09030002 CITY OF CUPERTINO � � I�QjAtTj�N
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: 0002
10210 LEBANON DR TBD - Tf) BE DET RMI
PERMIT ISSUE DATE
VER'S NAME:
FPT 3.ZA p CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHTrEcT/ENGINEER: BLDG ELECT PLUMB MECH
a ore C LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is W I NDW R E P LCMNT LIKE 4 LIKE
y in full force and effect.
Z License Class_Li
c.
Date tractor
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ARCHITECTS DECLARATION
I understand my plans shall be used as public records
tv
�yU
O y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
j:20 following reason.(Section 7031.5,Business and Professions Code:Any city or count
% y
K$Pi which requires s permit to construct,alter,improve,demolish,or repair any structure
u"rn prior to its issuance,also requires the applicant for such permit to free a signed statementSq.Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
Y F=-a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5100
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(M). 34214012 . 00
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure isnot intended oroffered for sale(Sec.704t,Buaineaa 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
as .).
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 Taw 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 contractors
License Law' B&P C far this mason
f7 I am4�;�
dSser Date
SATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's 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 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 Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc 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 mm r so to 0 OCsubject to the Workers'Compensation
Laws of California Dale IFUJ UU��ff
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 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a concoction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
0Z
Lcndees Address
U C) I certify that I have read this application and state that the above information is
LL, corccL I agree to comply with all city and county ordinances and state laws relating to
C V building construction,and hemby authorise representatives of this city to enter upon the
L+a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
hE" t� liabilities,judgments,costs and expenses which may in any way accrue against said City �y
V z in consequence of the granting of this permit. Date
APPLICANT UN RSTAN ND WILL COMPLY WITH A L ON POINT Issued ley:
so U 0
Re-roofs
Si f re oApplrcan ontractor Date T of Roof
HAZARDOUS MATERIALS DISCLOSURE Yl?e
Will the applicant or future building occupant store or handle hazardous material
termed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
c,Section 25532(a)? All roo s shall be inspected prior to any roofing material being installed.
❑Yeso
Will the applicant o future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Cl Yes n
I have read the hay ous 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 rat curcn' ve sten
that it is my responsibility to notify the occupant of the Date
req ' menta whi or to issuanc�e of a Certificate of cup ey Signature of Applicant
ax All roof coverings to be Class'%"or better
or auth agent Dale
ooh
CITY OF CUPERTINO
CUPE(�TINO GENERAL BUILDING
PERMIT APPI--jICATION FORM
APN# Date: 3 Z 2 0
Building Address: 1 D Z l p Z 1 z o ,#IV O W 04,VP F()p4 ,O
Mailing Address (if different from building address):
Owner's Name: Phone#:
�� 21-T 1W -5 ,jz 5
ontractor: Phone: 9 8
( L Llire ,� �( 5l`�V C7 /� Fax:
Contractor License#: 15—q g zl
Cupertino Business License#:
Contact—r:),,,, 2 �-rr/A/ Phone: y0' �5 710 0/2
�D
Fax:
Residential Commercial ❑
Job Desch '
on:
P
Building Permit Info:
Bldg C�`� Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B Ej II/III/V-A ❑ II/III B, IV-HT,`'-B S-`- Ql--�
Valuation: Square Footage:
Project Size: Express Standard ❑ Larg:, ❑ Major ❑
Green Building: 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.
Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 01/07/09
a CITY OF CUPERTINO
CITY Of GENERAL BUILDING APPLICATION
CUPEI�TINO
FEE S(--.'HEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
/ 1 WINREP Replacement windows/sliding glass B
/ door (e2 8 windows)
1 WINMEWSTR New Wi zdow-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electric,-.l Permit Fee E
1 MPERMITFEE Mechan:cal Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
IELCPLNCK 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-:stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
/ 1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel ,4z Documentation B
1BUSLIC Business License B
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ASSESSOR COPY
( 13 7007
Fe4,4 000) -to be
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Buildin De artment
JOB ADDRESS: ��► PERMIT #
v Z o r�� ►�ra✓! �- Q f'3
OWNER'S NAME: PHONE # G-1S 7/ 047
GENERAL CONTRACTOR: < < y� FAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSII4ESS 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
ontractor Signature Dat