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09040161 CITY OF CUPERTINO BUILDING DIVISIONPERMITIN.F. BUILDING ADDRESS: PERMIT NO. 22001 LINDY LN CRITCHFIELD CONSTRUCTION n9n40161 OWNER'S NAME: PERMIT ISSUE DATE "ONE: A CONTROL NO. (408) 371-3777 ABUILDING PERMIT INFO RCHITECr/ENGiNEER: BLDG ELECT PLUMB MECH 40 p LICENSED CONTRACTOR'S DECLARATION Job Description hu I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z m with Section 7000)of Division 3 of to Business and Professions Code,and my license is H it mu force an effect Z PNL UPGRADE/SWAP ? License CI L c 8 n F- Date Contncta—�ti _ .. ARCHITECTS DECLARATION L I understa d y p Itshall be used as public records y U rtAy� L o y Licc d PrucssstiUSILLL m OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the p Op� 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 a Z y prior to its issuance,also requires the applicant for such permit to file a signed statement EE'< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation Yt-a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $3000 i 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(SSW). 35627002 . 00 ❑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 Contractors License Law does not apply to 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 sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractors 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 Contractors License Law. ❑I am exempt under Sec. B&P C for this reason 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- _tion,as provided for by Section 3700 of the Labor Code,for the performance of Ute work for which this permit is issued. ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My wor s Compensation insurance c)rrier and Policy number are: Carrier. sx `aY—Policy No.L j4'5'-"M *0 CERTIFICATE F 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 manner so as to become subject to the Workers'Compensation Laws of California.Dare 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 Oforthwith 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 �+ the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lenders Name aLenders Address U 0 I certify that I have read this application and state that the above information is correct I agree to comply with all City and county ordinances and state laws relating to Vbuilding construction.and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes W W (We)agree to save,indemnify and keep harmless the City of Cupertino against ►F-o t� liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. APP CANT UN STANDS AND WILL COMPLY WITH ALL NON-POINT Issued b): Date U y SO RE U O -' ' Re-roofs Signature of Applican Contractor Date 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(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes No Will the applicant or future building occupant use equipment or devices which If a roof s installed without first obtaining an inspection,I agree to remove it hazardous air contaminants as defined by the Bay Area Air Quality Management all new n)aterials for inspection. (&W strict? ❑Yes ° *Usc the hazardous materials requirements under Chapter 6.95 of the Califor- Codc Sections 25505,25533 and 25534.1 understand that if the building h tenant,that it is my responsibility to notify the occupant of the t I prior to issuance of a Certificate of Occupancy. S ignaturc of Applicant Date d agent �� Date All roof coverings to be Class'J ''or better Community Development al. 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 '.UPEkTINO Building Department JOB ADDRESS:a,2C-01 (_, �•�P PERMIT # ) 0 L4 U1 I OWNER'S NAME:(rA `Jcct'i C PHONE # t-(08--qc? `l- 3 9? GENERAL CONTRACTOR: ; ; FAX # '90 -- 3 7r I am not using any subcontractors: Signature Date Please check applicable subcontractors and com lete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing lectrical 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 Owne /Contractor Signature Date 090g0tul CITY OF (XPERTINO CUPEkTINO GENERAI. BUILDING PERMIT APPLICATION FORM APN # / Date: (A Building Address: c-a100, l v-n L P,Ni Mailing Address (if different from building address): Owner's Name:Tof-A i*Aa5u Fr`i- -e Phone#: CjQ HOA: (Exterior work only) Yes ❑ No 10 If yes, provide letter from HOA Contractor: 0 ��h- _�O ��� �-� ©e-1 Phone: tAO S-371 - 3-17 Fax: Contractor License#: 7-13 3 Cupertino Business License#: Contact: 1- � Phone: ,1- o, 3 )._tAq-(- �} Fax: yOE-')-- �D-1 I - 5- q56 ResidentialP9- Commercial ❑ Job Description: Building Permit Info: Bldg ❑ Elect�/ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: I-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-3 El V Valuati n: 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 applicabl,;, include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.builditgr�en.or Revised 02/05/09 ' CITY OF CvUPERTINO CITY Of GENERAL BUILD ING APPLICATION CUPEkTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Desc ription Fee Permit Type Group 1GENRES or 1GENCOM ISTUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacemcnt windows/sliding glass B door (ea E windows) 1 WINMEWSTR New Window-structural shear B wall/maso:iry(includes plan ck fee) 1 EPERMITFEE Electrical °ermit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P I ELCPLNCK Stand Alo ie Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alo ie Mechanical Pln Ck (hrly) M IPLMBLNCK Stand AloZe Plumbing Pln Ck (hrly) P I STPLNCK-(3 Hr Min Standard flan Check (when no E/M/P) B when not over counter) hourly-stared alone / 1 BCBSC Cal Bldg :standards Commission Fee B ALL PERMIT I TYPES I BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B ITRAVDOC Travel &;documentation B IBUSLIC Business license B L 2 i< ,2n6 ` of 5