09020084 CITY OF CUPERTINO
BUILDING DIVISION PERMIT2n
BUILDING ADDRESS: PERMIT NO.
10362 SAN FERNANDO AVE
OWNER'S NAME: CONST Pl]FFMIT M'UE DATE
AVE NR A CONTROL NO.
-x-10 :
408) 379-3010
BUILDING PERMITiNFO
ARCHriECT/ENGINEER:
ELECT PLUMB METH
BLDG
0 0
u O 0 LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
2 m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'may in full foraandeffect CONN RES TO SANTRY SEWR SYS; SEPTIC TANK
j Z Ucensc Gaza Lle• d
F a Date contractor ABATEMENT
CHiTECTS DECLARATION
< I understand my plans shall be used as public records
D 0.
U
io H Licensed Professional
rn 3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y.� which requires a permit to construct,alter.improve,demolish,or repair any structure
_ prior w its issuance,also requires the applicant for such permit to file a signed statement Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
t= (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
89500
ERE
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 eve hundred dollars(5500). 35712024 . 00
[:11.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 Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of q 1)
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 Contractor's Li-
cense Law does not apply to an owner of property who builds or improves themon,and. R
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. .B&P C for this reason
Owner Date ,AN TAR
WORKER OMPENSATION DECLARATION
I hereby affirm under penalt of perjury one of the following declarations:
I have and will maintain a Ccrtifica of Conscnt to self-insure for Worker's Compen-
.ation,as provided for by Section 3700 the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Worker's Compensation Insurance carrier and Policy number are:
Carrier. 4fa"p"TA1'C` Q1141:10 Policy No.:d 0 M-1%9 y^Z �r
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,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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z t CONSTRUCTION LENDING AGENCY
Fr►�-� I hereby affirm that Utero is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Z Lender's Address
U C) I certify that 1 have read this application and state that the above information is
GL t"c correct.I agree to comply with all city and county ordinances and state laws relating to
O Vbuilding construction,and hereby authorim 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
„Hy t4 iiabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b�': Date
SOURCE REGULATIONS. J
%z2,. eilevw,.r. m Re-roofs G7
Signature of Applicant/Contractor are T Of]roof
HAZARDOUS MATERIALS DISCLOSURE Type
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 being installed.
❑Yes
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
.Strict?
❑Yes N
1 havc read the hamrdtws 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
requirements which must be met 'or to issuance of a Certificate of Occup ey. Signaturc of Applicant Date
�n�it/nlww 2- ' (of All roof coverings to be Class" "or better
Owner or authoZed agent
Date
.,-)q c)6� 0 C4
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEF�TINO PERMIT APPLICATION FORM
APN # Date: 2 Sir— 0,1
3-s7-)- fj'z.._ o z LA
Building Address:
t 0Owner's Nam Name Phone#:
�nd�!La Cosi�dl.e,�o�v� 6 Tv - y 1e,4 -'70'7 -T-
Contractor:
Contractor: Phone#: YvIC- 374-30f'D
CFax#: `f O4"' 3'79- V %l-4—
Contact:
Contact: a Phone#: L{D C•
Fax#: t-i fly' 37 C
Contractor License #: 5�04 (o6W 4
Cupertino Business License #: Is `{17 IF)"P. Oct
Job Description: (- 0^A e. iOUe A CA-- A-0
Q,P Ab av 4Ae. A-
Residential Commercial ❑
Valuation:
Project Size: Express Standard ❑ Large EI 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: (17
Quantity Fee ID Fee Description Fee Permit Type
Group
1 PCSEWER Commercial bu Iding P 1CPSS
sewer/sanitary sewer
1 BPREPIPE Commercial re-pipe per fixture P 1CPRP
1 PGASCOM Commercial Gas Piping System P
1-4 Outlets
1 BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1 BSEISMICOM Seismic Commercial P
Revised 01/07/09