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09040036 CITY OF CUPERTINO BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 7573 WATERFORD DR E G ELEC'TRICA I'ERM1T LSSUE DATE OWNER'S NAME: r S p CONTROL NO. "ONE: (408) 370-2222 BUILDING PERMIT INFO ARCHTTECTIFNGINEER: BLDG ELECT PLUMB MECH Cd a LICENSED CON'TRACTOR'S DECLARATION Job Description V I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions o,and my license is PNL U PG]2D 100 TO 2 0 0 AMP H in full fora and eft 1 S Z Li en a s ` L� n t- Dam Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records JW U.y Licensed Prufcssional O< OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the p O following mason.(Section 7031.5,Business and Professions Code:Any city or county y m 01 which requires a permit to construct.alter,improve,demolish•or repair any structure Valuation prior to ifs issuance,also requires the applicant for such permit to file a signed statement j Ft.Floor Area Z^= that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q Y F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 2 tj 0 y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation o[ APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of nal more than eve hundred dollars(M). 36617029 . 00 ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure isnot intended oroffered for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does 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 Cont=Oes 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 Contractor's License Law. B&P C for this reason ❑I am exempt under See Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury One of the following declarations: 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 f37Y for which this permit is issued. have and will maintain Worker's Compensation Insurance,as required by Section of the Labor Code,Corthe performance of the work for which this permit is issued. orker's Compensation Insurance carrier and Policy number am: er. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed it the permit is for one hundred dollars($100) or less) I certify that in the (o auce of the work for which this permit is issued,I shall not employ any person' an manner so a�to beCopt�,bjcct to the Workers'Compensation Laws of Calico a D / 1 Applicant NOTICE TO AP ANT: ler making this Certificate of Exemption,you should become s bjLd to the Worker's Compensation provisions of the Labor Code,you mus ,J Z forthwith 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 ALender's Name a Lender's Address C)0 I certify that 1 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 V building construction,and hereby authorise representatives of this city to enter upon the above-mcnuuno grope inspection purlxtses a (We)agree ve,i dcmnify and keep harmless the City o(Cupertina against rA liabilities,judg costs d expenses which may in any way accrue against said City U Z in consequence of c g 'ng of this permit. Date APPLICANT DE TANDS AND WILL COMPLY WITH ALL NON-POINT Issued b; SOUR GULA NS. Re-roofs - Signature of rcant/Contractor Dam T of Roof HAZARDOUS MATERIALS DISCLOSURE Type 1 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 roof: shall be inspected prior to any roofing material being installed. ❑Yes No If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant oruture building occupant use equipment or devices which t hazardous air contaminants defined by the Bay Area Air Quality Management all new r materials for inspection. trict? ❑yes No I have re th haz ous materials requirements under Chapter6.95 of the Califor- nia Health&S ty ode.Sections 25505,25533 and 25534.1 undersand that if the building docs not c ndy ave a tenant that it is my 775�ffi unt of the Date requircm nu wh' h must be met prior to issuaSignatur°of ApplicantAll roof coverings to be Class"a `'or better Owner thorixcd agentre �qoc),,2 CITY OF CUPERTINO CUPEkTINO GENERAL, BUILDING PERMIT APPLICATION FORM APN #� � � � 7() Date: B19� W ddress17xa EkFn(2-bj-4? . Mailing Address (if different from building address): Owner's Name: I � Phone#: 14 CA HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA �o — Contractor: Phone: Z4 cg— S-3vo-- 2� E - 6- ELfEiCT PJCAL (S EU(Y' Fax: Contractor License#: �t Cupertino Business License#: Contact: Phone: 0" -1INS Fax: Residential Commercial Job Description: p)kM aL, 2-(M Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): ccupancy Type: 1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Square Footage: Valuation: Project Size: Express ❑ Standard arge ::1 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. ?oints Achieved: For help, contact Build it Green at www.builditgreen.or Revised 02/05/09 CITY OF C'UPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEkTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Desc ription Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacem,;nt windows/sliding glass B door (ea f windows) I WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanic i1 Permit Fee M I PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alcne Electric Pln Ck (hourly) E 1MECPLNCK Stand Alcne Mechanical Pln Ck (hrly) M 1 PLMBLNCK Stand Alc ne Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone / 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES / l BSEISMICR Seismic I:esidential B 1BSEISMICO Seismic Commercial B / I TRAVDOC Travel & Documentation B 1BUSLIC Business License B /�� 5of5 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 Cl Tlf OF Fax(408)777-3333 r:UPEkTINO Buildi n De artment JOB ADDRESS: PERMIT # 0 OWNER'S NAME: PHONE # GENERAL CONTRACTOR: e. CA FAX# I am not using any subcontractors: _ l� Si;nature ate Please check applicable subcontractors and complete the followinginformation: 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 Met Sheet ck e 4�-1 Owner/Co actor Signature ate