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ARCHITEC IENGINEER:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions dc, and my license is
n full force and effect. 66� '�, +' �� j✓ S
License CI s Luc.
DateContractor
RCH1 ECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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 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 arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
I, as owner of the property, or my employees with wages as their sok 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 dors 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
sate.).
[11. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contrames 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 mason
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 -b sum for Workces 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
1700 of the Labor Code, for the performance of the work for which this permit is issued.
Ay Worker's Compensation Insurance carrier and Policy number am:
-arrier. Policy NO.: �q
Is _4
CRTTION
FROM WORKERS'
COMPENSATION INSURANCE
(Ibis 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. 1 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
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
Lendees Address
1 certify that I have read this application and stare that the above information is
correcL I 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 pe 'L
APPLICANT U, DERSTANDS AND LL COMPLY WITH ALL NON -POINT
SOURCEREG(1 A ONS.
Signatureof A'ir NContracto Date
HAZARDOUS MATERbialbISCLOSURE
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)? i
O Yes 1014.
Will the applicant or future building occupant use equipment or devices which
tit hazardous air contaminants as defined by the Bay Area Air Quality Management
strict?
❑ Yes Q do
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
docs not currently have a tenant at it is my responsibility to notify the occupant of the
requirements ch in
be e p 'or to issuance of a Certificate of Occupcy.
rid
Owner or authorized agent Date
UPGRADE_ PANEL ELECTRICAL I
PANEL TO 200A REPLA"Description
V SgKct C"-1, 6r\1
Issued i
Re -roof
Type of Roof
Sq. Ft. Floor Area
APN
Required Inspections
uccupancy type
All roo.'s 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
All roof coverings to be Class'%" or better
Date
1
CITY OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
nqoaDov
APN #36
Date:
Building Address:
Mailing Address (if ftom building address;:
/ TA -71E
' `�j` ,Q T� 1 S4 (i{I�i
I /
A-1- 61430'3rT (�
Owner's Name:U h� _ W , —jot,
Phone #: �6 > _ 16"
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: -ro M y .-rAV,;
Phone:
C
Fax:
Contractor License #: c c `f d
Cupertino Business License #:
Contact:--
Phone: `; ..2,
Fax:
Residential ❑ Commercial ❑
-�
Ai�F'
Job Description. `
Building Permit Info:
Bldg ❑ Elect Lam-
Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B �– --3
Valuation: V
Square Footage:
% - i C
Project Size: Express and ❑ Larg ,- ❑ Major ❑
Green Building: Please complete relevant portio a 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.builditreen.or
Revised 02/05/09
aRt",
CITY OF
CUPEt�TiNO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1 STUCOAP
Stucco Applications (up to 400 sf)
additionz.l stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows)
B
1 WINMEWSTR
New Wij idow- structural shear
wall/masonry (includes plan ck fee)
B
J
1 EPERMITFEE
Electrical Permit Fee
E
1 MPERMITFEE
Mechani gal Permit Fee
M
1 PPERMITFEE
Plumbin,; Permit Fee
P
1 ELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
IPLMBLNCK
Stand Alone Plumbing Pln Ck (hrly)
P
I STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourly-s•:and alone
B
1 BCBSC
Cal Bld€, Standards Commission Fee
B
ALL PERMIT
TYPES
/
1 BSEISMICR
Seismic Residential
B
1 BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
1BUSLIC
Business; License
B
F- ?-7k- `,� 0 0 1 I,-
5 of 5
kM
C17Y OF
'.UPEkTIN0
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: PERMIT #
20g0Z 1)L4k, QYUtherlf"k\4 GA 1'�)) Y en[ 020��
OWNER'S NAME: PHONE #(4-q) e� 0 3 —707 2 --
GENERAL CONTRACTOR: -7"k' A7v'z; C AX #
I am not using any subcontractors: �i 6
Sid nate~ Date
Please check armlicable subcontractors and corn lete the following information:
Owner/ Contractor Signature
Date
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 Rock
Tile
Owner/ Contractor Signature
Date