07080149CITX OF C U,Y�xi>lr�
BUILDING DIVISION PERMIT
r11lL1fN8 A1�p'EsNDE ANZA BLVD
NER'SNAGME:
ROMAN CATHOLIC WELFARE CORP
rARC—HITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
0p
vPI hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z UW Section 7000) of Division 3 of the Business and Professions Code, and my license is
ti in full force and effect
v� Z License Class Lic. 8
Dam Contractor
't ARCHITECT'S DECLARATION
i C < l understand my plans shall be used as public records
tyU
' m H Licensed Professional
' a OWNER -BUILDER DECLARATION
3 a i 1 hereby affirm that I am exempt from the Contractors License Law for the
: n oy following reason. (Section 703 1.5, Business and Professions Code: Any city or county
{z which requires a permit to construct, alter, improve, demolish, or repair any structure
r prior to its issuance, also requires the applicant for such permit to file a signed statement
? a that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
s (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
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
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 (Sec. 7044, Business
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 build or improve for purpose of
sale.).
O 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors 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 one of the following declarations:
I have and will maintain a Certificate of Consent to self -insure for Workees Compen-
ation, 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:
:artier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
PERMIT NO.
TBD TO BE DETERMINED 07080149
PERMIT ISSUE DATE
(This section need not be completed if the permit is Cor one hundred dollars ($100)
rr less.)
I certify that in the performance of the work for which this permit is issued, !shall not
employ any person in any al�rcr so as til become sub' to the Wpm ' Compensation
Laws of California. Date (L� a
Applicant
NOTICE TO APPLICA : If, after making this Certificate of Excmpuon, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Namc
Lender's Address
I 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
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(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 granting of this permit.
APPLICANT UMATIONS.
S AND WILL COMPLY WITH ALL NON -POINT
SO RC REG
Sig ore of Applicant/Contractor
Date
HAZARDOUS MATERIALS DISCLOSURE
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)7
❑ Yes P1.
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
Uistrict7
Yes o
1 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
does yyon currently have a ten t, that it is my responsibility to notify the occupant of du
pEllujfcmgms; wherhnust br t�e etgnor to issuance of a Certificate of O5"P cy_a'_
or
GENERATOR INSTALLED
31626091`.
Issued b�
Re -roofs
Type of hoof
Ft. Floor Area
SANITARY NO, CONTROL NO.
Job Description
$400
Required Inspections
BUILDING PERMIT INFO
ELECT PLUMB
ation
Type
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
SighaWo. of Applicant
Date
All roof coverings to be Class "B" or better
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: CathyS
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 31626091.00
DATE ISSUED.......: 08/15/2007
RECEIPT #.......... BS000002392
REFERENCE ID # ...: 07080149
SITE ADDRESS
10120 N DE ANZA BLVD
SUBDIVISION ......
CITY ..............
CUFERTINO
IMPACT AREA .......
OWNER ............:
RONAN CATHOLIC WELFARE
CORP OF
ADDRESS ..........:
10120 N DE ANZA BLVD
CITY/STATE/ZIP ...:
CUPERTINO, CA 95014
RECEIVED FROM ....:
LE.LEY ERICKSON
TBI - TO BE DETERMINED
LIC # 00096
CONTRACTOR .......:
COMPANY ...........
TBI - TO BE DETERMINED
ADDRESS ..........
CITY/STATE/ZIP ...:
,
TELEPHONE ........
FEE ID UNIT QUANTITY
),.MOUNT PD -TO -DT
THIS REC NEW
--
BAL
___ -----------------------
_____
BTEMP FLAT RATE 1.00
-- ------------------
62.10 0.00
62.10
0.00
0_00
EPERMITFEE FLAT RATE 1.00
38.37 0.00
37
38_ ------
----
TOTAL PERMIT
100.47 0.00
100.47
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
100.47
---------------
100.47
REFERENCE NUMBER
--------------------
2667
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------------------------------ -
103 UFER 304 ROUGH ELECTRICAL
CITY OF CUPERTINO
ri iNn-1 P -if P -1D, OWET
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s.
CITY OF
—UPER.TINO PERMIT APPLICATION FORM
APN
Date:
Building Address:
Owner's Name:
Phone #-,
j
Contractor: ~J
Phone:
License
Phone:
Cupertino Business License 4:
Contact:
Building Permit Info:
Elect di
Job Description:
Residential ❑
Commercial
Cost of Project:( -16,6
Qty. if
.. I
Fee Groun
Applicame BTEMP rt-lu.11.10 Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit issuance- ELECTRICAL
BUSLIC E usiness License BUILDING