The URL can be used to link to this page

09030055 CITY OF CLPERTINO BUILDING DIVISION PERMIT � � � Rk�kI� � PERMIT NO. BUILDING ADDRESS: 20031 NORTHWOOD DRBROTH ERS H M PERMIT L95UE DATE OWNER'S NAME: SA CONTROL NO. '+ONE: BUILDING PERMIT INFO ARCHTTECT/ENGINEER: BLDG ELECT PLUMB MECH REPLC 3 PATIO DOORS ALL a o c LICENSED CONTRACTOR'S DECLARATION LIKE 4 I r I KE RETRO—FIT Job Description Im C I hereby affirm that I am licensed under provisions of Chapter 9(commencing Zfthe Business and Professions Code.and my license is U, with Section 70(10)of Division 3 o y in full force and e G Q 5 v�Z License ��/ Lle•N o Date Contractor ARCHITECTS DECLARATION 1 understand my plans shall be used as public records DyU O y Licensed Professional OWNER-BUILDER DECLARATION j<m I hereby affirm that I am exempt from the Contractor's License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county Pi which requires a permit to construct,alter,improve,demolish,or repair any structure 'r'w prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S q x (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 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). ❑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 contractor(s)licensed pursuant to the Contractor's License Law. ❑I am exempt under Sec .B&P C for this reason Owner 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 worker's Compen- ,stion,as provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. ❑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 Worker's ompensation Insurance carter 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(S 100) or Icss.) I cenify 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 O forthwith comply with such provisions or this permit shall be deemed revoked. Z h—' CONSTRUCTION LENDING AGENCY HCn 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.) W A Lender's Name 0 Lender's Address U 0 1 certify that I have read this application and state that the above information is V.0-4 f� correct.I agree to comply with all city and county ordinances and state laws relating to OU building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W t W (We)agree to save,indemnify and keep harmless the City of Cupertino against 04 „Fy 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 / 0-4 APPLICANT UNDERSTAN ;AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURC�REGULATI_,, G Re-roof'sSignaturor a HAZARDOUS MATERIALS DISCLOSURE Type of 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 roots 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 it hazardous air contaminants as deftficd by the Bay Area Air Quality Management all new materials for inspection. ,strict? C]Yes ONO 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 ha ant that it is my responsibility to notify the occupant of the Date requircmcnts wh' st be et prier to issuance of a certificate of Occu . S ignatL re of Applicant All roof coverings to be Class'n"or better Da Ownor authanze-agen' er C ITY OF C UPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # Date: � I 3 /s In 9 Building Address: / Mailing Address (if different from building address): Owner's Name: ,�wv1 � l 0� Phone#: HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Contractor: Phone: Fax: Contractor License#: 9,�Ioocl Cupertino Business License#: Contact: Phone: <e-60 r-PrG43aV� ` Fax: Residential Commercial ❑ Job Description: Building Permit Info: Bldg 0�- . Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-13 Valuation: ) Square Footage: ) I�� Project Size: Express [Standard ❑ Large [] Major ❑ Green Building: Please complete relevant portion A the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. ?oints Achieved: For help, contact Build it Green at www.builditgreen.or Revised 02/05/09 anu ,� CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEkTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP pl)lications (up to 400 sf) B additional ;stucco application 1 WINREP Replacement windows/sliding glass B / door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) I EPERMITFEE Electrical Permit Fee E I MPERMITFEE MechanicE l Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P l ELCPLNCK Stand Alo le Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alo-ie Mechanical Pln Ck (hrly) M IPLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P I STPLNCK-(3 Hr Min Standard flan Check (when no E/M/P) B when not over counter) hourly-stand alone 1 BCBSC Cal Bldg . Commission Fee B ALL PERMIT TYPES I BSEISMICR Seismic Residential B IBSEISMICO Seismic Commercial B ITRAVDOC Travel & Documentation B IBUSLIC Business License B 5 of 5 tf C'o A 00 Af L i i/w ld V1 . Q rte, —BW sHEF CAM SAT pTS 11UPOTINO M) C* Wli-N THE cjrj 4 Ai',,) ())?DINA ED 'ION J& kept cul to 17/7S**�mu 178 GeniLo cl,/t a/teraiyO/7'LLa. p�ugrho �,i�-bssjon fron Not -'4170. DDn%i of thebe Peccauo 1171,Qtv Ore Ur to tL. n< j/ ar C�� .��- ... �, � � 2 .,��-9_ � �� a : . ..� ,., a : .�_ =-- �.- . �` :�` �H��_.. �� ^{1, V �/ �'\ / C /'. - - I /( t A"rl T e7l v V I VQ VVI C� 1-i I it -N)IN r -y%.A.f v I A I(I A In v L. i ILe- ssF ss O/P cl, OA Wv 4, Community Development 10300 Torre Avenue k ' Cupertino CA 95014 Telephone(408)777-3228 CIV OF Fax(408)777-3333 rUPEkTINO Building Department JOB ADDRESS: PERMIT # � 3 a j "t o fc �C' �V OWNER'S NAME: To PHONE # t--'�00 72- GENERAL ZGENERAL CONTRACTOR: FAX # I am not using any subcontractors: t .3 ignature 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 /3 U Owner/Contractor Signature Date