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09030093CITY OF CUPERl'INU BUILDING DIVISION PERMIT G�1TRCT��• BUILDING ADDRESS: 20095 APPLE OWNER'S NAME: "40NE: ARCHITECT/ENGINEER: u p p LICENSED CONTRACTOR'S DECLARATION U P: I hereby affirm that I 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 e y in full force and effect. , v� z License Clan C.7J i. t a el _c;._ 1 s = y Date 2 - Contractor A CH1T'ECl'S DECLARATION < I understand my plans shall be used as public records X06 U. in Licensed Professional < OWNER -BUILDER DECLARATION qH 1 I hereby affirm that I am exempt from the Contractor's License Law for the 00 following reason. (Section 7031.5, Business and Professions Code: Any city or county 42� which requires a permit to construct, aper, improve, dcmolLsh. or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement = G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 Y F- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or A 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 ($500). ❑ 1, 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 Contractors Li- cense Law docs 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 reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: z z° CA W? Ge A :D 2 UO wH OU W CA U I have and will maintain a Certificate of Consent to self -insure for Workces Compcn- on, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 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 Worker' Compensation Insurance carrier and Policy number are: Cartier PJN�) P.fi y No.:23'f3 -22h CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for anc hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, l 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 misting to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes (We) agree_ save, indemnify and keep harmless the City of Cupertino against liabilities jugents, cos d expenses which may in any way accrue against said City in consequence of the grandn of this permit. APPLICANT UNDERSTA DS AND WILL COMPLY WITH ALL NON -POINT SO RCE R CATIONS Signatu A canUContracwr Date HAZARDOUS MATERIAL CLOSURE 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(x)? ❑ Yes No Will the applicant or future building occupant use equipment or devices which -.it hazardous air contaminants as dcftncd by the Bay Arca Air Quality Management strict? ❑ Yes qNu 1 have read the hazardaus materials mquiremcns under Chapter 6.95 of the Califor- nia Health & Safct Code, Sections 25505.25533 and 25534.1 understand that if the building docs not currently ave a tenant that it is my responsibility to notify the occupant of the requircmens whit most be met prior to issuance ficate of occupancy. i�� _ i� - .212- . Cc' Owne orized agent _ Date BELLA C: 408)206-1540 Job Description ELEC VC PNL CHNG UPGRD TO 200AMP PANEL Sq. Ft. Floor Area 11 31633090.00 Required Inspections Issued b,: Re -roof: Type of Poof All roof:; shall be inspected prior to any roofij If a roof is installed without first obtaining an all new materials for inspection. Signatur-, of Applicant All roof coverings to be Class in," or better Date ial being inst ed. on, I a r o remove Date PERMIT NO. yra q n nny� PERMIT ISSUE DATE S A CON ROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB Job Description ELEC VC PNL CHNG UPGRD TO 200AMP PANEL Sq. Ft. Floor Area 11 31633090.00 Required Inspections Issued b,: Re -roof: Type of Poof All roof:; shall be inspected prior to any roofij If a roof is installed without first obtaining an all new materials for inspection. Signatur-, of Applicant All roof coverings to be Class in," or better Date ial being inst ed. on, I a r o remove Date UL CITY OF CUPEkTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # ( �q Date: 0 C, Bu�i ing Address::apoj` Mailing Address (if different from building address): Owner's Name: MG t G� � ) c -.rc Phone �(_4,oj)l 7 7 % 91 co g HOA: (Exterior work only) Yes ❑ N0. If yes, provide letter from HOA Contractor: -&-jIAV �r� Phone: S Fax: �'�� - � 7 Contractor License #: S Cupertino Business License #: Contact: Phone '4 3) Z� 6 6 ll Fax: Residential Commercial El Job Description: Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IVIII B, IV -HT, V -B ❑ Valuati n: Square Footage: Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ [GmeenBuilding: 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.builditg—een.or Revised 02/03/09 ad", CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEf�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) additional stucco application B 1 WINREP Replacement windows/sliding glass door (ea 8 windows) B 1 WINMEWSTR New Window -structural shear wall/ma ;onry (includes plan ck fee) B I 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechan: cal Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand A.one Electric Pln Ck (hourly) E 1 MECPLNCK Stand A one Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand A.one Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min when not over counter) Standard Plan Check (when no E/M/P) hourly -stand alone B 1 BCBSC Cal Bldj; Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel & Documentation B 1 BUSLIC Busines ; License B 5 of 5 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Buildin De artment JOB ADDRESS: PERMIT # OWNER'S NAME: Gr i c�� L.l- c,�- PHONE # 4 o-6 GENERAL CONTRACTOR: FAX # 4 0 I am not using any subcontractors:" o -3 1ignature Date -1-4- a -he 4:r,11ntwri1nQ infn, nfinn- Please crlecx a uk-aulc Duv1.vi'u"a..",i�.,. SUBCONTRACTOR .�. BUSI14ESS NAME BUSINESS LICENSE # Cabinets & Millwork C ent Finishing Electri 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 e Date 0 J r/Contractor Signature