07060153 -7777777777777777 7:
CITY OF CTIPERTINO C ? I' ktAIC)R
BUILDING DIVISION PERMIT
PERMIT NO.
BUILf41bIG„PD[}R%ILKINSON AV SIGURA C DNSTRUCTION 07060153
l U 7 G PERMIT ISSUE DATE
OWNER'S NAME: 06/19/2007
LIOR LANDESMAN 819 DUFF CT
SANITARY NO. CONTROL NO.
3NE: (408) 736-7952
BUILDING PERMIT INFO
rRCECT/ENGINEER: BLDG ELECT PLUMB MECH
p zOLICENSED CONTRACTOR'S DECLARATION Job Description
v Fhereby affirm that 1 am licensed under provisions of Chapter 9(commencing REPLACING VANITY FIXTURES PLUMBING WORK.
y ion 7000)oCDivicion 3 of the Business and Professions Code,and my license is
y in full force and effect.
v�Z Licen Lic•
p Datc Comracwr
t ARCHITECTS DECLARAT
i a a understand my plans shall be used as public records
>yU
LL H Licensed Professional
:or OWNER-BUILDER DECLARATION
ja f 1 he affrm that I am exempt from the Contractors License Law for the
O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
W which requires a permit to construct.alter,improve,demolish,or repair any structure Valuation
prior h)its issuance.also requires the applicant for such permit to file a signed statement Ft.Floor Area
?a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $450
q
e H (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 OCCll Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3561305-
Number Occupancy YP
not more than five hundred dollars(1500).
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 Conuactoes 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.).
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 docs not apply to an owner of property who builds or improves thereon,and RY.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's SANITA
License Law. B&P C for this reason
0 I am exempt under Sec
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
L]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 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 issued.
My Wor *m -al1';tlWnsLuaoceXEMcr and Policy number are:Cartier. Policy No.:IC TE F EPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(S 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
Laws of California.Date
Applicant
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
`A I hereby affirm that there is a construction lending agency for the performance of
�i> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Namc
Lenders Address
z
U 0 1 certify that I have ad this application and state that the abo
reve information is
correct.I agree to comply with all city and county ordinances and stale laws relating to
Vbuilding 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
fF,C/1 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 G TIO ° bb
C Re-roofs
SignaturcofA tcant/Contractor are T of Roof
HAZARDOUS MATERI DISCLOSURE Type
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.
0Yes 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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
District?
0 Yes No
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 not currently have a tenant,that it is my responsibility t°notify the occu ant of the Dale
requiremc h u t et 'or cc of a Certificate of pan Signatur;of Applicant
Y% U All roof coverings to be Class"B"or better
Owner or authorized agent Date
CITY OF ]UPERTINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35613054.00
DATE ISSUED. . . . . . . : 06/19/2007
RECEIPT #. . . . . . . . . : BS000001689
REFERENCE ID # . . . : 07060153
SITE ADDRESS 10972 WILKINSON AV
SUBDIVISION . . . . . .
CITY CUFERTINO
IMPACT AREA . . . . . . .
OWNER LICR LANDESMAN
ADDRESS .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4700
RECEIVED FROM . . . . : SIC�URA CONSTRUCTION
CONTRACTOR . . . . . . . : ILIN SIGURA LIC # 28892
COMPANY . . . . . . . . . . : SIGURA CONSTRUCTION
ADDRESS . . . . . . . . . . : 81c-, DUFF CT
CITY/STATE/ZIP . . . : SUTTNYVALE, CA 94086
TELEPHONE . . . . . . . . : (408) 736-7952
FEE ID UNIT QUANTITY i,-MOUNT PD-TO-DT THIS REC NEW BAL
------------- ---------- ----------- ----------
BPFIXTURE UNITS 1. 00 9 . 00 0. 00 9 .00 0. 00
PPERMITFEE FLAT RATE 1. 00 38 .37 0. 00 38.37 0. 00
----------- ---------- ---------- ----------
TOTAL PERMIT 47 .37 0. 00 47 .37 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------------
CREDIT CARD 47 .37 VISA
---------------
TOTAL RECEIPT 47 .37
CITY OF C UPERTINO
dF PERMIT APPLICATION FORM
CUPERTINO
APN# Date:
Building Address: Mailing Address (if different from building address):
�o
Owner's Nam : . Phone #:
or o G�q_1
Contractor: License #:
Contac � Phon `� Cupertino B�n���ens,.
AO Fax:
Building Permit Inf V�n� � IU1r�5
Bldg
Elect ElJ I lumb Mech ElEl
Job Description:
Residential 1-1Commercial El
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy-Grow
t Ll50 -0
Type of Construction: C-71 Please check this box if the project is a
16AJ_ second-story addition: El
Project Size: Standard ❑ Large ❑ Ma or ❑
Quantity Fee ID Fee Descri tion Fee Group
BAPPLOTHER ,Jther Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 10 KK to 500K Btu MECHANICAL
BBOILER3 Boil er> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Cc nstax—Resi/Mobile BUILDING
BELEC 1000 E lec 600V <= l OOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Ele,.- Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of 3
CITY OF C UPERTINO
alF PERMIT APPLICATION FORM
CUPEkTINO
Quanti Fee ID I'ee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP N,:w Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atrlospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Blde Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK flan Check Fee BUILDING
BPLANCKADD Plai Check Add Multi BUILDING
BPLANCKREP Plait Check Repeat Fee BUILDING
BPREPIPE Rei e Of Fixtures PLUMBING
BPSEWAGE '�ewa a Dis osal PLUMBING
BPSEWER Sewers PLUMBING
BPSpRINK Lawn SprinklerBackflo PLUMBING
BPSTORM torm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT :Zeinspection 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 Relocation of Furnace MECHANICAL
BREMFURNOV Rel c) Furnace> IOK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Ir stallation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Reri Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc ,tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Re:nodel Res Appliance ELECTRICAL
of 3
CITY OF C UPERTINO
OCF PERMIT APPLICATION FORM
CUPEI,TINO
Quanti Fee ID I'ee Descri tion Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vert Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE `.Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP T,,,m orary Power ELECTRICAL
BTEMPPERM emporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Eke Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
MPERMITFEE Meeh Permit Issuance MECHANICAL
j PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Plannin LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
3 of 3
Community Development
10300 Torre Avenue
axe,. Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
;UPEkTINO
Buildin De artment
JOB ADDRESS: m PERMIT #
PHONE #
OWNER'S NAME:
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRAC'T'OR 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
Owner/Contractor Signature Date