09030061 CITY OF CUPER.TINO ��tT � 1 �� 1�
BUILDING DIVISION PERNUT
PERMIT NO.
BUILDING ADDRESS:
18651 MEDICUS CT QREAT
PERMIT LSSUE DATE
OWNER'S NAME: INC
S CONTROL NO.
(4 0 8) 279-_1515___ BUILDING PERMIT INFO
ARCHTrECT/ENGINEER: BLDG ELECT PLUMB MECH
p C LICENSED CONTRACT'OR'S DECLARATION Job Description
m C 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 I N S T L F RO P LINE CLEAN—,OUT
o y in full force and effec�3
r�In Licenac LIC.k
n a Dal -Q f Contactor
ARCHITECTS DECLWh6N
I understand my plans shall be used as public records
m
�yV
u.in Licensed Professional
G< OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt Crum the Contactor s License law for the
no following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct alter,improve,demolish,or repair any structure
o-y prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 fl
t�-G (commencing with Section 7000)of Division 3 of the Business and Professions Cade)Or
y 5 that he is exempt therefrom and the basis for the alleged eumptin.Any violation o! APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mote thin five hundred dollars(5500). 3 7 5 2 6 0 0 5 . 00
0 1,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(See.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
re
own employees,provided that such improvements anot 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 Cnuactries ;
rty
reon,and.
whLi-
cense contrLaw acts for such pnot ly to an owner of rojects with a contractorr(s)licensed who
builds
pursuantt to the Contractor's
License Law. B&P C for this mason
0 I am exempt under Sec
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
'have and will maintain a Certificate of Consent to self-insure for Worker's compen-
on,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
113,NItavc 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 am:
Carrier.'DN1 LSU?Ary E�/Policy No n l c c�n as`i r^
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic 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 so as to become subject to the Workers'Compensation
Laws of California.Dam
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
1 hereby affirm that dare is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0 z Lender's Address
U C) 1 certify that I have ad this application and state that the above info formation is
torte--.I agree to comply with all city and county ordinances and state laws misting to
61.Vbuilding concoction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
o.o to liabilities,judgments,costs and expenses which may in any way accrue against said City /��%•�
U Z in consequence of the granting of this permit. Date
APPLI A UN ANDS A_NS W4LL,-COMPLY WITH ALL NON-POINT Issued ty:
SOUR R U S•
(7 Re-roof -
Si at fApplicanl/Contmctor 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 Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? / All rooi s shall be inspected prior to any roofing material being installed.
0Yes ONO
If a Too`is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
�t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
rice?
❑Ya °
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understated am if the building
does no currently h a an
drat it is my res m;ibilily to notify the Occupant of the Date
require en whit met 'o once oC a Certificate of Occupancy. Signatu fe of Applicant
7-6) All roof coverings to be Class"r "or better
Ovine o authorized agent Date
CITY OF CUPERTINO
:a REPIPE/SEWE:R/MAIN SERVICE
CUPEI�TINO PERMIT APPLICATION FORM
APN# Date:
J�75 A 00
Building Address: i s(o5 '
Owner's Name: Phone#:
Contractor: n Phone#: a-7 r - I
�e i /�r Vi �l C�•°LJ �'"��tirzz.��>U(r Fax#: Q-7"I - c
Contact: Phone#:,-�-1c—1 —
Fax#:
Contractor License#: <;-C3 10 G,S
Cupertino Business License#: 4S()
Job Description: t�'Z�l I rAA1 d it l
/
Residential [ Commercial ❑
Valuation: ��CJ
Project Size: Express Standard Large Major
LJ
Green Building: Please complete relevant portio:i 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 Cas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
f Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
` REPIPE/SEWS R/MAIN SERVICE
CITYCUPEI�TINO FEE S(--'.HEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standzrds Commission B ALL PERMIT
Fee TYPES,
1BSEISMICR Seismic Residential P
1PRSEWER Residential building P 1RPSS
sewer/sanitary so-wer
1PRREPIPE Residential re-p.pe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1BPFIXTURE Plumbing Fixtu•e P
1PGASRES Residential Gas Piping System P
1-4 Outlets
1BPGAS Gas Piping Syst.-m 5+ Outlets P
1PPERMITFEE Plumbing Permit Fee Issuance P
1PLMBLNCK Plumbing Plan Check P
1PLMBINSP Other Plumbing/gas Insp. P
f 1TRAVDOC Travel & Docurientation Fee B
1BUSLIC Business License B
Community Development
10300 Torre Avenue
a$ Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
CITY OF
`;UPERTINO
Buildin De artment
JOB ADDRESS: CS< S I tMEO( t.S <T. PERMIT # -
17 OWNER'S NAME: ►+�Jt= L PHONE # % I
GENERAL CONTRACTOR: FAX # r� c — 1 ES
I am not using any subcontractors: Date
Signature
Please check a licable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSI14ESS 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
Owner/Contractor Signature Date