09030082 CITY OF CUPERTIN0
BUILDING DIVISION PERMIT RAnLINE PERMIT .
BUILDING ADDRESS:
10600 CULBE D TBD - T7EXIS!TING!SEWER
ISSUE DATE
OWNER'S NAME:
CONTROL NO.
rflON :
BUILDING PERMIT INFO
ARCHITECTIENGINEER: ELECT PLUMB MECH
REPLACE O D 0
a p C LICENSED CONTRACTOR'S DECLARATION / CLEAT` OUT Job Description
U� I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
11,140. in full fore and effect
v�z License Class tractor �rr
Date Con
LQ /r
HI CrS DECLARATION
I understand my plans shall be used as public records
�yU
G y Licensed Ptufcssional
OWNER-BUILDER DECLARATION
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
e m Pi which requires a permit to construct.alter,improve,demolish,or repair any structure
y"^ prior ut its issuance,also requires the applicant for such permit to file a signed statement �; ,Ft.Floor Area Valuation
that he i.licensed pursuant to the provisions of the Contractor s Irccrrse Law(Chapter 9 q
Y= (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 Apr(Number Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(SM.
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structum is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conractoes 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.).
0 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 thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the conractoes
License Law. B&P C for this mason
0 1 am exempt under Sec.
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
for WOrkees
sa 'have and
ov ded for b Se tiomaintain a n 3700 of the Labor C ficate of Consent to lodes forethe performance of the
satian,as pro Y
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,at required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPI ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if fhe permit is for anc 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 to become su •ct to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE PUC f,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J',Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
Cir I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
1 certify that I have read this application and state that the above information is
V� corecL 1 agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby authorizes representatives of this city to enter upon the
s
W above-mentioned property for inspection purpose
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City —
V Zin consequence of the granting of this permit y: Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b,
S CE REGU A ONS.
S C NS. / 43 51?11__ Re-roofs
gnatureof It ontractor Date 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 Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof shall be inspected prior to any roofing material being installed.
0Yes a 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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes MIN.
1 have read the hazardous 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 Date
re tremcnts which ust be me 'or to issuance of a Certificate of occupamcx S ignatur,of Applicant
All roof coverings to be Class'A"or better
r or author agent Date
CITY OF C.UPERTINO
REPIPE/SEWE2/MAIN SERVICE
CUPEt�TINO PERMIT APPLICATION FORM
APN �(� Date: Q
#
Building Address: SO
Owner's Name: one#:
Phqqo 'Q 33
Contractor: r O Phone#: 4V9 Z/3 —
firu'ii Gu �� Fax#: �O Z1 01.
—
Contact: / Phone#: ( eg, �,,?,-6
AJ4� �/r,Ct SCA Fax#: q0,9
Contractor License#: q
Cupertino Business License#:
Job Description: �y ,�t�.4'.Z ,�;,,,t� ��'�►�✓�,� �✓�/��J�
Residential [ Commercial ❑
Valuation: 1260 6'0
Project Size: Express Standard Large Major
LJ
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:
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary sewer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Comriercial P
Revised 01/07/09
CITY OF CUPERTINO
y REPIPE/SEWER/MAIN SERVICE
CUEPI�T
INO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary sewer
1PRREPIPE Residential re-pip,;per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1 BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
/ 1TRAVDOC Travel & Documontation Fee B
r 1BUSLIC Business License B