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09030211 77 CITY OF CUPERTINO BUILDING DIVISION PERMIT � � � ` ' BUILDING ADDRESS: PERMIT NO. 10454 STERLING BLVD H & H CO PERMIT ISSUE DATE OWNER'S NAME: RpmgnTQ Dp(IPFATTFq V 2 5 121 SXMYA CONTROL NO. ')NE: (408) 224-7777 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH u p z LICENSED CONTRACT'OR'S DECLARATION Job Description U 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 RE P LC EWER LINE y in full force and rflec s 5 3 D124 License lass Date Contractor O - ARCHITECTS DECLARATZN —t I understand my plans shall be used as public records �yU U.y Licensed Professional y OWNER-BUILDER DECLARATION I hereby affirm that 1 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 Ka R.� which requires a permit to construct alter,improve,demolish,or repair any structure u y prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation ?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 0 Sq H (commencing with Section 7000)of Division 3 of do Business and Professions Code)err 2 ,y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars($500). 37523042 . 00 ❑I,az owner of the property,or my employees with wages as their sole compensation, will do dee work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law docs 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 Professionsro Cade)The Contractor's nd t t E> + cense Law does not apply to an owner of property who builds or impves thereo n,and, e j who contracts for such projects with a contractor(s)licensed pursuant to the Contractors + License Law. t " ❑I am exempt under Sec ,B&P C for this reason -ARY 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- sation,az provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 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 Compensadon)bsuran1ce carrier and Policy number are: Carrier. 5 +41 C f U1�Polity No.:ASt/D ��'�(aL1ve CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is far one 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 az 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. Zn� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of �ithe work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name az Lender's Address U C) I certify that I have read this application and state that the above information is LL F correct.I agree to comply with all city and county ordinances and state laws relating to U building construction,and hereby authorim representatives of this city to enter upon the above-mentioned property for inspection purposes. t a (We)agree to save,indemnify and keep harmless the City of Cupertino against „Hy cn liabilities,judgments,costs and expenses which may in any way accrue against said City f U Z in consequence of the granting of this permit. Date ►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b,r: SOURCE REGULATIONS. — 6 3 G -U Re-roofs Signature of Applf t/ antractor Date AZARDOUS MATERIALS DISCLOSURE Type of.goof 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)? �e All roof:,shall be inspected prior to any roofing ma al eing Ins ❑Yes Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspectio , agree to emove .it hazardous air contaminants az defined by the Bay Area Air Quality Management all new)materials for inspection. itstrict7 ❑Yes -KN. 1 have mad 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 have a tenant.that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. S ignatur-,of Applicant Date r? T-,-r- `d? All roof coverings to be Class'n"or better Owner or authorized Date CITY OF CUPERTINO REPIPE/SEWE,R/MAIN SERVICE CUPEkTINO PERMIT APP=LICATION FORM APN# 27�YA .5otl,g , O C� Date: Building Address: /1'Lt (ock Owner' Name: Phone#: ,,L, N Pre),oe-e- 30 3 TC,/ Contracto IPhone y- ?J�>17 p (' T Fax #: 7'7 - dS S 3 Contact: Phone#: Fax#: 7?G 'dSS Contractor License Cupertino Business License#: Job Description: ple paw /J'ti e. Residential ,� Commercial ❑ Valuation: �, o .sem Project Size: Express Standard Large [ Major 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 Descripi:ion Fee Permit Type Group 1PCSEWER Commercial bi..ilding P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial G is Piping System P _ 1-4 Outlets 1BCBSC Cal Bldg StanCards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Comrrercial P Revised 01/07/09 CITY OF CUPERTINO , 1 REPIPE/SEWER MAIN SERVICE CITY Of CUPETRINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT 1 Fee TYPES J 1BSEISMICR Seismic Residentizl P I 1PRSEWER Residential building P 1RPSS sewer/sanitary sew er 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas PipingSystem P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P 1PPERMITFEE Plumbing Permit:?ee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P 1TRAVD6C Travel & Documentation Fee B 1BUSLIC Business License B Community Development 10300 Torre Avenue 1'.' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 7UPEkTINO Building Department JOB ADDRESS: (�� PERMIT# 03 (D / (, q k�5 OWNER'S NAME: 13r,"0" PHONE # 70?- - 3 GENERAL CONTRACTOR: t, FAX # 6� I am not using any subcontractors: _-74 S: afore Date Please check applicable subcontractors and complete the following information: 21 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