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07010190 CITY OF CUPERTINO PERMIT T TSR IN R1t;�1ATI. BUILDING DIVISION ��'I RI1 PERMITNO. �+ BUILDING ADDRESS, PERMIT ISSUE DA JWNER'S NAME: SANITARY NO. CONTROL NO. ION . % / ��o CC � BUILDING PERMIT INFO ARCHITECCH TlE GiNEER: n� �C, BLDG ELECT PLM MEr ��� (� (� p p LICENSED CONTRACTOR'S DECLARATION Job Description m C I hereby affirm that I am licensed under provisions Of Ckapler 9(eammcltcing =Z UW with Section ndef of Division 3 of the Business and Profeasfons Code.and my license is "'4 H in full farce and effect ? License Class Li S F p Date�/—, Ly Conlra1- *0 ARCHfTECrs D a< t understand my plans shall be used as public records �yU yy Licensed Professional y 3 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 Kms,Pi which requires a permit to construct alter,improve,demolish,or repair any structure Valuation prior m its issuance,also requires the applicant for such permit to file a sighed statement St Floor Ft, Area —?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 JC YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or a that heis exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars(5500). ❑I,as owner of the property,or my employees with wages as their sole compensation, �� Required Inspections will do the work and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Conuactor's License Law dols 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.It. 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 does not apply to an owner of property who builds or improves themon,and who contracts for such projects with a comractor(s)licensed pursuant to the contractor's License Law. ,B&P C for this reason ❑I am exempt under Sec. 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-insum 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. ❑1 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 arc: carrier. CjI C�1�—Polity No.:SI CA7E 9Uv)D 07 /' $RTIFlOF 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 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 O CONSTRUCTION LENDING AGENCY H 1 hereby affirm that there is a construction lending agency for the performance of Cd> the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name 0. Lender's Address V I certify that I have read this application and state that the above information is LL I correct.I agree to comply with all city and county ordinances and state laws relating to O "V building construction,and hereby authorise representatives of this city to enter upon the above-mentioned property for inspccuon purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,casts�ad nscs which may in any way accrue against said Cityr:r of the Sha" f is permit. DateUZ NDER AND WILL COMPLY WITH ALL NON-POINT Issued by:ULATI S 3 e Re-roofs App scan ontractor Date 'j' of F.00f HAZARDOUS MATERIALS DISCLOSURE ypethe applicant or future building occupant store or handle hazardous material y the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety n 25532(a)? All roofs shall be inspected prior to any roofing material being installe . eti ❑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 Arca Air Quality Management all new materials for inspection. District? 0 Yes ❑No I have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 5.25533 and 25534.1 understand that if the building does not cu dy have a ten the tis my responsibility to notify the occupant of the Date require ich m t be et psi r w issuance of certificate of Occupancy. Slgnatur(:of Applicant ��� -r All roof coverings to be Class"B"or better Ow er authori zeda Date' Community Development m 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY Of Fax(408)777-3333 '-UPEkTINO Building Department JOB ADDRESS: PERMIT# OWNER'S NAME: PHONE # GENERAL CONTRACTOR: - FAX# 00fr-o- -t- 1,/0,Y-,Z 't. t. Li C, I am not using any subcontractors: Signaitire Date 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 ' e �._ Own r/Contractor Signature Date CITY OFCUPERTINO WATER HEATER CUPEk iNO PERMIT APPLICATION FORM APN# Date: 3 /;2, 1 Building Address: Owner's Name: Phone#: t 1 I iC)cf LUQ Contractor: Phor.e: License#: Contact- Phon Cupertino Business License#: Building Permit Info: Bldg ❑ Elect C9 Plumb El— Mech Job Description: �} Residential [ Commercial ❑ Cost of Project: �1 Strapped © On Platform Bonded New Location ❑ Replacement 2r Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER Water Heater/Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING