Loading...
09040021 CITY OF CUPERTINO BUILDING DIVISION PERMIT � � '` � " a:< PERMIT NO. BUILDING ADDRESS: 10965 NORTHSEAL SO TBD - r'O BE D PERMIT ISSUE DATE ')WNER'S NAME: 4JAY PAL SA CONTROL NO. PHO : BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH UPGRADE, KITCHEN COUTERTOP D D D D a p LICENSED CONTRACTOR'S DECLARATION AND RE]SLAC E SINK Job Description U 51 hereby affirm that I am licensed under provisions of Chapter 9(commencing m with Section 7000)of Division 3 of the Business and Professions Code,and my license is n H in full force and effect ? License Class a Date Contractor 3 t— ARCHITECT'S DECLARATION I understand my plans shall be used as public records �96U Z.o y Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor s License Law for the %O 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 prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S q EECyt_ (commencing with Section 7000)of Division 3 of tie Business and Professions Code)or I .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number not more than five hundred dollars($500). ❑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 oroffered 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.). ❑1,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 projects with a contractor(s)licensed pursuant to the Contracoes License Law. ❑1 am exempt under Sec B&P C for this reason owner Date WORK?PPMMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insum 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. ❑I 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 Worker's Compensation Insurance carrier and Policy number am: Cartier. Policy Ne.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for ono hundred dollars($100) or less.) I certify that in the performance of the worV for which this permit is issued,1 shall not employ any pe in any mgJ!T ome subject to the Workers'Compensation Laws of Cslifo Da Applicant NOTICE TO P ANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must 0 O forthwith comply with such provisions or this permit shall be deemed revoked. Z '+ CONSTRUCTION LENDING AGENCY [� I hereby alrirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) W QLender's Name 0 z Lender's Address U 0 I certify that I have read this application and state that the above information is LL" correct.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 W above.mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments,toss and expenses which may in any way scenic against said City U Z in consequence of the granting of this permit. late t y -- APPLICANT KD ER AND WILL COMPLY WITH ALL NON-POINT Issued b): SOURCE RE ATTONS. Re-roofs -- Signature of pplrcant/Contractor Dao T Of Roof 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 ':ode.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes 'ANo Will a roof s installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes ItNo I have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health afety Cade,Sections 25505,25533 and 25534.1 understand that if the building does not ntly have a tenant that it is my responsibility to notify the occupant of the requircme which must be mel prior o issuance of a Cenificate of Oc p . Signature of Applicant Date :1 1All roof coverings to be Class" "or better Owner r ri,cd agent IDatc Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPE�TINO Building Department JOB ADDRESS: l d S PERMIT # '�L,<OWNER'S NAME: AWt)P1 P - PHONE # I12 —,1 GENERAL CONTRACTOR: �D D t T f A +tel irvE FAX # PA 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 Owne ontractor Signature Date OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: A. All the work author.zed by this permit B. A portion of the wo:•k C. x None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. All of the work B. A portion of the work (complete section below) --TContractor Address/city. Phone # State License # Type of work to 3 _ 1 will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City . Phone Number Type of work to be -performed .......................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owners Signature: Date: Job Address: Permit# _Any changes to the information provided or this form shall be submitted to the City of Cupertino Build Department. f CITY OF CUPERTINO CUPEkT1NO GENERAL, BUILDING PERMIT APPLICATION FORM Qgo4w-1 APN # Date: -A /3/ 0 Building Address: C 6 5- Mailing Address (if different from building address): Owner's Name: S7 _ Phone#: HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA Contractor: -M t3 � WT?f Phone: SJR"2 � 5 w Fax: Contractor License#: Cupertino Business License#: Contact: �_ Phone: Fax: Residential Commercial ❑ �c �j(� Job Description: C)� q �'k� (cam�f�'-� f,rvJhr � C OA,'�n'j i I �Vk t^(\kQ I Building Permit Info: Bldg ❑ Elect ❑ Plumb �� Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-3 Z —7? Valuation: �� Square Footage: V1— — Project Size: Express [fl/ 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: �— For help, contact Build it Green at www.buildit r.-en.or Revised 02/05/09 aRt, CITY OF C'UPERTINO CITY E T1N© GENERAL BUILDING APPLICATION Cu FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1 STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Winc.ow-structural shear B wall/maso:iry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M I 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E IMECPLNCK Stand Alcne Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alcne Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stE.nd alone 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES ` 1 BSEISMICR Seismic Lesidential B / 1BSEISMICO Seismic Commercial B r 1 TRAVDOC Travel & Documentation B / 1BUSLIC Business License B 5 of 5