09050005 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � M � .
PERMIT NO.
BUILDING ADDRESS: ,
gonots
7627 HOLL GENMOR P PERMIT ISSUE DATE
OWNER'S NAME:
4 TTA
SA CONTROL NO.
BUILDING PERMIT INFO
ARCH1TECl7ENGINEER: BLDG ELECT PLUMB MECH
COOPER RE-PIPE & WATER D D 0 0
Q O Z LICENSED CONTRACTOR'S DECLARATION HEATER Job Description
i L O I hereby arm that I am licensed under provisions of Chapter 9(commencing
U waffirm
ith Section 7000)of Division 3 of the Business and Professions Code,and my license is
n O H in ful�E�AR
N 75 3
vgl Z Licen
ContractorCI'S DECLARATION
Sd< 1 understand my plans shall be used as public records
�Q.0
U.y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
a O 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
-y prior to its issuance,also requires the applicant for such permit to file a signed statement 3q,Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
Yt=$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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(5500).
1,as owner of the property,or my employers 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 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 conuacting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contmtors u-
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 Contractors
License law.
❑I am exempt under Sea B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 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.
❑1 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 are:
Carrier�� 7`�G A ham_.Policy N
CE CA1E OF EXEMPRON FROM WORKERS'
COMPENSATION INSURANCE
(rhis section reed not be completed if the permit is for one hundred dIshWall
or less.)
I certify that in the performance of the work for which this permit is issue
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.
Z 0� CONSTRUCTION LENDING AGENCY
H .r 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.)
W Lenders Name
] Lenders Address
U 0 I certify that 1 have read this application and state that the above information is
LL H corrocL 1 agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby authorize representatives of this city to enter upon the
0 U
above-mentioned property for inspection purposes.
t 94 (We)agree to save,indemnify and keep harmless the City of Cupertino against
rA 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
�+ APPLI A UNDERSTANDS AND WIL PMP LY WITH ALL NON-POINT Issued by:
ONS. 6c,
Re-roofs -
Signature of ApplianitContractor °Datee 'j' of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future bui ng occupant store or handle hazardous material
as defined by the Cupertino MunNo 1 Codc,Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
E]Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future ilding occupant use equipment or devices which
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0Yes Nu
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 nol currently have a tenant,that it is my responsibility to notify the occupant of the Date
re tai which must be met prior to i of a Certificate of Occupancy. S ignatur:of Appl ieant
_t�9 All roof coverings to be Class" `'or better
Owner or authorized agent Date \
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CIV OF Fax(408)777-3333
.;UPEI�TINO
Buildi�n De artment
JOB ADDRESS: PERMIT #
/ -- C
OWNER'S NAMEQO - p co c a PHONE
GENERAL CONTRACTOR:Gp4 ;Wd-r FAX # - -G72 Z
I am not using any subcontractors:
Signature Date
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
Owner/Contractor Signature Date
CITY OF C-,UPERTINO
REPIPE/SEWEIRJMAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
U22�
Building Address:
Owner's Name: Phone#:
- C o o8-P.s3�7/g�
Contractor: Phone#: 4/d 8 - S55 8 3V 6?
"10 ill GUAl13l�o Fax#: o1�- I�7 - 67s�
Contact: Phone#:
Fax #:
Contractor License#: 3 3 q 6
Cupertino Business License#:
Job Description:
Residential Commercial ❑
Valuation: o
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 Descripl ion Fee Permit Type
Group
1PCSEWER Commercial building P 1CPSS
sewer/sanitary Sewer
1 BPREPIPE Commercial re-pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P _
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF C UPERTINO
REPIPE/SEWERrNWN SERVICE
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1BCBSC Cal Bldg Standard, Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residenti<<1 P
1PRSEWER Residential buildir.g P 1RPSS
sewer/sanitary sem er
1PRREPIPE Residential re-pipe;per fixture P 1RPRP
L
1BPWSVCS Water Service P 1CPWS or
1RPWS
1PPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Pipe P
1 BPFIXTURE Plumbing Fixture P
1 PGASRES Residential Gas Pi ping System P
1-4 Outlets
1BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit 7 ee Issuance P
1PLMBLNCK Plumbing Plan Cl.eck P
1PLMBINSP Other Plumbing/gas Insp. P
1TRAVDOC Travel & Documentation Fee B
1 1 BUSLIC Business License B