICAL
BREMRECEPT F.ec tl, Switch & Outlets ELECTRICAL
BSEISMICRE eismic Fee Res BUILDING
BSEISMICOM eismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Tech Permit Issuance MECHANICAL
PPERMITFEEF lumbing Permit Issue PLUMBING
BPERMFEE 111cig Permit Fees BUILDING
BPLANCHK Flan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING