09030056 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
10394 BRE
OWNER'S NAME: PERMIT ISSUE DATE
PHO . SA CONTROL NO.
BUILDING PERMIT INFO
ARCHITECIYENGINEER:
BLDG ELECT PLUMB MECH
REPLCIINT OF 7 WNDWS ALL D D 0 D
uoo LICENSED CONTRACTOR'S DECLARATION LIKE4I,IKE RETRO-FIT Job Description
U4 C I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
Y m with Section 7000)of Division 3 of the Business and Professions Code.and my license is
y in full force and
23? Licensc C s
D23?
&-,m path Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�yU
`Oi_ Licensed Professional
y W OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
m 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 Sq.Ft.Floor Area Valuation
I=- (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 APN Number Occupancy Type
not mom 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 Required Inspections
and Professions Code:The Conhxtoes License Law does not apply to an owner of q
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(See.7044,Business and Professions Code:)The Contractor's Li-
ccnse 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 reason
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-insure for Workers Compen-
.ion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
[:11 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 Workers omp``en.sation Insurance carrier and Policy number
��l
EMam:
Cartier I V._ PION W No.:
CERTIFICATE OF EXEMPTION FROM ORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for Onc 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
0 O forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
E r CA 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.)
W A Lentices Name
Z
Lender's Address
V C) I certify that 1 have read this application and state that the above information is
LL E. ------I agree to comply with all city and county ordinances and state laws relating to
Q Ubuilding construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
CA liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. c
t"r APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roof.';
Signature of Ar Co or DatcT of Roof
OUS 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(x)? �� All roof3 shall be inspected prior to any roofing material being installed.
❑Yes LKnO
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
nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes o
1 have read the hazardous materials requirements under Chaptcr 6.95 of the Califor-
nia Health&SafetyCode, tions 25505.25533 and 25534.1 understand that if the building
does not currentlyhave nano that it is my responsibility to notify the occupant of the
requirements wh' met prior to issuance of a Certificax of Np ey Signatul a of Applicant Date
,,�
All roof coverings to be Class"r 'or better
Owner—o;' orize of are
al CITY OF �CUPERTINO Oq 05 00
CUPEkTiNO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 21 �5 1 Date:
Z/ A
Building Address:
N
Mailing Address (if different from building address):
Owner's Name: r2ob-,r� 14cose Phone #: S�
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: Phone: ?7 7
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone: 95 _C
Fax:
Residential Commercial ❑
Job Description: _
C/ ,Vlcoc er'/L-evA�— C7�--- o uvs oil (Kc P-G'(
Building Permit Info:
Bldg []/" 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 E� K2 i�3
Valuation: L �, Square Footage:
Project Size: Express Lj/ Standard ❑ Large ❑ Major ❑
[—GreenBuilding: 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.
''oints Achieved:
e'or help, contact Build it Green at www.builditgreen.or
Revised 02/05/09
tat-.I-
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTlNO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additionz 1 stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
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
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-s'and alone
I 1 BCBSC Cal Bld€; Standards Commission Fee B ALL PERMIT
TYPES
r 1 BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel &: Documentation B
1BUSLIC Business; License B
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