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09030005 CITY OF CUPERTINOiIA � r BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 10535 FELTON WAY MATTHEW SOMMER PERMIT ISSUE DATE ?IER'S NAME: A O. CONTROL NO. PHONE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB ME�CH u p C LICENSED CONTRACTOR'S DECLARATION Job Description '�m 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 TEMP POWER POLE =4 H in full force and effect va Z License Class Lic•N n F,a Date Contractor ARCHITECTS DECLARATION ee I understand my plans shall be used as public records J U O ti Licensed Professional 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 14.9 which requires a permit to construct.alter,improve,demolish,or repair any structure y^rn prior to is issuance,also requires the applicant for such permit to file a signed statement Sq,Ft.Floor Area Valuation Z< that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Yr (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $200 y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500). 35918011 . 00 ❑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 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 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 contractors)licensed pursuant to the Contractors License Law. 7 I am exempt B&P C for thhiis mason nen 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- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for#performance of the work for which this permit is issued. My Workers C9mpensa' nce carrier and Policy number arc: Cartier. Policy No.: 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 cenifv that in the performance of the w9rk for hick this permit is issued.I shall not employ any person in any manners s iRco t 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 ,Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of p, the work for which this permit is issued(Sec.3097,Civ.C.) (la ALenders Name az Lenders Address U 0 1 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 relating to V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W (We)agree to save,indemnify and keep harmless the City of Cupertino against FF,y Cn liabilities,judgments,toss and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. Date J —� 6)."5 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGU� 7 " S.v I Re-roofs w--� Signature of Applicant/Contractor Date T Of Roof HAZARDOUS MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material iefincd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety le,Section 25532(x)? All roof;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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes —OXC]" I 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 noury the upant of the Date requirements which mu met prito issuance of a Certificate of�c S ignatul a of Applicant All roof coverings to be Class'. or better Owner or authorized age t Date CITY OF CUPERTINO 'aITYOF TEMP POWER CUPEkTINO PERMIT APPLICATION FORM APN # Date: �3 Building Address: Owner's Name: Phone#: Contractor: Phone #: -c Fax #: Contact- Phone #: Contractor License #: Cupertino Business License#: Job Description: Residential Commercial Valuation (cost of projectv/,-, Type of Construction: N/A Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Pcwer>1K E IREAPI4 Amps I ERT<200 Res. Temp Pc wer<200 E Amps 1 ERT2001 K Res. Temp Power 200-1 K E Amps IEPERMITFE Electric Permit Issuance E 1 ELCPLNCK Electric Plan Check E / IBCBSC Cal Bldg Standards B ALL PERMIT _ / Commission Fee TYPES j IBSEISMICR Seismic Residential B 1TRAVDOC Travel & Documentation B Fee Revised 01/07/09 Community Development x� 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 »'CITY OF Fax(408)777-3333 CUPEkTINO Buildi:n De artment JOB ADDRESS: PERMIT # U 3 v OWNER'S NAME: PHONE # 7° GENERAL CONTRACTOR: FAX# I am not using any subcontractors: Si;;nature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical 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 Tile Date Owner/Contractor Signature