09040129 CITY OF CUPERTINO �
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
22445 CUPER PACIFI PL pERM1T(SSUEDATE
OWNER'S NAME:
' ' A 6 9 CONTROL NO.
(408) 452-8633 BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
UOOO LICENSED CONTRACTOR'S DECLARATION IOU DOSCiIptlOn
Uthereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is MN SWR LN R P LCMNT FOR 1 BTHRM EA UNIT(LIN I T S 10-
=y in full force and ef?cL Lie N
dry 2 License Clas Contractor 16)
p Datc r
ARCHITECTS DECLARATION
Lund�starµim�pl Ash he used as pulilic records
O in Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I 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
which inquires a permit ro construct alter,improve,demolish,or repair any structure
n—H prior h,its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q. 4 3 0 0 0
Yt=- (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 anC Accu Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy yp
not more than fire hundred dollars(s5oo)• 32615013 . 02
0 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 Contractors 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 arc 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 Li• en, �
cense Law does not apply to an owner of property who builds or improves thereon,and,
s ..
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. r
0 I am exempt under Sec. B&P C for this reason r
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 workers Compen-
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation insurance,as inquired by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My WorCompensation Insurance_ca�er and Poli number am:
Cartier.
I< pct S c6,'?
CERTIFICATE OF EXEMPTION FROM WORKERS' if
COMPENSATION INSURANCE
(chis section need not be completed if the permit is for 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 as 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 Z forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
F~•d rA
4 1 hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
az Lender's Address
[certify that I have read this application and state that the above inform
is
LUL" correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue againstsaid City
Date
U Zin consequence of the granting of this permit /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOU3�E RE ULAT�oNS. /
��f'✓iii Arc ]/'�/ i Re
Signature
-
Signature of Appl NContractor Dare T of Roof
HAZARDOUS MATERIALS 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(x)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes 00, If a roo''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 defined by the Bay Area Air Quality Management all new materials for inspection.
eistrict?
0 Yes 0
I 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
does not currently have a tenant,that it is my responsibility to notify the occupant Of the Date
requirements w ich mtst be met prior to trance of a Ccnificatc of Occoan� Sig -e of Appl icant
SGC— All roof coverings to be Class" "or better
Date
Owner or authorikA agent
01/22/2008 09:50 FAX 408 777 3333 CITY CUPERTINO !Jqv v`�� 1A OO1f002
1
CITY OF CUPERTINO
REPIPE/SEWS SERVICE
CUPEKTINO PERMIT APPLICATION FORM
APN# ( ( 1 „j Date: z3 Dcj
Building Address: •�-
4 PL
Owner's Name: Phone#:
uugt vibw t mow ySoo
Contractor: Phone#: 4N -91 - 6U YD
fAftt-(G Fax# - I1$q
: -
Contact: Phone#: Ib$-94 f _ Ot(2.p
iSew M4A #T t Fax#: 4w - 1744- ?/
Contractor License
Cupertino Business License#: 2(0.-
Job Description:
i Mklu SEw� L1NE ?,;M CtM01T FW- P,A9*'11-Ii�oeldl e 0- ut1�11T� �uµrr5 1� to 1(0
Residential Commercial ❑
Valuation: 3
Green Building Check list must be completed and attached to this application.
Green Building Points:
Quantity Fee ID Fee Description Fee Permit 'hype
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary s-wer
1BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Ga,Piping System P
1-4 Outlets
1BSEXSMICOM Seismic Commercial P
t 1BSEISMICR Seismic Resider,tial P
f
/ 1PRSEWER Residential building P 1RPSS
sewer/sanitary s,.wer