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09040034 CITY OF CUPERTINO Z� M+ TX�N BUILDING DIVISION PERMIT ► PERMIT NO. BUILDING ADDRESS: 20634 NANCY CT DALCON INC. 09040034 PERMIT ISSUE DATE OWNER'S NAME: S A CONTROL NO. "LONE: (408) 293-1690 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH v p p LICENSED CONTRACTOR'S DECLARATION Job Description _ tmi P I hereby affirm that I am licensed under provisions of Chapter 9(commencing z�d with Section 7000)of Division 3 of the Business and Professions Code,and my license is R P L C 10)AMP PNL W/U PGRD 100/200 H in full force and effect in Z License Class Lic.#cmr 3 t— Date ContraARCHrfEC7'S DECLARATION a` I understand my plans shall be used as public records �uJ U.y Licensed Professional < OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the jp oe� following reason.(Section 7031.5,Business and Professions Code:Any city or county li which requires a permit to construct alter,improve,demolish,or repair any structure rn prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation G that he is licensed pursuant W the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area y—$ (commencing widt Section 7000)of Division 3 of the Business and Professions Codc)or $2385 y R E 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 eve hundred dollars(SM. 35915035 . 00 I,as owner of the property,or my employees with wages az 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 Contractor's License Law dors 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.). Q 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- cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such pmjects with a contractor(s)licensed pursuant to the Contractors License Law. I am exempt une Sea r B&P C for s re n Owner ) Date PENS ON 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 Worker's Compen- .on,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 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 Workers Compensation Insurance carrier and Policy number am: 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 less) I certify that in the perfo ante of the work for which this permit is issued,I shall not employ any person in y az to o sybjcct to the Workers'Compensation Laws of California. tC ' Applicant NOTICE TO APP :if,an64nffdng this Certificate of Exemption,you should become subject to the Workers Compensation provisions of the Labor Code,you must ,J`j. forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY E..t Cn I hereby affirm that there is a construction lending agency for the performance of (Y > the work for which this permit is issued(Sec.3097,Civ.C.) W ALenders Name az Lenders Address U 0 I certify that I have read this application and state that the above information is LL" correct 1 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 W above-mentioned property for inspection purposes a (We)agree to save,indemnify and keep harmless the City of Cupertino against i.4 l) liabilities,judgments,costs and expenses which may in any way accrue against said City U'Z in consequence of the gramin this permit Date 0"r APPLICANT UNDERSTAND AN OMPLY WITH ALL NON-POINT Issued b): SOURCE REGULATIONS V — Re-roofs Signature ofApplican ontractor ate HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Mum Cipal 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. 01 Yes No If a roof .s 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 defined by the Bay Area Air Quality Management all new r.)aterials for inspection. ,trict? Yes 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- ria 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 occ ant f the requirements which must be me o to issuance of a Certificate of Oc Sig aturf'.of Applicant Date All roof coverings to be Class"J '`or better Owner or authorized agent D goyo03q aL (-' PERTINO CITY OF ..0 CUPEkTINO GENERAI. BUILDING PERMIT APPLICATION FORM APN #�b 9 1 :5b 3 U Date: Building Address: z Mailing Address different fro�ldin ad ss): r4 Owner's NamepPhone#: r work only) No HOA: (Exterior y) Yes ,� ❑ If es, provide letter from HOA " ' /�� Contractor: Phone: (40P 10 0k9C-. '.0 �G�� L Fax: Contractor License#: S��/6 Cupertino Business License#: Contact: .D,,f-v1 o Le-c- Phone: ')dj Fax: (46IL Residential Commercial Job Description: .0 / Zt�— ��U lryv,� fi/ c.;)-vU «iLL - 44 Building Permit Info: gr �%� ��,e Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Cl ss): Occupancy Type: r I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Valuation: � �� Square Footage: tt 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: 1 For help, contact Build it Green at www.buddit2reen.or Revised 02/05/09 CITY OF C;UPERTINO CITY Of GENERAL BUILD[NG APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Afplications (up to 400 sf) B additional stucco application 1WINREP Replacem:nt windows/sliding glass B door (ea f; windows) 1 WINMEWSTR New Window-structural shear B wall/mascnry(includes plan ck fee) / 1 EPERMITFEE Electrical Permit Fee E I 1MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P I ELCPLNCK Stand Alc ne Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M I PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P I STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 9 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT / TYPES 1 BSEISMICR Seismic Residential B IBSEISMICO Seismic commercial B / ITRAVDOC Travel & Documentation B I BUSLIC Business License B 5 of 5 4y Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ' UPEkTINO Buildi:n De artment JOB ADDRESS: o z ;"n `. PERMIT # 01O L/ (D OWNER'S NAME: Q, ` 5 wa,K PHONE #( 2 GENERAL CONTRACTOR: 2A&41 FAX# I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSIrIESS 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 Til Owner/Contractor Signature ate