09040141 CITY OF CUPERTINO
BUILDING`DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
10684 CARVER DR HANEY ELECTRIC 09040141
OWNER'S NAME: PERMIT ISSUE DATE
(TTc rt: TFC2TCA IJQ21JEN 611_8 A-142—ST11 RP -q
)NE: S A CONTROL NO.
(831) 763-9044
ARCHITECrrENGINEER: BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
v p p LICENSED CONTRACTOR'S DECLARATION Job Description
U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section and
of of Division 3 of the Business and Professions Code,and my license is RPLC (E)ELCTRC L PANL W/200 AMP ELCTRC L PNL
��y in full force and effect.
j Z License Class Lic•N
C-0 Date Contractor
ARCHITECTS DECLARATION
a< I understand my plans shall be used as public records
�yU
4 C y Licensed Professional
v3:1 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
C p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.41-9 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
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
y=$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
$900
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 five hundred dollars(5500). 37532014 . 01
❑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 a an owner of q 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
as .
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 docs 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 un er ac B&P C for this reason
Owner. ,6 "' Date 2'7 0
ORK> F'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Conscnt 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.
❑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 Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc 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 to become subject the Workers'Compensation
Laws of icant California.DateLL �Z
Appl _ r
NOTICE TO APPLICWTV l C 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 N 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.)
aQ Lender's Name
z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
LL correct construction,
agree to comply with all city and county ordinances and state laws relating to
0 V building consction,and hereby authorize representatives of this city to enter upon the
U at e,nmcndoncd property for inspection purposes 1/7
>4 WLL (We)agree to save,indemnify and keep harmless the City of Cupertino against
tto 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 C( Z -0 51
APPLICA`ff DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: �t�zw
SOURCE E ATIONS.
'4/'-2' -0 Re-roof;
Signat of pp,cantfContractor Dare f
Type Of Roo
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 roofs shall be inspected prior to any roofing material being installed.
❑Yes V 4o 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 dcfrned by the Bay Area Air Quality Management all new materials for inspection.
Oisuict?
❑Yes b"u
1 have read the hazardous materials requirements underChapter 6.95 of the Califor-
nia Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the building
does not cu rre 0y have a tenant,that it is my responsibility to notify the occupant of the
rcquircm,n ich must be met prior to issuance of a Certificate of Occupancy. S ignatul a of Applicant Date
Z7-of All roof coverings to be Class'j$`'or better
Owner or authorized agent Date
tat �� RTINO
CITY OF .,UPE
CUPEkTINO GENERAI__j BUILDING
PERMIT APPLICATION FORM
APN # � Date:
Building Address:
069 rn MIL) )/,j
Mailing Address (if different from building address):
Owner's Name: Phone#:
Gun- � 3 -rs-ri u9 H b sH*-J �o —� S s 3
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: Phone: 0 3
HPA_E, C 1 C7►vt C. Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Jf S St H o V4cy j Fax:
Residential [_ Commercial
Job Description: IzEpLAci C-) c c-r&t&q(__ Zoo et_4 P
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [✓]� `Z 3
Valuation: Square Footage:
Project Size: Express 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:
IFor help, contact Build it Green at www.buildit$!reen.or
Revised 02/05/09
CITY OF CUPERTINO
CITY°FGENERAL BUILDING APPLICATION
CUPEi�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description 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)
1WINMEWSTR New Window-structural shear B
wall/mz sonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechar,ical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
I STPLNCK-(3 Hr Min Standarl Plan Check (when no E/M/P) B
when not over counter) hourly-:stand alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
I BSEISMICR Seismic Residential B
1 BSEISMICO Seismic Commercial B
r, 1 TRAVDOC Travel & Documentation B
1BUSLIC Business License B
5 of 5
Community Development
- 10300 Torre Avenue
Cupertino CA 95014
M Telephone(408)777-3228
Fax(408)777-3333
C1T1f OF
;UPEkTINO
Buildir� De artment
JOB ADDRESS: PERMIT # ✓l�
o C)Ll
En- brit lJ� n:�J
OWNER'S NAME: o PHONE # Z.,►o , 3
GENERAL CONTRACTO 9tjr,, LFAX#
I am not using any subcontractors: Date
Signature
Please check applicable subcontractors and complete the followin BUSINESS LICENSE #
-Z- SUBCONTRACTOR BUSINESS NAME
Cabinets &Millwork
Cement Finishing
Electrical C 3
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
z7 a
Owne /Contractor Signature Date