08110058 CITY OF CUPERTINO � .
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
opjinoig
10201 N DE ANZA BLVD PRINCIPAL BUIL PERMIT ISSUE DATE
OWNER'S NAME:
12009
S A CONTROL NO.
HONE:
(415) 434-1500 BUILDING PERMIT INFO
ARCHI'IEC(ENGINEER: BLDG ELECT PLUMB MECH
u p C LICENSED CONTRACToR'S DECLARATION Job Description
CT
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
wilts Section 70(10)of Division 3 of the Business and fessuons Code.and my license is
n�a wthSecin full meand0 c7$-0$" COMM'L `II, NEW WALLS& CEILNGS IN SOME AREAS SEL
jZ LicenyfCl L'c•# NEW FINEHS, INCLD M/E
y p Dair v Contra r
ARCHITECTS DECLARATION 13Jxa—peca5 **1/13/C9 TEMPORARY PERMIT #09010053 EXPIRED
C� I understand my plans shall be used a$public records
u7
JyU
w H Licensed Pmfcssional
O< OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
m 9 which requires a permit to construct,alter,improve.demolish,or repair any structure
y"y prior toils issuance,also requires the applicant for such permit to file a signed statement V; ,Ft.Floor Area Valuation
—?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q 750000 5 O O O 0
YtZ-$ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
2. .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
Oct more than five hundred dollars($500). 32634070 . 00
0 I,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 Contractors License Law does not apply to n 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 Contractors Li-
rty
who contracts Law for sucnot h projects with a contractor(s)
ply to an owner of I who
censedbuilds
pursu nut to the Contractors
License Law. B&P C for this reason
0 1 am exempt under Sec
Date
Owner
WORKER'S COMPENSATION DEC(-ARATIOW
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self"nsum for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
2/1 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 Workers Compensation Inca carrier and Policy number ale: �— 1
Cartier. rJP �) �'ir Yblicy No.:
CERTIFICATE OF EXEMPTION FROM WORK RS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is for one hundred dollars($100)
or less)
1 certify that in the performance of the work for which this permit is issued.I 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 z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
rA I hereby affirm that there is a construction lending agency for the performance of
pC > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
p+ Lcndces Address
V Z 1 certify that I have read this application and state that the above information is
w correct 1 agree w comply with all city and county ordinances and state laws relating to
U building construction.and hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes
nWi (We)agree to save,indemnify and keep harmless the City of Cupertino against
F"t to liabilities,judgments,costs and expenses which may in any way accrue against said City CEJ/i�
U Z in consequence of the granting of this permit Date
o APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b:i:
Zignxtureof
� Re-roofs ,�✓plicanUContractor Da T of EZoof
HAZARD ATERIALS 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 roof:;shall be inspected prior to any roofing material being installed.
0Yes "° 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 naterials for inspection.
District?
0 Yes OfNii
I havc read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 75505.25533 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
requirements which be mel prior to issuance of a Certificate of Occu c, Sig
natul a of Applicant
All roof coverings to be Class" or better
Cwncr or authorized t Da
CITY OF CUPERTINO
BUILDING DIVISION PERNIII' CO1�iTRA OR TNFQRMATIONr /=I Ifs
BUILDING ADDRESS: PEAMff NO.
10201 N DE ANZA BLVD PRINCIPAL BUILDERS, INC aRlinning
OWNER'S NAME: PER'MU ISSVT:DATE
24.0 2!rQ9K!1!QN ST
PHONE: S AAtt 2 8 0 9 CONTROL NO.
(415) 434-1500
ARCHI`MCDENGIN ' BUILDING PERM'r INFO
BLDG ELECT" PLUMB MECH
Aop LICENSED CONTRACTOR'S DECLAM71ON Job Description
2 axI hereby affirm Wt I Am i1cmad under pmvisou of Chapl"9(cem AB
n< aviNSaian TO(IU)MDimmn 30fdc Busk ad fcW=Code.admylka is
mfull rom>•and Wza�s�� COMMnL TI, NEW WALLS& CEILNGS IN SOME AREAS SELCT
t3z LiceotP CI Lk.11
H Das CMnvunur NEW FINSHS, INCLD M/E
E ARCHIECTS DECI.ARAnON 13'ML:pG *
4mc Iundcrsundmyplansshallheusedapublicmeorm 1/13/09 TEMPORARY PERMIT #09010053 EXPIRED
D-U
I
C Lianad Pmfcaum al
3 OWNER-BUILDER DECWIATION
f I Icreby aRn Nat I am ucmpl fmm line Convenor's Lkarue Law for the
E O O fallowing maaoa(Section 10313.Busass and Paar�ous Cade:My city m cmnly
5 m 9 which mquims•penin ro cmuuuq after,imptwe,demolLW.a repair any atamrt
_z j, prior m its issuance.Alan mquirm the applicant for such Parnell m file a signed material,
x
< WaWislicenscdpurmantbNapm.imanaatKConvaclor.Licc elaw(Oapux9 Sq.Ft.Floor Area Valuation
,,FF (ctrmmcadng wide Seesan1000)of Division 3 of lava B.A.and Pmfuasons Cdc)a
i r 3 that he u eamnpl aAAf Am And the Eau for the alleged eswpdoc Any violWa.of $750000
Section 1031.5 by any appllanl fa A permit subjects the apprIMAL 10•dall penalty of APN Number Occupancy Type
nee'roamthat'Emhandled dollarsCLI ' 32634070. 00
L o tho.,of the tom suty,a my at imca eea wish wage a tM(..cmnpeaudou,
wdldelbework.Cdoh The mumunatmtended I -defaakpply AO A.aasrsa Required Inspections
and Pmfasaru code The Co, A.Luse Law tach ml apply If an AMine'W9h of 9 P
Mon a Y who n.prod imicowa th improm wW Arc
nounhk hivtscl(a Nmugh hu
awn m.the
Nat melt inepromemmta me tit iearWed a oicui.finale Ir.
however.the Wilding ur impmwnrnt u hand o did am)ear of mpanne( .the mic Of
Euildv will Mere do Wadm of proving than,k did ml Wild m imprort(a putpna of
eek.).
C L u Miner of 01 property.w oeluaimlY cunaasng-'fill Bteteed mMAIMS Or
com em the projet,(Sec 70u.Bain.and Hm(edmts Cade)The Covmeur's Li-
comae law does not apply N an train"of progeny wb0 Wilds m inpmm Nunn,and,.he convacs far such projects with A enn rmmrts)licensed pwsusnt b the CMnvacme$
Lime law.
❑lamcampnuudu See A&PCferthumamn
Owner Due
WORKERS COMPENSATION DEM AMTION
rt
1 hereby&in=under penalty of perjury ante of the fallawinif d IrxfiWac
Cl r hsrcmnd will mdntsinaCcrtiOoa of CMmmllm YSr-Inswe forwmlaYscmnpen
radon,As provided for by Salon 3100 of Me la or Cede,far Ne petratmari¢of de
w�orrkk for which Nu penin is Caecal.
ly I'
and urill maintain WmkCs Compensation a regained by Sawn
3100 of the labor Cade.fa the pdmrna en of tae wank fu whicia Nis P"neilmarl
My Werke,Compensation hsmrmce ceniar and Polity number AM: -
Camiec rJF_2E$1 A/g7pbncy No.: Y t
CERTIFICATE OF ID(EMMON FROM WORK
COMPENSATION INSUMNCE
trite rcdm Aced imlaccanplead if Ne pnmh kforane hundred d,n,m($100)
or tui)
I eervfy that in Ne perfatmance of NM work for which this p"mil k Luted,I"I not
employ.,pe.A in my maoacr An as A,ErtomA mbjecl to the WorknY Compeoation
laws of California.Due
Appniant
NOTICE M APPUCANT.If,after making this Ccrdacaa of Eeemptkn.you should
become subs An the warps Compeusaion prwwm of Ne labor code.you mus,
O forthwith comply with each aarisom a Nall INC
IMS permit shdammed mwke6
Z 2 CONSTRUCTION LENDING AGENCY
[-.> IhcrtEyairma the dime lea comtructinn lending agency for the performance:of
the wor
a k far which this Polack is laud(Sou.3091.Civ.C)
1 Q Undoes Nam.
7 Lender's Mdrau
U O I wary that 1 hale rot die appliaion And sera that the abom infomutan k
II. P conal I Agee At comply with all city and county ordinances and a=Ian tekting m
O U Wilding construction,And hemby anNMnm reptesmuvm,aftlss city m uta upon Ne
W aWue-meeiaad property fee iapedtrn purposes
_ a
(We)agree to tart.indemnify and keep hatmken the City of Cupertino against
fn incomagidgmenu.cusumd othis pa which may to my any acctee agsma mil Ory
U'z Acaauequcnce of the RTrANof this WILL
'+ APPLICANT UNDERSTANDS AND WILL COMPLY WTm ALL NON-POINT Issued by: Date
;OUR G N a,/.7—�- f
S�gnuurt of Applian�VCMnvxmr Re-roofs
HAZARDA111firgATERIALS DISCLOSURE Type of Roof
WILL the applicant"future Wilding occuPantsrwe a balk hmrdous malntal
a dcOmd by de Cupertino Municipal Cade.Chaps 9.11 ad the HoIN and Safety
CMde.Section u53z(e)+ / All roofs shall be inspected prior to any roofing material being installed.
CYm CNo
Will the apptiontor future Wilding ancapusasc Niipmoulwdcvl=whkh If a roof is installed without first obtaining an inspection,I agree to remove
emit ha>ardcus air ronuminmu As de0md by Ne Bay Aro Air Quality Mmagemeal all new materials for inspection.
Dicncrt
CYa M No
I haat Mewl Ne buvdm s materiab mquimmew underChapter695 of the Califar-
nkHuW kSarcjy Cdo Sanas 15505.15533ad 1S51(.1 undreamed"ifft banking
las ror carMil,home.trnme dun it is my responsibility m entry Ne accWal of the
rtqenawh =IpdarmissuatnaafaearifRemaf Zy Signature of Applicant Date
our aramNMnma r Dm All roof coverings to be Class's!'or better
cue/ 1 00.5t
GITYOF CUPERTINO
C TENANT IMPROVEMENT
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
11 N O$
Building Address:
10 2.61 Al. Ar42A BL-Op
Mailing Address (if different from building address):
Tenant ® (If tenant please provide a letter from the building owner approving the tenant improvement.)
Building Owner 11
Tenant/Building Owner's Name: Phone 4: gOIC_$63-6`f06
rv.
Contractor: Phone#:
�fLTacz�t,.` 8ur�v�.�S 4115'- y3Y- 1500
T40 QUa' Si s5oo SF ca Fax #: y 15- 434- 1506
Contractor License# �ZSO56
Cupertino Business License#:
Contact: Phone#:415-6$6— a93fs
?Rv sc ria` 3u='_z'Fz C Fax #: 415 43-1- Isob
Alternate Contact: Phone#: 4(5- 31-4- y12-5
M6.zT iSLJN`M A
��c �A� 3urc aEiL Fax #: t _ g - 5a
Valuation (cost of project):
Job Description (be specific):
1-M�tzroTL %.S.
iZ,a- �aeSc N6� w�"5 d.-s� C-GLc.-T�,S lSA\i�1 SowE DZbp,r,
Tenant Improvement Includes Re-Roof. Yes ❑ No [ f yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No I
Type of Construction (Usage Class): Occupancy Type:
I-A, I-B ❑ II/IIIN-A ❑ 11/III B, IV-HT, V-B ® 3
Project Size: Express ❑ Standard Large❑ Major ❑
Green Building: Please complete Leed for commercial interiors checklist& attach it to the application
or if applicable,include in plans & sheet index
LIKED Points Achieved
*** For Office Use Only*** Over The Counter❑ Revised 8/08/08