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07060197
777777 CITY OF CUPERTINO BUILDIXG DIVISIGV PERMIT Z��RMl�T�� PERMIT NO. BUILDING ADDRESS: 20314 NORTHGLEN SQ RICHARD ALFRED A AND ALFRED 07060197 OWNER'S NAME: PERMIT ISSUE DATE RICHARD ALFRED A AND ALFRED A 06/22/2007 SANITARY NO. CONTROL NO. NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 !0 Q LICENSED CONTRACTOR'S DECLARATION Job Description UJ P 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing .z M with Section 70(10)of Division 3 of the Business and Professions Code,and my license is INSTALL S KYL I TE S. H in full force and effect. j ? License Class Lic.ff t, Date Contractor uJ uJ ARCHITECTS DECLARATION w1 understand my plans shall be used as public records U .a W F Licensed Professional N OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the p O following reason.(Section 7(131.5,Business and Professions Code:Any city or county `<$ which requires a permit to construct,alter,improve,demolish,or repair any structure u } prior to its issuance,also requires the applicant for such permit to rile a signed statement Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area 2 O O 0 H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i 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 ofNumber Occupancy Type not more than five hundred dollars(5500). 3 16 41 0 4 4 .qV ❑I,as owner of the property,or my employees with wages as thew sole compensation, will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractors 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 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.). ❑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 Li200, 66 - cense Law does not apply to an owner of property who builds or improves thereon,and. pursuant to the Contractors CATE who contracts for such projects with a contractor(s)licensed p u?L1 , P c c License Law. ❑f am exempt under See. ,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 Workers Compen- sation,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 Workers Compensation Insurance carrier and Policy number are: Cartier: Policy No.: CERTIFICATE OF 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,1 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 Workers Compensation provisions of the Labor Code,you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. Z" CONSTRUCTION LENDING AGENCY (~.r►�-� I hereby affirm that there is a construction lending agency for the performance of p;> the work for which this permit is issued(See.3097,Civ.C.) W A Lender's Name z Lender's Address U C) I certify that 1 have read this application and state that the above information is (3. ► correct.I agree to comply with all city and county ordinances and state laws relating to rJ U building construction,and hereby authorim representatives of this city to enter upon the Uabove-mentioned property for inspection purposes. f>~ (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 U,Z in consequence of the granting of this permit. Date ►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. Re-roofs Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof 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 ❑No Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove ,mil hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes ONO I 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 docs not currently have a tenant,that it is my responsibility to notify the occupant of the rcquircmcnts which must be met prior to issuance ora certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class"B"or better Owner or authorized agent Dare CITY OF C.UPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO CPN# Date: Building Address: Mailing Address (if different from building address): 31V r 5 �e Owner's Name: vPhone #: r< `/d g !`',,� a ;z Contractor: � / 5 License #: Contact: ( Phone: Cupertino Business License#: Fax: Building Permit Info: Bldg (A Elect El Plumb ElMech ElJob Description: / Residential ❑ .Cn S ez `� r�`> Commercial ❑ Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: Please check this box if the project is a second-story addition: ❑ i eroject Size: Standard ❑ Large ❑ Ma or ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER ether Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boilc r> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX In i/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax —Resi/Mobile BUILDING BELEC1000 El cc 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING ] of 3 CITY OF C'UPERTINO C1 OF � 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 Nev, Comm Mechanical MECHANICAL BNUCOMMP 1,ew Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atnospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE I11d Permit Fees BUILDING BPFIXTURE Pb114 Fixture PLUMBING BPGAS Ga;:Piping System Fee PLUMBING BPINTERCEP Incl Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Ple n Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE "ewa a Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn Sprinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Inst ill/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Re location of Furnace MECHANICAL BREMFURNOV Re]c) Furnace> l OK btu MECHANICAL BREMHEAT heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE P(,le/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Relpfl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT R--pair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL of 3 CITY OF CrUPERTINO Cin of PERMIT APPLICATION FORM CUPERTINO -)uantity Fee ID Fee Description Fee Group BREMSIGNAD Rm,il Signs Add Branch ELECTRICAL BREMSIGNS Rerr odel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Ve nt Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD ,'5cb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL 'Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP I emporary Power ELECTRICAL BTEMPPERM Tem porary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE El,,-c Permit Issuance ELECTRICAL MPERMFEE lVechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Plannin LR Comme/Multi-Faro PLANNING PLLONGRNGR Plannin Long Range Residential PLANNING Of 3 OWNER-BUILDF R VERIFICATION 1. (Check one) I or my immediate family i parent, spouse or child) will perform: A. _XL All the work authorized by this permit B. _ A portion of the work C. _ None of the work If B or C is checked, c:)mplete 2 or 3 below. 2. A state licensed contractor will be hires to do: A. — All of the work B. _ A portion of the we rk (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' con ipensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be --performed ............................................................................................. I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owner's Signature: Date: 97-3-2,A 7 Job Address: 2 d O P- Permit# Any changes to the information provided oit this form shall be submitted to the City of Cupertino Build DeRartment. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Fax(408)777-3333 ,UPEkTINO Building Department JOB ADDRESS: PERMIT# 7 0 /! 7 OWNER'S NAME: Icy e `- PHONE # - GENERAL CONTRACTOR: © FAX# I am not using any subcontractors: Signature Date Please check applicable subcontractors and com Clete 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 Tile azz er/Contractor Signature Date