09040140 CITY OF CUPERTINO �r
BUILDING DIVISION PERMIT �*� � � � �� +
PERMIT NO.
BUILDING ADDRESS:
19999 STEVE RE K KOSCH ESE TRI
PERMIT ISSUE DATE
OWNER'S NAME:
A CONTROL NO.
t
(408) 243-3012
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
u O Z
LICENSED CONTRACTOR'S DECLARATION Job Description
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'<y in fullCoreeandeffect INST CEILNG LIGHT(DIMMR) IN BDRM
Z License Class Lic•8
n c Date Contractor KO SH EL EC BUS LIC RENWD 4/27/9
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�yU
`a y Licensed Professional
y.1 OWNER-BUILDER DECLARATION
g� 1 hereby alTirm that I am exempt from the Contractor's License Law for the
C p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter.improve,demolish,or repair any structurer,-H prior to its issuance,also requires the applicant for such permit to file a signed statement Sq Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $145
y 5 a— 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(s5=. 31621090 .303
I,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 Conuactoes License Law docs 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
Las 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 Contractor's
License Law.
❑1 am exem t unde Sect ' f B&P C for this mason
Owner ? YrY UDate
WORD. 'S CO PENS T10N ECLARATlON
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Content 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.
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 Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any maMCriy_y Jcyme subject to the Workers'Compensation
Laws of California.Date `1--T�:C7(y N
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
,'Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[..r.-. I hereby affirm that there is a construction lending agency for the performance of
pG.7 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
0 Lender's Address
1 certify that 1 have read this application and state that the above information is
LUL cormI 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
above-mentioned property for inspection purposes.
W
W (we)agree to save,indemnify and keep harmless the City of Cupertino against
to 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 �r v�
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b:/:
SOUR ULA N 7 LPq
J
C �12 Re-roofs -
Sign t/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of goof
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
Cede,Section 25532(x)? , All roof:;shall be inspected prior to any roofing material being installed.
C]Yes `a' 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
.cit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
13 Yes o
I 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 not currently have a tenant,that it is my responsibility to notify the occupant of the
LO-wner
ents ragent
et prior to issuance of a Certificate Qf {lan�• Signator of Applicant Date
L �( r All roof coverings to be Class'n"or better
au r' Date
r
a�tCITY OF 1--.UPERTINO
CUPEkTINO GENERAI-_j BUILDING
PERMIT APPLICATION FORM
Lo 0 , L -.
APN # Date:
Building Address:
Mailin Address (if differ nt from building address):
Owne 's Name: � �� -Tr-CC n S Phone#: "C L 5
HOA: (Exterior work only) Yes ❑ No
If yes, provide letter from HOA
Contractor: Phone: �C `5- /Cel #
1<'—e `0.V1 i<o". Fax: _�—
Contractor License#: -:�-9 1 9 2
Cupertino Business License#: L-
Contact: Phone: .
(_,c,uv,
Fax:
Residential Commercial ❑
Job Description: vn D _
_� �' / l (l 1� t l (vZ l ✓1 1 �� Y}�:�1 �r�lrib 1
L4 C
Building Permit Info: —/
Bldg El Elect Lid Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B 0''. V—j
Valuation: J�2 Square Footage:
r
Project Size: Express r Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portior 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.builditgj-een.or
M F H 1-�:/,--- I— Revised 02/05/09
CITY OF C.UPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Des,:ription Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/mas3nry (includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechani gal Permit Fee M
1 PPERMITFEE Plumbiq;Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standarc. Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1 BCBSC Cal Bldj; Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1 BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1BUSLIC Business License B
5 of 5
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
;UPEkTINO
Building Department
JOB ADDRESS: PERMIT # t�C'l
jq7qq She cc i y 43Q3 V er-�in o
OWNER'S NAME: 7?- e -j V6 PHONE # OSFq
GENERAL CONTRACTOR: E te ct fi t FAX #
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
7/0 q _
Owner/Contractor Signature Date