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09020047 CITY OF CUPERTINO ` " BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 22445 rTTPF.RTINO PA IFI FL BI pERMn`ISSUE DATE OWNER'S NAME: , A CONTROL NO. 40 (408) 452-.8633 BUILDING PERMIT INFO BLS ELECT� PLUMB� ARCHITECTfENGINEER: a ce C LICENSED CONTRACTOR'S DECLARATION Job Description U1 hereby affirm that I am licensed under provisions of Chapter 9(commencing RE—PIPE -DOMESTIC WATER E with Section 7000)of Division 3 of the Business and professions Code,and my license is y in full force and Lie S 3 v�Z Licen Cas Comtraetor Date ARCHITECTS DECLARATION ee I understand my plans shall be used as public records D UJ y O I- Licensed Professional OWNER-BUILDER DECLARATION a}3 I hereby affirm that I am exempt from the Contractor's License Law for the p O following mason•(Section 7031.5,Business and Professions Cale:Any city or county Valuation m which requires a permit to construe alter,improve,demolish,or repair any structure =APNNumber rea v"9 prior to its issuance,also requires the applicant for such permit to file a signed statement =[ - e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3 5 0 0 0 ° (commencing with Section 7000)of Division 3 of the Business and Professions Code)or Occupancy Type y 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 3261501-- . 0 2 not more than five hundred dollars(5500)• ❑[ss owner o[the property.a my employees with wages as their sole compensation, Required Inspections will do the work.and the structure is not intended or offered for sale(Sec.7041•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 oro lotion for the owner. however,the building or improvement is sold within one year P 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 ho Codelds or improves thereon.Li cense Caw does not apply to an owner of property who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. B&P C for this reason 1 am exempt under Sec. Date�-- Owner WORKER'S COMPENSATION DECLARAIT 1 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- ..ion,as provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit is issued. required by Section 0 1 have and will maintain Worker's Compensation Insurance,as req 3700 of the Labor Code•for the performanrricof and policy the work f number are. permit is issued MyWorkees ompen_satlnInsll�a�rj O .ryeucit. ' Carrier: !6j 3 (� 7 policy No.:f •" `nth SZ CER'►'1FICAo OF ExEm N ONINSRFROM WORKERS ' (This section need not be completed if the permit is for one hundred dollars($100) or less.) I rens.)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 s �he hedeemLab CoCadeayou must ,J Z forthwith comply with such provisions or this pe Z� CONSTRUCTION LENDING AGENCY for the performance of H�.. I hereby affirm that there is a construction lending agency Ix> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name 04 Lender's Address U I certify that]have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to u E building construction,and hereby authorize representatives of this city to enter upon the O Uabove-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 Date d rA U'Z in consequence of the granting of this permit. P, APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued f ly: S70 ;CJRE oxs. Ap f 00 Re-roofsSignaturelicanl ontractor °"� Type of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous in as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety All roofs shall be inspected prior to any roofing in being installed. Code,Section 25532(a)? L' C]Yes Lam° If a roof is installed without first obtaining an inspection, agree o remove Will the applicant orjn.. re ntbuild' g occupant use equipment or devices which all new materials for inspection. lit hazardous air coaminnod by the Bay Area Air Quality Management strict? 0Yes []No 1 have read the hazardous materials requirements under Chapter 6.95 a(the Califor- niaHealth&Sa.ctyCodc,Sccuons 25505.25533 and X34`lutonndrrstfn uParbtiadhe Date docs not currently have a tenant.drat it is my res ty Signat ire of Applicant requirements w ch m be met pryr t°iss re°f a ce"ir"te°f°"°per'• All roof coverings to be Class' "or better Owner or authori agent �/ CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE VCWITOCUPER,�TINO PERMIT APPLICATION FORM APN #3A(P r D-1)13 - 3 . C)LA Date: Building Address: q ys CU iint� apd,—Ccs Owner's Name: Phone #: 5 unn�� ►'�l CtA'lUl� qDt'`�S�-S(oC�� Con ctor: Phone #: qD8 95(-'Wz0 Contact: � U Phone#: 1.� .69(f I/� JOSAph &C `u)a • Fax#: y' Contractor License#: -7 q S 9--7U Cupertino Business License #: Job Description:��i'� � •��a,�` ��. Residential [� Commercial ❑ Valuation:, Project Size: Express ❑ Standard ❑ Large I] 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: ��TT Quantity Fee ID Fee Description Fee Permit Type Group IPCSEWER Commercial building P 1CPSS sewer/sanitary sewer IBPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09