09030033XZ ad 00
�Fui
�qU
> tr, F
�0
�A]N
IOC
K$�
-tZY
EFC
i
0C
z,
�+ U
F�
a=
i>a �
a
UC
wF
C] �
Fp
►.+ Co
U e
r
C
DIVISION ITY OF CUPERTINO
PERMIT
BUILDING
..:....,
BUILDING ADDRESS:
PERMIT NO.
20630 VALLEY GREEN DR
CONSOLIDATED PLUMBING
OWNER'S NAME:
FRRn
PERMIT ISSUE DATE
..LONE:
S A CONTROL NO.
(408)978 -3093
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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
in full force and e
TEMP P "-RMI T GOOD THRU 4 / 9 / 9 ; ORG # 0 9 0 2 010 9 ; S EWER
License ass LIc.1f Z
Date eontracwr _F
LINE R �-,PLCMNT
ARCHrfECI'S DECLARATION I
1 understand my plans shall be used as public records
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
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
prior to its issuance, also requires the applicant for such permit to file a signed statement
license Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Cnde) or
$80000
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 ($500).
32610054 . 01
0 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Conuactoes 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.).
0 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 U-
ccnse 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.
0 1 am exempt under See. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I 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.
05 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 Workers Compensation Insurance carrier and Policy number afire::
q
Cartier. l &21 , 7f J(r oliry No.: A I 1J QO 10 7
n6
CERTIFICATE OF EX ON FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certilty that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so at 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 Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
)
+ CONSTRUCTION LENDING AGENCY
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.)
Lender's Name -
Lenders Address
I certify that I have read this application and state that the above information is
+ correct I agree to comply with all city and county ordinances and state laws rclating to
+ building construction, and hereby authorize representatives of this city to enter upon the
above - mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
r in consequence of the granting of this permit.
AP 1CANT UNDE AN AND WILL COMPLY WITH ALL NON -POINT
Issued b is Date
SO CE REGU
'0
Re -roofs _
Type of ' Zoof
Sig attire of A lican ontractor Date
HAZARDOUS MATERIALS DISCLOSURE
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 roof: shall be inspected prior to any roofing material being installed.
❑Yes RI No
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new f naterials for inspection.
District?
0 Yes ®No
`materials
1 have read the hazardorus requirements under Chapter 6.95 of thc Califor-
nia Health & Safcty Codc, Sections 75505.25533 and 25534.1 understand that if thc building
d of currently ha a tens t, that it is my responsibility to notify the occupant of the
re rcmcnq whit et prior to issuance of a certificate of Occupancy.
Signatur,; of Applicant Date
All roof coverings to be Class'n" or better
Owner or auth
'zc agent 9fatc
;TY
CUPEI�TINO
CITY OF CUPERTINO
TEMPORARY PERMIT
PERMIT APPLICATION FORM
07030 �!>3
APN #
Fee ID
Date:
(0-e)-T-4-00
5-2-oft
Original Permit #
1TEMPPMT
Temporary Permit Good
Building Address:
1TEMPPMT
291N �-30
for 30 days - Commercial
Owner's Name:
-
Phone #:
� v -, � P - N o P,
Ccwj iT 0-iotj
Ce C> -8 7 7-- 7 ,q q5
Contractor:
Phone #:
CpoS�� l��'i�d
Idt �i►�G
Fax #:D$ -01 - o
Contact:Gt2.px&
AV N(A
Phone #: qp g -97g --' pcf 3
Temoorau Permit
o-
Contractor License #:
Sb s t b
Contractor and /or Owner accept complete
re onsibility for correcting additions
Cupertino Business Licen Z
Job Description:
completed Blue Prints. 1 V cR.:)-E �->- k,r P u�-�' LIA6 -g m IF t;
Permit good for (30) thirty days
From S, ! 0
Valuation (cost of project)5ignature
�b C(�1 —
Type of Construction:
Project Size: Over the Counter
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1TEMPPMT
Temporary Permit Good
B
1TEMPPMT
(Flat Fee)
for 30 days - Commercial
-
only.
1BCBSC
Cal Bldg Standards
B
ALL PERMIT
J
Commission Fee
TYPES
01/07/09