07050002 .77777777777777
CITE'OF CUPERTINO
BUILDING DIVISION PERMIT 0R EotEO][MATIQN ,
BUILDING ADDRESS:
PERMIT NO.
1 0 8 2 4BT--avail—RD T1TZ I GNAL y
OWNER'S NAME: PER 1
RENTALS
E AVE SAN CONTROL N0.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o a a
i p LICENSED CONTRACTOR'S DECLARATION
t= I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
„Uj with Section 7000)of Division 3 of the Business and Professions Code,and my license is
a- in full force and effect.
Z License Class Lic.N
p Date Contractor
ARCHITECTS DECLARATION
--� 1 understand my plans shall he used as public records
4
�- Licensed Professional
OWNER-BUILDER DECLARATION
z I hereby affirm that I am exempt from the Contractor's License Law for the
:ofollowing reason.(Section 7031.5,Business and Professions Code:Any city or county
0
which requires a permit to construct,alter,improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.F . Floor Area Valuation
(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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of AP lel Number Occupancy Type
not more than five hundred dollars($500).
O 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 Contractor's License Law does not apply to an owner of q P
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.).
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 et pt under Sec. _ B&P C f this .son
O Dale
WORKER'S COMPENSATI0 DECLARATIO
I ereby affirm under penalty of perjury ne of the following larat ons:
rave and will maintain a Ccrificatc oC nsent to self-insure for Worker's Compen-
__..un,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 Worker's Compensation Insurance carrier and Policy number arc:
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 k r whi thi it is issued,I shall not
employ any person in y manner so aobbc s 'c t rs'Compensation
Laws of Califom' to
Applicant
NOTICE T PPL.ICANT:If,after making this lcclificatc of P,mption,you should
become su ect to the Worker's Compensation provisions ti Lahor Code,you must
Oforthwith comply with such provisions or this permit shall&deemed revoked.
" CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
�
the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name
z Lender's Address
Q 1 certify that 1 have read this application and state that the above information is
corecL I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorise representatives of this city to enter upon the ^\
W above-mentioned property for inspection purposes.
L1. (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any y accrue against said City
z in consequc f the granting of this permit.
" APPLIC NDERSTANDS AND WILL COM WIT L N-POINT Issued by: Date
SOUR GUL.ATIONS.
- Re-roofs
t S' natrc of Applicant/Contractor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
tll the applicant or future building occupant store or handle hoz r us material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the He and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes L7no
Will the applicant or future building occupant use equipment or devices which If a roof is insta led without first obtaining an inspection,I agree to remove
hazardous air contaminantsas do ned by the Bay Area Air Quality Management all new material 3 for inspection.
.;trio?
Q Yes o
I have read the hazardous materials requirements u r Chapter 6.95 of the Califor-
nia Health tyCod e,Sections 25505 33 and .I understand that if rite building
does not tly have a tenant. my rcs ibility f the occ ant f the
require which must be ora Signature of Applicant Date
Ow r or authorized agent tc
All roof coverings to be Class'T or better
CITY OF CUPE]2TINO
2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: bethe
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36202028. 00
DATE ISSUED. . . . . . . : 05/01/2007
RECEIPT #. . . . . . . . . BS000001162
REFERENCE ID # 07050002
SITE ADDRESS . . . . . : 10824 PUBB RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA .. . . . . . .
OWNER . . . . . . . . . . . . : FREDERICK TY
ADDRESS . . . . . . . . . . : PO BOX 845
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95015
RECEIVED FROM RECEIPT INTERFACE
CONTRACTOR NATIONI.L CONSTRUCTION RENTALS LIC # 22537
COMPANY NATIONhL CONSTRUCTION RENTALS
ADDRESS . 1355 F::LIPE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95122
TELEPHONE (818) 221-6057
FEE ID UNIT QUANTITY AMOU]4T PD-TO-DT THIS REC NEW BAL
_____ ----- ---------- -
BTEMP FLAT RATE 1 .0052 . 10 0 . 00 62 .10 0 .00
EPERMITFEE FLAT RATE 1 .00 38 .37 0 .00 38 .37 0 . 00
----- ----- ---------- ---------- -------
TOTAL PERMIT 10 .47 0 .00 100 .47 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-----------------
--------------- --------------------
CREDIT CARD 100.47 AMEX
---------------
TOTAL RECEIPT 100 .47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
__ _ -------- ----------------------------
-- ---------------------
103 LIFER 304 ROUGH ELECTRICAL
CITY OF CUPERTINO
P POWER
CITY OF
CUPEkTINO PERMIT APPLICATION FORM , -1 b JC0n
APN# � 0, /� Date: 7'
0 J
Building Address: ! 74 v,
Owner's Name: < Ph;4.
Contractor: Ph
on License #:
Mal
Contact: Phone: Cupertino Business License #:
Building Permit Info: �J -
Elect ❑
Job Description:
Residential Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
(' EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
Community Development
10300 Torre Avenue
7 kw
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
-UPEkTINO
Buildin r Department
JOB ADDRESS: 2� �v � PERMIT,#?a OWNER'SNAME: f C1C l PHONE #
GENERAL CONTRACTOR Utft Y? FAX #
I am not using any subcontractors:
Signat ire Date
Please check applicable subcontractors and com lete the following information:
SUBCONTRACTOR BUSINES S 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
Till
or
Owner/Contractor Si a Date