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09040058 CITY OF CUPERTINO � BUILDING DVISION PERMIT PERMIT NO. BUILDING ADDRESS: 10138 COLD HARBOR AVE TBD - TC BE DE pERMrl'L95UEDATE OWNER'S NAME: A CONTROL NO. 'TONE: BUILDING PERMIT INFO ARCHTiECTIENGINEER: BLDG ELECT PLUMB MECH UC C LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby al firm that I am licensed under provisions of Chapter 9(commencing 03)U with Section 70(X))of Division 3 of the Business and Professions Code.and my license is RE PLC/RF'PR ELEC TC L PANEL 7 a. in full force and effect v�Z License Class Contractor 3 y Date ARCHITECTS DECLARATION LL 1 understand my plans shall be used as public records ;yU 4 O y Licensed Professional OWNER-BUILDER DECLARATION 1 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 m f,% which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation u y pr to its issuance.also esquires the applicant for such permit to file a signed statement Sq.Ft.Floor Area Z< thatiohe is licensed pursuant to the provisions of the Contractor's License Law(Chapter 92500 yF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or J1 $ 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 fire hundred dollars(M). 36909043 . 00 0 1,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 Conuactor'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 sok.). construct as owner of the property,amexclusivelysinend contracting with licensed contractors i' conswct 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 Late' B&P C for this reason 0 I am exempt under Sec. Owner Date /n • WORKER'S COMPE iSATION DECLARATION I hereby affirm under penalty of 'ury rete of the following declarations: I have and will maintain a Certificate of onscm to self-insure for Worker's Compen- _tion,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 oC the Labor Cork,Cor the performance of the work for which this permit is issued. My Worker s Compensation insurance carrier and Polity number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or Icss.) i certify that in the performance of the work for which this permit is issued,I shall not employ any person in any mann��fficatc corn ' t to the Workers'Compensadon Laws of Califoro(a.Dptc Applicant /t�'V NOTICE TO APPLI NT:if, of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must ,J Z forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of fYr the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name a Lender's Address I certify that i have read this application and state that the above info rmatiun is LUL cored I agree to comply with all city and county ordinances and state laws relating to O V building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. >,W (We)agree to save,indemnify and keep harmless the City of Cupertino against Hliabilities,judgments,costs and expenses which may in any way accrue against said City �j V Zin consequence of the granting of this permit. late 1(� 0 / APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. 4/1'11-11 Re-roof Signature of Applicant/Conuactor Date T of Roof HAZARDOUS MA ALS DISCLOSURE Type 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)? �Ne All roots shall be inspected prior to any roofing material ing installed. 0Yes If a roo r is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which tit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. strict? 0 Yes RN. 1 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 docs not currently have a tenant.that it is my responsibility to notify the occupant of the Date requirements which must be prior to issuance of a ecrtihcate of occupancy. $ignatu re of Applicant All roof coverings to be Class'''`or better Owner or authorized agent Date cvt-A- 6t CITY OF CUPERTINO COF CUPERTINO GENERAL, BUILDING PERMIT APPLICATION FORM APN # G rl � Date: Building Address: / Q l 3 d jr Mailing Address (if different from building address): Owner's Name: Phone#: k,� ��N� L�uN � ,dog 9 73 z)?/ HOA: (Exterior work only) Yes [f No ❑ 4o i 21 ZL 4gA If yes, provide letter from HOA Contractor: Phone: Tf5 Fax: Contractor License#: Cupertino Business License#: T Contact: Phone: Fax: Residential Commercial Job Description: Y� ¢�e� Y•` I�a+^L� Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: I-Al I-B ❑ II/III/V-A ❑ II/III B, IV-HT,V.B S r t Valuati n:SSquare Footage: -PZ�c7O. ao - 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: For help, contact Build it Green at www.builditg.:een.or Revised 02/05/09 _ ` 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 Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea :; windows) 1WINMEWSTR New Win low-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Al,)ne 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 IB '.BSC Cal Bldg. Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Seismic Residential B 1 1BSEISMICO Seismic Commercial B / IT AVDOC Travel 6:Documentation B 1 BUSLIC Nu-sines, License B 5 of 5 Community Development 10300 Torre Avenue Cupertino CA 95014 ' Telephone(408)777-3228 n Fax(408)777-3333 CITY OF `'UPEkTINO Buildin De artment JOB ADDRESS: PERMIT # b OWNER'S NAME: PHONE # 0 0 3 GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Date Si,--,,nature 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 Date Owner/Contra for Signature