09020072 CITY OF CUPERTINO
BUILDING DIVISION PERMITC1T � 3It � 'I�1 �
BUILDING ADDRESS: PERMIT NO.
10053 BRET AyF OMEGA
OWNER'S NAME: PERMIT ISSUE DATE
^vp A CONTROL NO.
408) 24.3-0404
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
O p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Dom' n 3 of thc Business anCd ProCcssions Code my license is
7 y in full force and ellectls..� '� 200 AMP COMM'L C I RCT PANL W/12 KW CONSTNT POWR
Z License Cl "�'-, Lic.M
-�G DateContractor CAPCTY
—ARCHITECTS DECLARATI N
I understand my plans shall be used as public records
�dU
`Q y Licensed Professional
n 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
C p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.,--9 which requires a permit to construct.alter,improve,demolish,or repair any structure
y Z prior to its issuance,also requires the applicant for such permit to role a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 3q.Ft.Floor Area Valuation
yF (commencing with Section 7000)of Division 3 of ahc Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of $2500
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(5500).
❑1,as owner of the property,or my employees with wages az their sole compensation, 3 7 5110 2 ) . 00
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q ns 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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors 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.
❑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:
I have and will maintain a Certificate of Conscnt to self-insure for Workcrs 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 on pe�naadgn��bra mace rricr and Policy number are:
Cartier. CSL \ Polity No
Carrier
OF EXEMPTION FR,9M 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,I shall not
employ any person in any manner so as to become subject to the Workcrs'Compcnsadon
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 0 forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
[~-h 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
A Lender's Name
a Lenders Address
U 0 1 certify that I have rad this application and state that the above information is
w correct.I agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby authorial representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit.
►' APPLICANT UNDERSTAN ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION . f /
Re-roofs
Signature of Applicant/Contractor Date ` f
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ✓/
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installe .
❑Yes 44o
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
it hazardous air contamiaz defined by the Bay Area Air Quality Managcmern all new maerials for inspection.
,trict?
❑Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if dhc building
docs not currently have a tenant,that itis my responsi '' to notify the occupant M the
requirements which must be met prior to iss o a ccrtinc� of Occupancy. Signature of Applicant Date
Owner or authorized agent Date
All roof coverings to be Class'W'or better
ULCITY OF I-UPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #
2� -7 -15) ( ( � 01 6 " Date: C -2
Building Address: ' 0 0 -3 � E,T
-
Mailing Address (if different from building address):
Owner's Name: D A[ ,l A , 1 V ENKA-tFAHMPhone #: l ��
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contract
or: Phone: �-—C_.
C �-- Lk C Fax:
Contractor License#: B q C
Cupertino Business License#:
Contact: (iPhone:
Residentia Commercial Fax:
Job Description:
I ,
Building Permit Info:
Bldg ❑ Elect VPlumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B []5 " - 3
Valuation: n t�-, Cq G C) Square Footage:
1
Project Size: Express ❑ Standard ❑ Large [] Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.or
Revised 02/05/09
CITY OF 41UPERTINO
CITY of GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1 GENCOM
1 STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 3 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alcne Electric Pln Ck (hourly) E
1MECPLNCK Stand Alcne Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alcne Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Man Check (when no E/M/P) B
when not over counter) hourly-stz nd alone
1 BCBSC Cal Bldg '31tandards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
t� 1 BSEISMICO Seismic Commercial B
1TRAVDOC Travel & Documentation B
1BUSLIC Business .'-icense B
of 5
Community Development
F 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`'UPEI�TINO
Building Department
JOB ADDRESS: PERMIT # 0
2-E �-
OWNER'S NAME: PHONE #
GENERAL CONTRACT FAX # —Z
I am not using any subcontractors: l O
Signature' Date
Please check apphcable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS 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 Roc
Tile
Owner/Contractor Signature Date