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06100036rQ0 2ZtVit �Qy t: LU �C4a C4 �yU 4, F- :Qy v7 -1 �CQ <�W V^w -?< Fcc- i5� BUILDING DIVISION PERMIT BUILDING ADDRESS: 20650 VALLEY GREEN DR OWNER'S NAME: APPLEC INE: ARCHITECTIENGINEER: 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect IQ License ClLic. at v Date Contractor p ARCHITECTS DECLARATION 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the 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 prior to its issuance, also requires the applicant for such permit to rile a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (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 not more than five hundred dollars (5500). ❑ 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 and Professions Code: The Contractor's 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.). ❑ I, 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 themon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractofs License Law. ❑ I am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION �z 0 zN W? a Q az U 0 w F, OU Uz I hereby affirm under penalty of perjury one of the following declarations: ] I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- tion, as provided for by Section 3700 of the tabor Code, for the performance of the ork for which this permit is issued. ] I have and will maintain Worker's Compensation Insurance, as required by Section 700 of the Labor Code, for the performance of the work for which this permit is issued. ly Worker'g Compensation Insurance carrier and Policy no be �� - - ,� R artier: PolicyNo.: (A C E OF TONT INSURANCE WORKERS' 717-M L1q�Q (This section treed not be completed if the permit is for one hundred dollars/i!(S 1 '00)) r less.) certify that in the performance of the work for which this permit is issued, I shall not mploy any person in any manner so as to become subject to the Workcrs' Compensation aws of California. Date Lpplicant IOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should ccome subject to the Worker's Compensation provisions of the Labor Code, you must arthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of he work for which this permit is issued (See. 3097. Civ. C.) .endcr's Name tender's Address 1 certify that I have read this application and state that the above information is :orect. I agree to comply with all city and county ordinances and state laws relating to wilding 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 liabilities, judgments, costs and expenses which may in any way accrue against said City in consequen of the granting of this permit. APPLI UNDER NDS AND WILL COMPLY WITH ALL NON -POINT SO EGUL O signuure of XPPIicam&om5Actor Date HAZO&DOUS MATERIALS DISCLOSURE 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)? �, /`, ❑ Yes bk 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 District? ❑ Yes )<No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safcty Codc, Sections 25505, 25533 and 25534.1 understand that if the building does not curren ly, ave a tena�{. that it is my responsibility to notify the occupant of due revuiremen h must yC;Nrior to issuance of a Certificate of Occupancy. Owner or IN ELECTRIC INC. I PERMIT NO. 06100036 (408) 286-2800 PERMIT ISSUE DATE SANITARY NO. CONTROL NO. Job Description BUILDING PERMIT INFO BLDG ELECT PLUMB INSTALL TEMPORARY BACK UP GENERATOR Sq. Ft. Floor Area Required Inspections Issued by: Re -roofs Type of Roof r Occupancy Type Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better Ciro of CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM YN # 7 Date: 7/�, 6// Building Address: Mailing Address (if different from building address): cA qEoitl Fee Group MECHANICAL Owner's Name: Phone #: `f08—g7 - 3S06 Contractor: --6,7 License #: Contact, Phone: x%47 ( Y 1 1 Cupertino Business License#: �, Fax: l 0 s,3Y Building Permit Info: S'ta-U �em�� "� 6c,-Jet---^erez*0r-. Bldg Elect E Plumb ❑ Mech ❑ Job Description:/'S ^^AA Residential ❑ It k u �0�_k U� Commercial Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: �. Type of Constructions1 Please check this box if the project is a 11 G� c,7 r ,�a a , :Ie � � � ✓� second-storyaddition: Construction Tax BUILDING roject Size: Standard ED/ Large ❑ Major ❑ Ind/Off/Comm/Quasi Quantity Fee ID BAPPLOTHER Fee Description Other Appliances Fee Group MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 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 Constax — Resi/Mobile BUILDING BELEC 1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3