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07060077 CITY OF CUPERTINO BUILDING DIVISION PERMITPERMIT NO. BUILL11r l� �REs ONNY DR TBD TC BE DETERMINED 07060077 OWNER'S NAME: PERMIT ISSUE DATE LIPMAN PETER H AND CORINNE S 06/11/2007 NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH p Q LICENSED CONTRACTOR'S DECLARATION Job Description LU F I hereby affirm that I am licensed under provisions of Chapter 9(commencing z vvi with Section 7000)of Division 3 of the Business and Professions Code,and my license is CHIMNEY REPAIRS, SHOULDER UP t y in full force and effect. h�? License Class Lia# F p Date Contractor ARCHITECTS DECLARATION i a I understand my plans shall be used as public records iA.0 U.y Licensed Professional y OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the :00 following reason.(Section 7031,5,Business and Professions Code:Any city or county $ which requires a permit to construct,alter,improve,demolish,or repair any structure ?Z} prior to its issuance,also requires the applicant for such permit to file a signed statement _< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area 5000 Valuation t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)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 35914045 Number Occupancy Type not more than five hundred dollars($500). 0 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 forsale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of q P 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.). 0 1,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. 0 I am exempt under Sec. B&P C for this reason OwnerDate WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: r]1 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. 0 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 Workees Compensation Insurance carrier and Policy number are: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is foronc 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 A Laws of California.Date ff Q r s ; //�7 Applicant I 1 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. Z" CONSTRUCTION LENDING AGENCY Fr►�-� I hereby affirm that there is a construction lending agency for the performance of GY the work for which this permit is issued(Sec.3097,Civ.C.) aA Lendces Name 0 z Lender's Address U 0 1 certify that I have read this application and state that the above information is Vi correct.I agree to comply with all city and county ordinances and state laws relating to 0U building construction,and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes. Lar (We)agree to save,indemnify and keep harmless the City of Cupertino against „4 c4p) liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature of ApplicanUConractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Rc of 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. ❑Yes 0 No If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which Iemit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? Cl Yes ❑No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building docs not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a certificate of Occupancy. Signature e f Applicant Date Owner or authorized agent Dare _ All roof coverings to be Class"B"or better CITY OF C'UPERTINO CITY OF PERMIT APPL=ICATION FORM CUPEI�TINO ,LPN# Date: A ri Building Address: Mailing Address (if different from building address): Owner's Name: Phone#: G( 1 n 11.E /Veler- k 1` m FYI 0� 2-�� 0 Contractor: 40 b,0- c4e; t-rn �' rp,� License #: Contact: r-l n Y\-P-- i r m"Phone:'f Gg 2.,;3,-&qCupertino Business License#: Fax: FOS 44/46—3`7,7/ Building Permit Info: Bldg �5' Elect ❑ Plumb ❑ Mech ❑ Job Description: ��° U/10 Residential G�'► rn Commercial ❑ Sq.Ft. Floor Area: �0 V-S 1S rod, I�2Z0 Sq.Ft.: Cost of Project: ' L Occupancy Group: Type of Construction: b r lCi� C.k i m 1�E' Please check this box if the project is a second-story addition: ❑ Project Size: Standard% Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boller<= 100,000 Btu MECHANICAL BBOILER2 Boiler-> 100K to 500K Btu MECHANICAL BBOILER3 Boilor> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 B)filer> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX In(VOff/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH IHotel and Motel BUILDING BCONSTAXR Constax —Resi/Mobile BUILDING BELEC 1000 Elec 600V<= l 000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD ]Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 CITY OF CvUPERTINO a10 PERMIT APPL=ICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Corr.in. Housing Mit. Fee BUILDING BNUCOMME N-,w Comm Electric ELECTRICAL BNUCOMMM Nevi Comm Mechanical MECO BNUCOMMP 1\ew Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atnospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Didg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Ga:;Piping System Fee PLUMBING BPINTERCEP Incl Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plat Check Repeat Fee BUILDING BPREPIPE R� i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn Sprinkler/Backflo PLUMBING BPSTORM S torm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER V�ater Heater/Vent PLUMBING BPWSVCS M ain Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfin MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfin MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Re location of Furnace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD In itallation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rerr, Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc J, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT R(pair/Alter Heating MECHANICAL BREMRESAPP Reniodel Res Appliance ELECTRICAL 2 of 3 P .11 CITY OF (:UPERTINO CU aloF PINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Thl;atrical Lighting Fix ELECTRICAL BREMVENFAN-- - Vent Fan Sin le Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD ,3cb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Teiuporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plu:,mbing Permit Issue PLUMBING PPLBG P11imbing Fee sq foot PLUMBING PLLONGRNGC Plannin LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING 3 of 3