06100186 CITY OF CUPERTINO
BUILDING DIVISION PERMIT +e0�tt RMATI�N.
BUILDING ADDRESS: PERMIT NO.06100186
10201 N DE ANZA BLVD
PERMIT ISSUE DATE
OWNER'S NAME:
GRANLIM PARTNERS GEMY 10/26/2006
SANITARY NO. CONTROL NO.
jNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is COMMERCIAL LINE CLEAN OUT
?�H in full force and effect (01
8
Z License lass Lic.#
t iv Datc Contractor &A Ilk 1 iyt��(-LS'f
ARCHITECTS DECLARATION
2 cot'U-'t I understand my plans shall he used as public records
)y
Oy Licensed Professional
n OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
<$ 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 $ Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
sea 7200
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
L 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 APN Number Occupancy Type
not more than five hundred dollars(E500).
❑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 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.).
❑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 In-
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 Contractofs
License Law.
❑1 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:
❑1 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 F v
work for which this permit is issued.
❑1 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 Worker's Com ens n Insurance carrier and Policy number are:
A�/ n
Cartier. S tJ�'1`C W u N% Policy No.:I' 06 0 5/0
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 this permit is issued,1 shall not U
employ any person in any manner so as to become subject to the Workers'Compensation OU
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
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
E~..n her 1 hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097.Civ.C.)
W ALender's Name
az Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL H correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
G1 (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. �— G
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ^ 2
SO E REGULAytONS.
,,JL r fns 0_ Re-roofs
Signature of Applicant/Contractor Dae Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yp
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.
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑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 urrently have a tenant,that it is my responsibility to notify the occupant of the
rcqui is which must t prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
be
0A 14- All roof coverings to be Class 'B or better
O ner or authorized agent Date
CITY OF CUPERTINO
t'm 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN 32634070 . 00
DATE ISSUED. . . . . . . : 10/26/2006
RECEIPT # . . . . . . . . . 36572
REFERENCE ID # 06100186
SITE ADDRESS . . . . . : 10201 N DE ANZA BLVD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . : GRAFLIM PARTNERS GEMY
ADDRESS . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : RENE LIMA
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . .
ADDRESS .
CITY/STATE/ZIP ,
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- ------ - --- ------ - -------- -
BPSEWER SEWER SYSTEM 1 . 00 21 . 58 0 . 00 21 . 58 0 . 00
BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 --- - -38_37 -- - ---0_00
- ---- - - --- -- - - - - - -- -
TOTAL PERMIT 164 . 95 0 . 00 164 . 95 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - - - -- - --- - ---- - -- ----- - - --- ---- ----
CASH 164 . 95
TOTAL RECEIPT 164 . 95
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 507 FINAL PLUMBING
CITY OF CUPERTINO 0(01001 S�j
REPIPE/S ERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN # �aW -s4- V ! Djte:/
Building Address: „� r ^ j
Owner's Name: Phone#:
Contractor: Phone: License #: 9 }
Contact: Phone: Cupertino Business License#:
t, ie7 L \A0,� 8 S_
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ,
Job Description:
Residential ❑ Commercial 2]
Cost of Project:
LC�
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers x PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING