08110090BUILDING DIVISION PERMIT
BUILDING ADDRESS: PFAMrr NO.
4 INFINITE LOOP SAN JOSE CONSTRUCTION 081.1.0090
OWNER'S NAME: I I PERMIT ISSUE DATE
PHONE:
O 6 UCF.NSED CONTRACTOR'S DECLARATION
VI hereby affirm that I am licensed under provisions of Chapter 9 (commencing
- with Section 70DD) of Division 3 of the Business and Professions Code, and my license is
o SS in NII force and erred
L.I. a.0 LJc. I
qqq rate Contract
i
ARCHITECT'S DECLARA71ON
E aZ 1 understand my plans shall be used as public records
C6
C In Licensed Professional
a OWNER -BUILDER DECLARATION
I hereby alarm that I am exempt from the Contractors License Law for the
p O following mason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit to construct. alta, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to f is a signed statement
< drat he is licensed pursuant to the provisions of the Contractors license Law (Chapter 9
$ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be is exempt Iherefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any appliam for a permit subjects the applicant m a civil penalty of
not more than five htudmd dollars (SSM
❑ L as owner of the property, or my employees with wages as their sok compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Code: The ConuaMes License Law does not apply to an owner of
property who builds or improver thereon, and who does such work himself or tgrough 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
rale.).
❑ I. as owner of the property, am exclusively contracting with licensed contractors to
construct the pmjea (Ser. 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 Contractors
License LAW.
❑ I am exempt under Sec . B dr P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby afrtrm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sadon, as provided for by Section 3700 of the Labor Code, for the performance of the
wort 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 i—A
My Workers Compensation Insurance rifler and Policy number am:
Grier. Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(408)986-8711
Job Description
CONTROL NO.
BUMDM PERMIT INFO .
BLDG ELECT PLUMB MECH
REV STRUC REVIEW OF UNSTRUCT WALL SYSTEM NOTE: 2.
ON SHT A2,2 ORIG #08100066
Ft. Floor Area
31602107.01
Required Inspections
(This section need not be completed if the permit is for one hundred dollars ($100)
or las)
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- Due
Applicant
NOTICE TO APPLICANT. If, afkr making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Coda you must
Oforthwith comply with such provisions or this permit shall be deemed revolted.
CONSTRUCTION LENDING AGENCY
[� I hereby afrrm tsar there Is a construction lending agency for erre performance of
a > the work for which this permit is inued (Sec- 3097, Civ. C)
W 0 Lenders Name
z Lender's Address
U I eetwy dal I have mead this application and sate that the above Information is
LL, E correct. I agree m comply with all city and county ordinances and slate laws relating m
0 SV' building contraction, and bereby authorize representatives of this city to enter upon the
W above -mem Gond property for inspection purposes
06 (We) agree to save, indemnify std keep harmless the City of Cupertino against
or to liabilities, judgments, costs and expenses which may N any way scene against said City
in CORSCqUU= Of the Z=LiRg Of this
:.i 4
t.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:
SOURCE REGULATIONS.
Signature of Applian✓Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hrardoua material
as deflned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes E] No
Will the applicant or future building occupant use equipment or devices which
emit hwzmdous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
1 have toad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health ger Safety Code, Socwns 25505.25533 and 25534.1 undersand the if the building
does not currently have a taint, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized ascot Date
Re -roofs
Type of Roof
Valuation
Occupancy Type
Date
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.
Signature of Applicant Date
. All roof coverings to be Class'R" or better
0 f// o (-)? (-)
a
CITY OF CUPERTINO
CUPEf�TINO REVISION/DEFERRED
PERMIT APPLICATION FORM
APN # Al <� -7` or
Date: ///2 y /d
Original Permit #: O 0
Building Address: q A L. -„o
Mailing Address (if different from building address):.
Owner's Name:
Phone #: yoX -1�207
41W awe/
Contractor:
Phone: ?d 6 a"" 711
.�•,. .+- ,o/.a� o �'D
C/
Fax: 9S-6 CIa78
Contractor License #:
Cupertino Business License #: �J�►o�y�
Contact: � ��
Phone: L/dl' J-17/ 7 �a3
Fax:
Building Pe t Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Residential F7 Commercial
Job Description:
J4'
,4-1'7-A'- ( l/
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction (Usage Class):
* Occupancy Type:
1-A2 1-B V/ II/III/V-A ❑ II/III B, IV -HT, V -B ❑
Valuation (cost of project)
Project Size: Express Fr Standard LargeEl Major
Green Building: Please complete relevant ortion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditpreen.org
Revised 10/01/08
CITY OF CUPERTINO
CUPEKriNO REVISION/DEFERRED
PERMIT APPLICATION FORM
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
1REVCOMNEW
Revision Commercial New
B
1*
/
1REVCOMTI
Revision Tenant Improvement
B
1* TI
1REVSFDWL
Revision SFDWL
B
1R3SFDW
1REVRESADD
Revision Addition
B
1R3SFDADD
1REVRESREM
Revision Remodel
B
1R3SFDREM
1DEFINSP
Deferred Submittal not R-3
Inspection
B
1DS
1DEFPLNCK
Deferred Submittal not R-3 Plan
Check
B
1DS
1DEFR3.INSP
Deferred Submittal Inspection
B
1DSR3
1DEFR3PLNCK
Deferred Submittal R-3 Plan Chk
B
1DSR3
1,