09020062 CITY OF CUPERTINO �n T
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMrr NO.
7495 PROSPECT RD AZTEKA BUILDERS
OWNER'S NAME: PERMIT L95UE DATE
.,ONE. SIAA CONTROL NO.
(707) - 10-0377
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 a a
o c LICENSED CONTRACT'OR'S DECLARATION Job Description
m I hereby affirm.hat 1 am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
in full force andeft _- '� 3 �. RPLC P1.TI0 DOR W/4FT GARDEN WNDW & REPLC SIDING
License C Lic-f►
y�.o Date — Contractor z asy/ W/S TUC C:O
pRCHITECrS DECLARATION
I understand my plans shall be used as public records
�C6
U. Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Conuactoes License Law for the
Ofollowing 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
n Z} prior to its issuance,also requires the applicant for such permit to file a signed statement
F=e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yF-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 1 O O 0
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 APN Number Occupancy Type
not more than five hundred dollars(5500). 3 6 615 0 3 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do die work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law docs not apply to an owner of q 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contracoes 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 contractors
License Law.
❑I am exempt under Sec. B&P C for this mason
Owner Date
WORKERS 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 for Workers Compcn-
.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 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 Compensation Insurance carrier and Polity number arc:
Carrier; Policy No.:
CERTIFICATE 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 th}a�ncr so as obcctlmo�thbj '�! 'Compensation
Laws of California.
Applicant
NOTICE TO APP ANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z. CONSTRUCTION LENDING AGENCY
[~i 1 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.)
QLenders Name
►7 z Lenders Address
V 0 1 certify that I have read this application and state that the above information is
lL" correct.I agree to comply with all city and county ordinances and state laws relating to
0 above-mcntoncd property for inspection purposes.
V building construction,and hereby authorize representatives of this city o enter upon the
C W
a (Vire)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs rases which may in any way accrue against said City
U Z in consequence of the ryttin this permit.
" APPLICANT UN STA DS AND WILL COMPLY WITH ALL NON-POINT Issued br': Date �-2
SOURCE REGVEATIONS.
Re-roofs -
Signatur,o Applicant/Conwactor Date
�� HAZARDOUS MATERIALS DISCLOSURE Type of]roof
Will the applicant or future building occupant store or handle hazardous material j
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety 2
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing m erial being installed.
❑YesNo
Will the applicant or future building occupant sex equipment or devices which
If a roof is installed without first obtaining an inspec 'on,I ag� e to re ove
nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r Iaterials for inspection.
District? J
C]Yes ♦'Irl No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safely Codc,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
require ts whi nt0st be m t rinr .S once of a Certificate er I upanft.app? Signaturc of Applicant Date
Owner
! ao)VAAtttherized agent ��� /V Y a/�D All roof coverings to be Class" `r or better
,( -(t2
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CITY OF CUPERTINO
CITY Of
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # �� (� � � � � Date:
Building Address:
Wr9s P pOs-p E C7- k s ; Cu PC K T SL), 64)- -94�D l Lt
Mailing Address (if different from building address):
Owner's Name: sly I U j YN 6t)?A�N Phone#: �r'1 p
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: Phone: -01 — 003 - oZ898
j— 7— 1 enc 0 � VlldffS Fax: U 1 _ Ll-1 q -5,
Contractor License#: el7a 7 3 U
Cupertino B sines License #•
Contact: a U V0 i Phone: 6�} - 803 - Z
Fax:
Residential Commercial ❑
Job Description: � �
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W( N�*W P_ePV1 S1�( r��`STU«
BuildingPermit Info:
Bldg E / Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B [�
Valuation:/ Square Footage:
b�
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.builditreen.or
Revised 02/05/09
CITY OF C-.UPERTINO
CU
CITY
OF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/mas,)nry(includes plan ck fee)
1 EPERMITFEE Electrics: Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand AI)ne Electric Pln Ck (hourly) E
1 MECPLNCK Stand Al ane Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Al ane Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
J 1 BSEISMICR Seismic Ptesidential B
1BSEISMICO Seismic '—ommercial B
1 TRAVDOC Travel &:Documentation B
1BUSLIC Business License B
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Assessor's Parcel Number:
Name of owner. R1V I I F't-�JA O P-1 r1,)-J
Project address. 7z-i-q.- pgoSp&cr a , CfJPr/-:RT/sU,9 (/-p7L
Contact person. G-A UR D PI Lone. �F d
Fix.
Net square footage of lot.
/ l� ExistingProposed U
Square footage: First floor: 16 � u r t4'-w8 ��r'I 1)ih Vx1 "l
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces in3ide the garage? Y N
privacy protection planting required for the project? Y
On what floor(s) is work being done?
Brie description of wor � � � ore- �� o , o r
<le-lalle or ✓ C
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Code editions:2008 CBC -N)2008 CFC -N)2008 CMC (Y-N)
2008 CPC N)2008 NEC N)
Effective 1/1/08
Plan Review Process Work Book Page-B-Revised 1/1/08
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