The URL can be used to link to this page

09030202 CITY OF CUPERTINO p BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 10584 JOHANSEN DR TBD — TO BE DE OWNER'S NAME: PERMrr ISSUE DATE PHONE: S A CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u o p LICENSED CONTRACTOR'S DECLARATION r u I= I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description =Z� with Section 70(10)of Diviaon 3 of c Business and Professions Code.and my license is =H in full force and effect.C�� 80�/ 7 COPPR REPI PE& RPLC WTR HTR& RPLC WTR SVC(MN)FRM D j? License Cls Lic.i E.o Date �-0Contractor HSE T() METER**MASTERSERV INC. PD BUS LIC ARCHITECTS DECLARATION a U I understand my plans shall be used as public records C y Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the in o following reason.(Section 7031.5,Business and Professions Code:Any city or county c m which requires a permit to construct.alter,improve,demolish.or repair any structure y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement =o that he is licensed pursuant to to provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation Y.f (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or 6 2 0 0 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 more than five hundred dollars(6500). 37536015 . 01 ❑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 q P 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 We.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 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. [-]I am exempt under Sec B&P C for this mason OwnerDate WORKER'S COMPENSATION DEC-la-RATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self-insure far Workces Compen- .tion,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ave 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's r.-OComp"a"tion Insurance carrier and Polity number are: y Cartier. .i Al �C'iPolicy No.:&Z 2W11 _2 Q�� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for anc hundred dollars(6100) or less) I certify that in the performance of the work for which this permit is issued,I shall not C, any person in any manner so s bccom y�bjecl to the Workers'Compensation Laws of California.nate 5,9 2rff`�f• Applicant — t;5sa. _ 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. Z h CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of �i •� the work for which this permit is issued(Sec.3097,Civ.C.) WCL A Lender's Name Z Lender's Address V 0 I certify that I have orad this application and state that the above information is Vm correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city a enter upon the W above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against V) liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. t APPLICANT UNDERSTANDS AND WILL COMP WITH ALL NON-POINT Issued )y: Date �j�' SOURCE REGULATIONS. Re-roo s Signature of ApplicartContractor Date HAZARDOUS MATERIALS DISCLOSURE Type o ROOF 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 roofs shall be inspected prior to any roofing material being installed. ❑Yes W'No Will the applicant or future building occupant use equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove tat hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. strict? Cl Ycs1N 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 ---G.G- does not currently have a tenant.that it is my reaponsibilil to notify the occupant of the requirements which mustbc priors' trance tcatcofOccupany. Signature of Applicant Date All roof coverings to be Class"{"or better Owner or auth zed age Date _ CITY OF (:UPERTINO a, REPIPE/SEWER/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM Date: APN# 37 3 5' Building Address: 'DQ '5O na m S e n f Owner's lame: ^e� Q 1 Phone#: N 650,�S 1. 6 601 IY�d, 1 -l.J Phone#: Contractor: ' �NST�c�s'�'�.v N C_ Fax#: SUS-40S-4100 Contact: Phone#: '�N�Rf3GT02 Fax4: Contractor License#:'S'gQQ -7 Cupertino Business License#: Job Description: Ciecenep�� ,2oz�1,62 lf Residential Commercial ❑ Valuation: Project Size: Express ❑ Standard Large[:: ] Major F1 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 Grou 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP IPGASCOM Commercial C as Piping System P 1-4 Outlets 1BCBSC Cal Bldg Stan lards Commission B ALL PERMIT TYPES Fee IBSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF (.UPERTINO REPIPE/SEW EjZ/1VJ[AIN SERVICE Ty Of FEE SCHEDULE CUPEkTI O Fee Descripti 3n Fee Permit Type Quantity Fee ID Grou 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Resider tial P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1RPRP 1PRREPIPE Residential re-pipe per fixture P 11 p 1CPWS or 1BPWSVCS Water Service iRPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1BPWATER Install/alter Wzter Pipe P 1BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets P 1BPGAS Gas Piping Sy;tem 5+ Outlets 1PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVDOC Travel &Documentation Fee B L 1BUSLIC Business License Community Development a `+ 10300 Torre Avenue t. Cupertino CA 95014 Telephone(408)777-3228 "CITY OF" Fax(408)777-3333 rUPEkTINO Buildin De artment JOB ADDRESS: lO�� ^I5o/� 1� PERMIT # G 10& +V OWNER'S NAME: xr/RR.g, ,65.¢j -- HONE # oZ6Z ,c-� GENERAL CONTRACTOR: S2�' 5 C < /0 I am not using any subcontractors: 4��r Signature Date Please check applicable subcontractors and con: Tete the followinginformation: 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 Zeec� 0 er/Con actor ature - SignDate