09040124 CITY OF CUPERTINOTIrM1 � r
BUILDING DIVISION PERMIT
s•r:
PERMIT NO.
BUILDING ADDRESS:
101 K PER PERMIT ISSUE DATE
OWNER'S NAME:
SAU U CONTROL NO.
J
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
COPPER REPIPE/WATER MN
p C LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
_Z, with Section 70011)of Division 3 of the Business and Professions Code,and my license is
n a ag in full force and effect
z License Class �'��n Lic.N
y E Dater a`j Contractor 11f
ARCHITECT'S DFCLARATON
I understand my plans shall be used as public records
to
�yU
L O y Licensed Ptufcssional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
a0 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m V which requires a permit to construct.alter.improve,demolish,or repair any structure
4—W prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's Uccnsc Law(Chapter 9 q
ts-C (commencing with Section 7000)of Division 3 of the Business and Professions Code)tar
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).
0 I,Is 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.7041,Business Required Inspections
and Professions Code:The Contractor'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
sale.).
❑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-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's
Henze Law. B&P C for this reason
0 I am exempt under Sec
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 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.
ave 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;�T oO�WI
Carrier.LS`CY�-L �"e rco�Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Rothe completed if the permit is for one hundred dollars($100)
or less.)
I certiCv 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.
z O CONSTRUCTION LENDING AGENCY
Fr�r I hereby affirm that there is a construction lending agency for the performance of
a.7 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendees Name
= Lender's Address
z
U zI certify that 1 have read this application and state that the above information is
corrccL I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
0 Uabove-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
tF-t liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of th of this permiL Date
5APPLICA ER N DWI .,PLY WITH ALL NON-POINT Issued by:EGUL �� 4� Re-roofs lic"t/con ter DareT of B.00f
HAZARDOUS MATERIALS DISCLOSUREYPeill 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)7All roofs shall be inspected prior to any roofing material being installed.
0Yes 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
_.nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
QYcs o
I have read the hazardous als requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code ons ) 3 and 75534.1 understand that if the building
docs not current a ten is responsibility to notify the occupant of the Date
lie hichmu 'or ee mnfoe£apncy. U� Signature of Applicant
Cl All roof coverings to be Class" `'or better
Owner o orix agent Date
(-)7c)q
CITY OF (;UPERTINO
REPIPE/SEWEIUMAIN SERVICE
CUPEt�T1NO PERMIT APPLICATION FORM
APN# Date:
� a � S�'� � � L
Building Address:
I() 10_ *,-2 o r., L�
Owner's Name: Phone#: _ �3`3 y 2--
Contractor: Phone#: Z 5
, t,., Fax#:
Contact:
Phone#: �U�' - 3c/f 1
f(' Fax#:
Contractor License#: L{ V'S
Cupertino Business License#:
Job Description:
Residential Commercial ❑
Valuation: -/ o v
Project Size: ExpressLkr Standard Large [] Major
Lj
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 Description Fee Permit Type
Group
1PCSEWER an building P 1CPSS
sewer/sanitary;;ewer
1BPREPIPE an rea pipe per fixture P 1CPRP
1PGASCOM Commercial Gas Piping System P -
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
TYPES
Fee
1BSEISMICOM Seismic Commercial P
Revised 01/07/09
CITY OF CUPERTINO
REPIPE/SEWER/MAIN SERVICE
CUPEI�TINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
IBCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICR Seismic Residentia. P
IPRSEWER Residential buildin; P 1RPSS
sewer/sanitary sew:r
1PRREPIPE Residential re-pipe per fixture P 1RPRP
1BPWSVCS Water Service P 1CPWS or
1RPWS
IPPRSEWG Private Sewage Disposal System P
1 PCESS Cesspool P
1BPWATER Install/alter Water Npe P
1 BPFIXTURE Plumbing Fixture P
1PGASRES Residential Gas Pi,)ing System P
1-4 Outlets
I BPGAS Gas Piping System 5+ Outlets P
1 PPERMITFEE Plumbing Permit Fee Issuance P
1 PLMBLNCK Plumbing Plan Ch,;ck P
1PLMBINSP Other Plumbing/g,.s Insp. P
J1TRAVDOC Travel & Documentation Fee B
1 BUSLIC Business License B