07060074 CITY OF CUPERTINO
BUILDING DIVISION PERMITQ��` TQ � �� '
pf PERMIT NO.
'u"VNJ�DRS�:___GE BLOSSOM DR TBD — TC BE DETERMINED 07060074
``JJ KHlV PERMIT ISSUE DATE
OWNER'S NAME:
JOE LOO 06/11/2007
SANITARY NO. CONTROL NO.
INE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p C LICENSED CONTRACTOR'S DECLARATION Job Description
tu p 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
:ZU widtSection7000)ofDivi'on3ofthcBusinessandProfessionsCo andmyliccnseis POOL DEN:O, DISCONNECT GAS/ELECT AT METER.
y in full force and of ` �`/7J r CONTRACTOR X—TREME CONCRETE PD FOR BL.
v�Z License CI Lie.8
E Date Contractor
ARCHITECTS DECLAR I
I a a I understand my plans shall be used as public records
)yU
u.y Licensed Professional
O e OWNER-BUILDER DECLARATION
1 hereby alTirm that I am exempt from the Contractors License Law for the
p oe� following reason.(Section 7031.5,Business and Professions Code:Any city or county
m fi which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement t'9 Ft.Floor Area Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $5500
t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
',J, that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3661107-, W Number Occupancy Type
not more than five hundred dollars(5500).
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 for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors 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.).
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 dt P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 I 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 Workers 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 Polity number are:
Carrier: 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 thisit is issued,I shall not
employ any person in any manner so as to become sub' orkea'Compensation
Laws of
Applicant
NOTICE TO APPU rtiricate of Exemption,you should
become subject to the orker's Compe ' n p tons of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
z"" CONSTRUCTION LENDING AGENCY
E-r 1 hereby affirm that there is a construction lending agency for the performance of
rY.> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendces Name
Lender's Address
UC) I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
tHr liabilities,judgments,costs and expenses which may in any way accrue against said City
U 2 in consequence of the granting of this permit. Date
nUCANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
ONS.
Re-roofs
Signat ppli n Dale Type of Roof
H DOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mu 'ipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
Yes No If a roof i;installed without first obtaining an inspection,I agree to remove
Will the applicant r future building occupant use equipment or devices which
emit hazardous air con inanl9 defined by the Bay Area Air Quality Management all new materials for inspection.
District?
C)Yes No
I have read the hazard us materials requirements under Chapter 6.95 of the Califor-
Safety Ccdc,Sections 25505,25533 and 25534.1 understand that if the building
does not ntly ha tenant,that it is my responsibility to notify the occupant of the
require n hick m be met prior to issuance of a Certificate of occupancy. nature of Applicant Date
All roof coverings to be Class"B"or better
Owncr,. uthorizc ag Date
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk : Lot:
APN 36611077. 00
DATE ISSUED. . . . . . . : 06/11/2007
RECEIPT #. . . . . . . . . BS000001603
REFERENCE ID # . . . 07060074
SITE ADDRESS . . . . . : 7599 ORANGE BLOSSOM DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JOE LOO
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : RICO BELTRAN
CONTRACTOR TBE - TO BE DETERMINED LIC # 00096
COMPANY TBT- - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY TMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- -- -------- ---------- ---------- ----------
BPERMFEE VALUATION 5, 500 .00 126 .36 0 . 00 126 .36 0 . 00
BSEISMICRE VALUATION 5, 500 . 00 0 .60 0 .00 0 .60 0 . 00
-- -------- ---------- ---------- ----------
TOTAL PERMIT 126 . 96 0 .00 126 . 96 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CASH 126 . 96
CHANGE -13 . 04
---------------
TOTAL RECEIPT 126 . 96
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
• CITY OF C'UPERTINO
a U
CUPERTINO PERMIT APPLICATION FORM
APN# � � Date:
Building Address:
Owner's Name:---�� i �,l Phone #:
Contractor: �- Licen #: J "I/ 7
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Contact: (P-nv
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fro I,`�
Building Permit Inf .
Job Description: ; (__ „ Q ��
Cor��.c,� ec u�C
Residenti Commercial: ❑
Sq.Ft. Floor Area: Cost of Project: ,J U�
Qty. if
A lic ble Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BSEISMICOM 'eismic Commercial BUILDING
BSEISMICRE 'Seismic Residential BUILDING
BPLANCHK flan Check Fee BUILDING
BUSLIC IWsiness License BUILDING