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09030024 CITY OF CUPERTINO BUILDING DIVISION PERMIT � R� �} � } M+�lll .F ' BUILDING ADDRESS: PERMIT NO. 21617 ROSAR E ^ OWNER'S NAME: PERMIT L95UE DATE Ho . SA CONTROL NO. ARCHITEC IENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH TEMP P3WER TO RELEASE oo LICENSED CONTRACTOR'S DECLARATION EXISTING METER REL. 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 e'='�y in full force and effect 6 r�Z License Class Lic.# y Date 3 —O Contractor..& AR HITECTS DECLARAMN -t 1 understand my plans shall be used as public records DyU 4 C y Licensed Professional ti OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractofs License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county K rL which requires a permit to construct.alter.improve.demolish,or repair any structure y prior to its issuance,also requires the applicant for such permit to file a signed statcmcm £ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation I-$ (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 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than rive hundred dollars(5500). [11,as owner of the property,or my employees with wages as their sole compensation, will do Ute 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 fl 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 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.). ❑1,as owner of the property.am exclusively contracting with licensed contractors to construct die 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 Contractors 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: ❑1 have and will maintain a Cerliricate of Consent io 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 isstied. ❑I have and will maintain Workers 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 Ca�mpe tion Insurance ca er and Policy number am: Carrier fJ 1&a Policy No.: 719 Qfl 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 ceW v that in the performance of the work for which this permit is issued.1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California Datc 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. Z''~ CONSTRUCTION LENDING AGENCY [~-r r0+ I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued(Sec.3097,Civ.C.) WI:L Q Lendces Name z L.endees Address U 0 I certify that I have read this application and state that the above information is VLH sorted l agree to comply with all city and county ordinances and stale laws relating to 0 V building convection,and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against 04 c,n liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit "4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date -6 SOU=S. ,/,v�� Re-roofs _ Signature of Applicant/Contractor Date 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 roofs shall be inspected prior to any roofing material being installed. ❑Yes 09No If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or forum building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new IT aterials for inspection. District? ❑Yes �Nu 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if the building docs not currently have a tenant that it is my responsibility to notify the occupant of the requirements w ,ch be met prior o 4 uance of a Ccniricate of Occupancy. Signature of Applicant Date All roof coverings to be Class"r `'or better Owner or authorized agent Dam 1 CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM �l6 b0 2 APN # Date: Building Address: c>214 / O d e� Mailing Address (if different from building address): Owner's Name: //� Phone #: HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Contractor: Phone: yam-- a% -- 6,4 Fax: — Contractor License#-.4 Cupertino Business License#: Contact: Phone: z,,brS- - —7� � C a0,-W'le s Fax: Z,,12� 7 s Residential 191 Commercial Job Description: �� C�,5 C '7iCi t e�a°`1;Z-- Building Permit Info: Bldg ❑ Elect D' Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B E?' 11 -3 Valuation: CIO Square Footage: Project Size: Express a Standard ❑ Large ❑ 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: I� For help, contact Build it Green at www.buildit r een.or Revised 02/05/09 (tat --, CITY OF [-".UPERTINO Cin OF GENERAL BUILDING APPLICATION CUPEf�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Des,:ription 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 (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) r 1 EPERMITFEE Electrica. Permit Fee E 1 MPERMITFEE Mechani,;al Permit Fee M I PPERMITFEE Plumbin,;Permit Fee P 1 ELCPLNCK Stand Al one 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-si and alone 1 BCBSC Cal ME, Standards Commission Fee B ALL PERMIT TYPES ` 1 BSEISMICR Seismic Residential B / 1BSEISMICO Seismic Commercial B / 1 TRAVDOC Travel 8; Documentation B 1BUSLIC Business; License B C j < Z0 5 of 5