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07030346 CITY OF CUPERTINO BUILDING DIVISION PERMIT �C�N7CJ[tAGTC'� lRATTON' PERMIT NO. BUILDING ADDRESS: OWN A . I- imATEWSKI MARC AND L TEE— NDJFSTRIAL AVE s@@TA&910.2 0 0 7 CONTROL NO. TRT 7L' _ BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH ZLICENSED CONTRACTOR'S DECLARATION Job Description 0 I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Busineqa-ndPr0cssions nd in license isi w in full force and effect. ( / UPGRADE PANEL TO 200 AMP Z License C s Lic.—Contra -p Datc ARCHITECTS DECL ATI a 1 understand my plans shall he used as public records LU t" Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the jO following reason.(Section 7031.5.Business and Professions Code:Any city or county 3.9 which requires a permit to construct,alter,improve,demolish,or repair any structure } prior to its issuance,also requires the applicant for such permit to file a signed statement r Ft.Floor Area Valuation _< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 �q -$ (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 Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars($500). 0 I,as owner of the property,or my employees with wages as their sole compensation, 36936017 will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law dues 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&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-insure for Worker's Compen- ..-.ion,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 Worker ompensation Insurance carrier and Policy number 7d.2, ,7-2 j Carrier � '~ C-(2- PolicyNo.: CERTIFICATE OF EXEMPT ION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or Icss.) 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 Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. O CONSTRUCTION LENDING AGENCY rte. 1 hereby affirm that there is a concoction lending agency for the performance of > the work for which this permit is issued(Sec.3097,Civ.C.) A Lender's Name Z Lcnder's Address C) I certify that I have read this application and stale that the above 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 W above-mentioned property for inspection purposes. CL (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgmcnts,costs and expenses which may in any way accrue against said City /2 � 2 in consequence of the granting of this permit. Date �3� ��CJ -7 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. 0Yes Pct 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 L hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection. _.strict? 0 Yes No 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 Date requirement_%which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant All roof coverings to be Class"B"or better Owner or authorized agent Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: bethe COPY # 1 Sec: Twp: Rng: Sub: Bl}:: Lot: APN . . . . . . . . : 36936017 . 00 DATE ISSUED. . . . . . . : 03/29/2007 RECEIPT #. . . . . . • . . : BS000000825 REFERENCE ID # . . . : 07030346 SITE ADDRESS . . . . . : 20; 71 GILLICK WY SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : MAJEWSKI MARC AND KOLSTEE-MAJE ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : CU:?ERTINO CA, 95014-4412 RECEIVED FROM . . . . : RECEIPT INTERFACE CONTRACTOR . . . . . . . : ANTHONY FISHER LIC # 21713 COMPANY FI;3HER POWER AND DATA INC ADDRESS 94 ) INDUSTRIAL AVE CITY/STATE/ZIP . . . : PKJO ALTO, CA 94303 TELEPHONE (6 :0) 325-5768 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- - --------- ---------- ---------- ---------- BELEC200 METERS 1.00 29.43 0 . 00 29 .43 0 . 00 BSEISMICRE VALUATION 2, 650 .00 0 .50 0 .00 0 .50 0.00 EPERMITFEE FLAT RATE 1.00 38 .37 0 .00 38 .37 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 68 .30 0 .00 68 .30 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------------------- CREDIT CARD 68 .30 visa --------------- TOTAL RECEIPT 68 .30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------------- 103 UFER 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL Community Development " _. 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 ,CITY OF Fax(408)777-3333 rUPEkTINO Buildin De artment JOB ADDRESS: PERMIT# c;� c -:� 1 61 / 1 ick 0--"-703,:::�-:� (--( C OWNER'S NAME: 'F-[Ler) N(4—V Lk-)5 K % PHONE# 46)S- q l-&- 1533 GENERAL CONTRACTOR: N 1A FAX# I am not usingany subcontractors: Si;na e pshe r �` t E- ate Please check apphcable subcontractors and complete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing ✓ Electrical i S�1 e( toCt- e :Ja C 17 13 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 rZ er :n:iEktor 'gnature Date 03/28/2007 13:21 FAX 408 777 3333 CITY CUPERTINO 11001/003 r CITY OF C'UPERTINO *CO PERMIT APPLICATION FORM CUPEkTINO C)703 03' 6 AFN# a - 'j1 - t�/ Date: 31 c1 . Building Address: 1 Mailing Address(if differe�at froln building address) 0 C Ck Own 's Name: Phone#• G- fS-3-3 - Licensc#: r_ / � (:ontraetO 6 G &3 '1 I ( s V1 mer ;I�err C Contact: �-- phone: 105�' 4' Cupertino Business License#: TD n t—i S tQ l" Fax:IoJO 4q� -,356,1 c 1 BuildingPermit Info: Bld Cl Elect Plumb D Mech C_] Job Description: Commercial ❑ Residential Nz �a a Sq-Ft-: Sq.Ft.Floor Area: Cost of Project: O1, Occupancy Grou ; -- Type o onstruc ion: Please check this box i!-the project is a second-storyaddition_ ❑ Project Size: Standard ❑ Lame ❑ Maim❑ -- Fee ID Fee Descri tion _ Fee Grou Quanti Iy�CHANICAL BApPLGTHER Other A li antes --Iv�CHANICAL BBOILERI Boiler�= 100,000 Btu B$OILER2 Boiler> 100K to 500K Btu --MECHANICAL BBOILEM Boiler�500K to 1M Btu . MECHANICAL BBOU,ER4 Bo:.ler> IM to 1.75 M Btu _MECHANICAL BROILERS Boiler> R Btu _wcHANICAL BCONSTAX Construax BUILDING BCONSTAX ind/Off/Cuasi __ BUILDING BCONSTAXB Con.Tax Zone _ B -DG BCONSTAXH Hotel ael $jJILDING BCONSTAXR (:onstax obile __ BUILDING BELEC1000 Elec 60000A __ ELECTRICAL BELEC1001 Elec 600V>1000A ELECTRICAL $ELEC200 E lee Svcs 600V,=200A _ELECTRICAL Energy BUILDING BBNERGY +� BIDING BENERGYADD Buergy Add Multi __ BU•ZLDING $INVESTXGA Investigation fee 1 of 3 - CITY OF (:UPERTINO CITY Of PERMIT APPLICATION FORM CUPEkTINO 2uantity Fee ID Fee Descri tion Fee Group BREMSIGNAD Rmll Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR lboatnical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS V m ilation Systems MECHANICAL BSCBLVD 36 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 Teal ora Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE El�c Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mf ch 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 ZADDCHG Address Change BUILDING S of 3