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09020085CITY OF CUPERTINU BUILDIN r, DIVISION PERMIT BUILDING ADDRESS: OWNER'S NAME: ARCHriECT/ENGINEER: I 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. License Class Lie. 8 Date Contractor 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 Contractors 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 file 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). ❑ 1, 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 Contactors 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 sakJ as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code:) The Contractors u - 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 Contractors License Law. ❑ [ am exem undeESec - , B & P C for This on Ownerall& Date WORKER'S COMPENSATION DECLARATION 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 Workers Compen- ,on, as provided for by Section 3700 of the Labor Code, for the performance of the 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 Workers Compensation Insurance carrier and Policy number arc: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section teed not be completed if the permit is for one hundred dollars (S 100) or less.) I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner ofpe subject to the Workers' Compensadon Laws of Caliro Applicant AAO d &94r NOTICE TO A0PLIdANT. If, atter making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith 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 the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lenders Address I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building 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 scenic against said City in consequence of the granting of this permit. APPLICANT UNDERSTA SAND WILL COMPLY WITH ALL NON -POINT SOURCE EG INS C Signatu o Applicant/Contractor I Dati HAZARDOUS 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)? ��.,,,////// C] Yes pO_ No Will the applicant or future building occupant use equipment or devices which i hazardous air contaminants as defined by the Bay Area Air Quality Management ..rict? `l ❑ Yes No 1 have read the harardouss materials requirements under Chapter 6.95 of the Califor- nia Health & Safcty Code, Sections 25505, 25533 and 25534.1 understand that if the building docs not currently have a en L. that It is my responsibility m notify the occupant of the rcyuirem�/,ts which must be et prior tom oC a Certificate of Occupancy. SERVICE 408)377-050 PERMIT NO. PERMIT ISSUE DATE CONTROL NO. BUILDING PERMIT INFO ELECT PLUMB MECH Job Description FILL IN POOL W CRSHD RCK&SOIL Ft. Floor Area 31633090.00 Issued by Re -roofs Valuation Occupancy Type Required Inspections Type of F.00f All roofs shall be inspected prior to any roofing material being installed. If a roof I's installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant All roof coverings to be Class 'W' or better Date 0q c) --2-, 0o es CITY OF CUPERTINO DEMO CUPEkTINO PERMIT APPLICATION FORM APN# 3!(P 3 3 0 g O.12-1) v Date: Building Address: ac»9s A pLe C -k �isG Mailing Address (if different from building address): Owner's Nam Phone: N►A�P-%A,k r.1. ►a- a�� B k� -� �tZ►ty� �>Z s Aa- 1a-Contractor: Contractor:Aco 6(-u I'l W g V -0-C+0 C;l�v'ViG 11C. U Phone: (4o 6 37lf—65 C,) - B Fax: q o %) 31 ? — cl Contractor License #: 3o a- r7 3 Cupertino Business License #: 3( 0 Contact: Phone: ALL PERMIT TYPES 1BSEISMICRE Fax: Residential�C] Sq Footage iq Commercial ❑ Sq Footage Job Description: 7- % LL 14 `loco k- 014 c k- Valuation: t � 3 JLC , o 0 Project Size: Express ❑ Standard ® Large ❑ Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-RE;sidential B 1SFDWL-DEM 1DEMOPRES Pool Demo Residential B 1SFP00L-DEM / 1BCBSC Cal Bldg, Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09 otal Available Points in Specific Categories' I I 4+ 96+ 42+ 66+ 43+ Mir imum Points Required in Speck Categories Ij-jl 0 30 5 6 9 ` Project has not yet met the following recommended minimum requirements:��- Total Project Score of At Least 50 Points Required measures: -A3a: 50% waste diversion by weight v -12: 15% above Title 24 -N1: Incorporate GreenPoint Rated Checklist into blueprints r Minimum points in specific categories: -Energy (30 points) r-fAQ/Nealth (5 points) -Resources (6 points) -Water (9 points) 0 2007 Build It Green Single Family Gn enPoint Checklist 2007 Version Page 7 of 7 .• PROJECT g y u v W d r c U � C Enter description here, and enter points available for measure in appropriate categories to the righ. 0 0 0 0 0 0 Enter desorption here, and enter points available hr measure in appropriate categories Io Bre righ. 0 0 0 0 0 0 Enter description here, and enter points available for measure In appropriate categories to On ngh. 0 0 0 0 0 Enter descrcation here, and enter points available for measure in appropriate categories to the ngh. 0 0 0 0 0 0 4. Innovation: List innovative measures that meet the green building obiectives of the Guidelines. Enter up to a Build It Guidelines Green Checklists and maximum combined total of 20 pts. See Innovation Checklist for suggested measures, using the link to the right. 0 0 r 0 OI _ 0� 0 _ 0 0 0 0 0� 0 _ 0 TO 0 0 0 0 _ 0 0 0 0 0 _. Oi 0 Innovation In Community: Enter description here, and enter points available for measure in appre viate categories to the righL 0 �0 Innovation In Energy: Enter description here, and enter points available for measure In appropriati, categories to the right Innovation In IAQ%eafth: Enter description here, and enter points available for measure in appm{ riate categories to the right 0 YO Innovation In Resources : Enter description here, and enter points available for measure In appm rrlete categories to the right Innovation In Water: Enter description here, and enter points available for measure In appropriate categories to the right 0 Total Available Points in Other = 4 0 otal Available Points in Specific Categories' I I 4+ 96+ 42+ 66+ 43+ Mir imum Points Required in Speck Categories Ij-jl 0 30 5 6 9 ` Project has not yet met the following recommended minimum requirements:��- Total Project Score of At Least 50 Points Required measures: -A3a: 50% waste diversion by weight v -12: 15% above Title 24 -N1: Incorporate GreenPoint Rated Checklist into blueprints r Minimum points in specific categories: -Energy (30 points) r-fAQ/Nealth (5 points) -Resources (6 points) -Water (9 points) 0 2007 Build It Green Single Family Gn enPoint Checklist 2007 Version Page 7 of 7 CITY OF 47UPEI�TINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: PERMIT # 0q O,� dc>ff.�o /206 t5-6-. (mac , OWNER'S NAME: PHONE # D GENERAL CONTRACT( l 1,41- 10 - , in r,4 FAX # I am not using any subcontractors: Si mature Please check applicable subcontractors and corr Clete the following information: Date r Owner/ Contractor Signature bate SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavatione r �, a (Smi n a.3 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 r Owner/ Contractor Signature bate