09020051CITY OF CUPEKYINU
BUILDING DIVISION PERMIT
BU}EDING ADDRESS:
20183 NORTHCREST SO
OWNER'S NAME:
O
ARCHITECT/ENGINEER:
app LICENSED CONTRACTOR'S DECLARATION
1 v Ct hereby affirm that I am licensed under provisions of Chapter 9 (commencing
R with Section 7000) of Division 3 of dtc Business and Professions Code, and my license is
n = y in full fora and ef�A6rs
=
v� Z License ClassLam• x
F, a DateConuanor
DECLARATI N
1 understand my plans shall be used as public records
�yU
4 O H Licensed Professional
OWNER -BUILDER DECLARATION
n I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following mason. (Section 7031.5, Business and Professions Code: Any city or county
e m ii 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
Z < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
v1-- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not more than five hundred dollars (5500).
❑ 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 or offered for sale (Sec. 7044, 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 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 Contractor's 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.
❑ I am exempt under Sec. B dt P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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I have and will maintain a Certificate of Consem to self -insure for Worker's Compen-
,ation, 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 Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workefs Compensation Insurance carrier and Polity number are:
Cartier. NakWM4 4%0 Policy No.: r • Do Ct_o. of
ERTIFICATE OF EXEMPTION 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
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
Lender's Address
I certify that I 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
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 accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR �EGGLA ONS. I
y 10 , / a
re of Applia
Signatunt/Con tor t
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)?
❑ Yes 10 No
Will the applicant or future building occupant use equipment or devices which
t hazardous air contaminants as defined by the Bay Area Air Quality Management
arict?
❑ Yes JN.
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k Safety Code, Sections 25505,25533 and 25534. 1 understand that if the building
does not curreRtiy have a tenant, that it is my responsibility to notify the occupant of the
requ' KCntnts which must )t met prior to issuance of a Certificate of Occupancy.
I YLo f.9
0 or authonzed agent 1 Date
A
FURNC RPLCMNT
Issued b
Re -roof
Type of
. Ft. Floor Area
umber
PERMIT NO.
PERMIT ISSUE DATE
SA CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
Required Inspections
Occupancy Type
All roofs 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 'W' or better
Date
U� 0a01--��Z
CITY OF CUPERTINO
WATER HEATER
CUPEI�TINO PERMIT APPLICATION FORM
APN_5# / � � .-7 ��
Date: 10 200'
Building Address:
2 a /d 3 N o r-�kC rt s+ CA '?"6L
Owner's Name:
Phone #:
C,Ntrl •c .Sw�
4d 9) o Y?2,&-
Contractor: R f A (rLt w w-",
Phone #: 4 (71. 7_3S. it 7d
(mike For )
Fax #:
Cupertino Business License #:
Contractor State License #:
BO (3 Z3
Contact:
Phone #:
Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Residential Commercial ❑
Job Description:
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation (cost of project): !� (-Stu --
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 achieved:
Revised 01/07/09
CITY OF CUPERTINO
WATER HEATER
CUPER,TINO PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee
Group
Permit Type
1 PCWHEATR
Commercial Water
HeaterNent
B
PCWHEATR
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT TYPES
1BSEISMICOM
Seismic Commercial
B
1PRWHEATR
Residentia. Water
HeaterNent
B
PRWHEATR
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT TYPES
1BSEISMICRE
Seismic Residential
B
1 PPERMITFEE
Plumbing Permit
P
1 TRAVDOC
Travel &
Documentation
B
1 BUSLIC
Business License
B