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09020054 CITY OF CUPERTINO BUILDING DIVISION PERMIT ' � ` .. . PERMIT NO. BUILDING ADDRESS: 22445 CUPERTINO RD PArTFTC PERbII'1'ISSUE DATE OWNER'S NAME. I19GEIR AVE CONTROL NO. PHO 408) 45:-8633 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH 0 me C LICENSED CONTRACTOR'S DECLARATION Job Description v C I hereby off am licensed under provisions of Chapter 9(commencing Z ut with Section 7000f1u 3 of the Business and Professions Code.and my license is RE P I P E l,OR 15 UNITS, 1-15 y in full force and t q11�C o t erg Z License Class Contractor" �,p Date ARCHIT'ECT'S DECLARATION ee9I understand my plans shall be used as public records ? U `IL H Licensed Professional y 0 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county ym Pi which requires a permit to construct alter•improve,demolish,or repair any structure 14 prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation C that he is licensed pursuant to the provisions of the Contractor's License Taw(Chapter 9 Sq F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or880000 ythe alleged exemption.Any violation of that he is exempt therefrom and the basis for APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mots than five hundred dollars(5500). 32615013 . 02 ❑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 oroffered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractors 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.). ❑1,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 docs 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. ❑I 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 Consent to self-insure Cor 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. ❑I 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 CompensaU I carrier and Policy nurm'bTer�are: Carrier C 7 O Policy No.: y V C /i CERTIFICATE F XEMPTION 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,I shall not employ any person in any manner so as to become subject to the Workers'Compensation 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY H►N. I hereby affirm that there is a construction lending agency for the performance of �i the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lenders Name z Lenders Address U O 1 certify that I have read this application and state that the above information is LL cormcL I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes a (We)agree to save,indemnify and keep harmless the City of Cupertino against F.c C/I 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 UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b3: Date SO RCE GU AMON . 1 Re-roofs ` — Signature of licant/Contracter Date 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 bein installed. C]Yes eNo If a roof is installed without first obtaining an inspection,I arae-to-reiTove Will the applicant or future building occupant use equipment or devices which lit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection. trict? ❑YesIu 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 currently have a tenant that it is my responsibility to notify the Occupant of the requiremen whit: mast be m Prio to issuance of a Certificate of Occupang Signature•of Applicant Date L All roof coverings to be Class'"or better Owner or au u orized agent Date CITY OF CUPERTINO REPIPE/SEWERIMAIN SERVICE CUFEkT1NO PERMIT APPLICATION FORM APN # Date: c2/it 09. Building Address: cpqws O er's Name: - Phone#O 66� -S�© hr Lqf C ctor: - Phone#: U - Q rJ; 1 Fax#: 1J08 Contact: U Phone#: !10$ c9`(411ZQ J- () n /&M uxl-1 /, Fax#: Contractor License#: 7c46 9'1(p Cupertino Business License #: Dpa t40 n Job Description: T 60, 13 I5rrnifs Z c4 (? 1 Residential ❑ Commercial Valuation: 000 . • Project Size: Express ❑ Standard ❑ Large [ Major❑ Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points: Quantity Fee ID Fee Descripti,3n Fee Permit Type Group IPCSEWER Commercial bui'ding P ICPSS sewer/sanitary sewer IBP PIPE Commercial re-pipe per fixture P 1CPRP I PGASCOM Commercial Ga,,.Piping System P 1-4 Outlets IBCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES IBSEISMICOM Seismic Commercial P Revised 01/07/09 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 f'UPEkTINO Building Department JOB ADDRESS: PERMIT #09 n Zoo . 2t!`l f— C&06-2-r1A11r A D CC/pa9.149 OWNER'S NAME:Sv n n t/ Q i N-/ M0. 60 h PHONE # ;V GENERAL CONTRACTOR: FAX # I am not using any subcontractors: �'®c1 ptt �GG� 1 l Loo Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSI14ESS 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 Tile Owner/Contractor Signature Date