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