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CITY OF CUPERTINO
PERMIT
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20530 TOWN CENTER LN
TBD — To BE DETERMINED
09010108
'ER'S NAME:
PERMTr ISSUE DATE
S A CONTROL NO.
PHONE:
ARCH1TEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
T.I. 1 :3THRM, ELECTRICAL & MECHANICAL STAY SAME
in full force and effect
License Class Lic. x
(114 6 S Q 1
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
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 u) its issuance. also requires the applicant for such permit to file a signed statement
9
Sq. Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
(commencing with Section 7010) of Division 3 of the Business and Professions Code) or
$8000
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 ($500).
36955082- . 01
❑ I, as owner of the property, or my employees with wages as their sok 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 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
sale.).
as owner of the property. am exclusively contracting with licensed contractors to
�I,
truct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law docs 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.
❑ I am exempt under See B & P C for this reason
ter ---Date
WORKER'S PENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 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.
❑ I have and will maintain Workcr'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 are:
Cartier. 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 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
2' forthwith comply with such provisions or this permit shall be deemed revoked.
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.)
Lender's Name
Lender's Address
D1 certify that 1 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
~ building construction, and hereby authorirt representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in an way scenic against said Cil
n 1 g fx Y� Y Y g Y
in consequence of the granting of this permit
Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON OINT
Issued by:
SOURCE REGULATIONS.
_ _ `T /
-
Re -roofs —
Signature of Applicant/Con-""'" Date
HAZARDOUS MATERIALS DISCLOSURE
Type Of Roof
Will Tho applicant or future building occupant store or handle hazardous material
n defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
de. Section 25532(x)?
All shall be inspected prior to any roofing material being installed.
❑ Yes 9� No
roofs
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new rr aterials for inspection.
District?
❑ Yes No
1 have read the hasardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Section 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
'or
Date
requirements which must be met p to issuance of a Certificate of Occup
/Y/
Signature of Applicant
V-q
All roof coverings to be Class 'A!' or better
Owner or authorized agent '
1L7111_`
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File Edit Actions Details Links Favorites Help
Permit Number % 09010108
Address" I
20530 TOWN CENTER LN
(OK J
Status" C- Closed
City/State/Zip
CUPERTINO CA 95014
14v Back
Master Number IQI Notes
3
APN
36955082.014
Unit
I Contractors
Project
IQI
Apply Date 01/26/2009 Operator
pakg
lil,,,,-;_., _;,,!��,_,
r_,,;;i:,;,-.,,
Fees
Permit Issue Date 04!16/2009 Operator
pakg
I Owner Name
"I ZHONG XIAM TAO
I Plan Reviews
Certificate Issued 06117!2009 Operator
PALM
Use Default
Inspections
Certificate Type
Address
Home - 20530 TOWN CENTER LN
Certificate Number
[4` Print Permit
City/Skate/Zip
CUPERTINO CA 95014
lra •',Adjustments
Permit x Property Zoning Applicant Contractor "
Defined Fields
IF Holds
Permit Details
Purpose/Special Conditions
F-}] Copy Permit
Permit Type 1B TI IQI
T_ I _ 1 BTHRM, ELECTRICAL 6 MECHANICAL STAY SAME
l Close Permit
TENANTIMPROVEMENT
(1146SQ)
—
�-% Overrides
Usage Class" IIIIII B, QI
IIIIII B. IV-HT,V-B NEW
FILMED 6/2011
[_.-�L Supplemental Fields
Applied Value " 8000
Notes
SQUARE FT. 1146
Calculated Value 0 II
Q
I� Attachments
US C-404 Type 437 IRI
ALT: NON-RES, NON-HSKPG
I
Permit Form x AUTOPERM - PERMIT
Ownership 1 -Private
Project Size EXPRESS -EXPRESS
I[]Add Default T
Permit issued 04J16J2009
Enter the purpose or any special conditions for this permit
BUILDING DIVISION PERAUT
BUILDING ADDRESS:
20530 TOWN CENTER LN TBD — TO BE
OWNER'S NAME:
PHONE:
u O 0 LICENSED CONTRACTOR'S DECLARATION
to
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z
t,` j with Section 7000) of Division 3 of the Business and Professions Code, and my license is
n < a in full force and effect
j n ? License Class _ Lic. p
F ats Date Contractor
r
, ARCHITECT'S DECLARATION
0.
U 1 understand my plans shall be used as public records
U. rn Licensed Professional
n w
OWNER -BUILDER DECLARATION
Yy<f
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
% ❑ O following mason. (Section 7031.5, Business and Profusions Code: Any city or county
K m 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
_zr
< that he is IieeuuJ pursuant to the provisions of the Contractor's License Law (Chapter 9
F=❑
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y .. 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
not more than five hundred dollars (5500).
❑ 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
and Pmfcssions Code The Conttactoes 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
sale.).
0 1, as owner of the property. am exclusively contracting with licensed contractors to
tdnswct 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 contractors) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner
WORKER'S CWPENSATION DECLARATION
I hereby affirm ander penalty of perjury one of the following declarations:
❑ Iha+ and will maintain a Certificate of Consent to self -insure for WorkersCompen-
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:
PEKMI l IVU.
D 09010108
PERMTT ISSUE DATE
S A 0 9 CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
T.I. 1 BTHRM, ELECTRICAL & MECHANICAL STAY SAME
(1146SQ)
Sq. Ft. Floor Area Valuation
8000
APN Number Occupancy Type
36955082.01
Required Inspections
Cartier. Policy No,:
CERTIFICATE OF EXEMFTION 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 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 Workcri Compensation
Laws of California. Date
Applicant d
NOTICE TO APPLICANT: If, after making thts� rtificatc of Exemption, you sh old
become subject to the Workces Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z — CONSTRUCTION LENDING AGENCY
.-y
Fr o --r 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)
WLI. A Lenders Name
a z Lenders Address
U O I certify that 1 have rad this application and state that the above information is
CL '-' correct. 1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction. and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
cn liabilities, judgments, costs and expenses which may in any way accrue against said City
tJ Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT Issued by:
SOURCE REGULATIONS.
Signature of Applicam/Contnccmr""-"'"' Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstom or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
C] Yes NNo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcrrncd by the Bay Area Air Quality Managcmcnt
District?
❑ Yes Idl No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be mel pr or to issuance of a Certificate of Occuppncy., l
Owner or
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "_ ' or better
S�-
CITY
OF
CUPEkT1NO
CITY OF CUPERTINO
TENANT IMPROVEMENT
PERMIT APPLICATION FORM
Dqol of og
APN # _
Date:
Building Address:
Mailing Address (if different from building address):
'>0
( v YK
Tenant F (f t6riant please provide a fetter from6the building owner approving the tenant improvement.)
Building Owner ❑
Tenant/Building Owner's Name: �
Phone #:
�
Contractor:
Phone #:
7-
Fax #:
Contractor License #:
Cupertino Business License #:
Contact:
Phone #:
—5Gls AM
Fax #: (ZDe) 4y
Alternate Contact:
Phone #:
Fax #:
Valuation (cost of project):
Job Description (be specific):
i
Tenant Improvement Includes e -Roof: Yes ❑ NoE] If yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No �(
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V-B�
—
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete Leed for commercial interiors checklist & attach it to the application
or if applicable, include in plans & sheet index
LIKED Points Achieved
*** For Office Use Only*** Over The Counter ❑ Revised 8/08/08