09050016BUILDING DIVISION PERMIT
OWNER'S NAME:
ARCHITECrfENGINEER:
acgZ
pp LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Codeand my license is
n H in full force and eftgt.� fLic Z 3 C
v� Z License CI s C ��1 Contractor 'a
AJ
3 t- w Dam AR HrrECTS DECLARATION
J � d I understand my plans shall be used as public records
JyU
4 C H Licensed Professional
n OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
r o O following reason. (Section 703 1.3, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improv, demolish, or repair any structure
n — rn prior to its issuance, also requires the applicant for such permit to flit a signed statement
- ? < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
xF (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 (See. 7044, Business
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 Contractor's L-
eone Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a conuactor(s) licensed pursuant to the Cntractoes
License Law.
❑ I am exempt under Sec. B & P C for this reason
Owner Dam
WORKER'S COMPENSATION 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-
Aon, 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, at required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker"; Comn3adon Insurancc1e carrier and Polity number arc:
Cartier. -Ji4N 4� Policy No:d 77
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section teed not be completed if to permit is far one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workcrs' 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z 0-4 CONSTRUCTION LENDING AGENCY
IA
F~.t 4 I hereby affirm that there is a construction lending agency for the performance of
Ix > the work for which this permit is issued (Sec. 3097, Civ. C.)
W 0 Lender's Name
Z
Lender's Address
V 0 1 certify that 1 have read this application and state that the above information is
L1, Corect. I agree to comply with all city and county ordinances and state laws relating to
OU building construction, ction, and hereby authorize representativesof this city to enter upon the
above-mentioned property for inspection purposes
a(We) agree to saw, indemnify and keep harmless the City of Cupertino against
rA liabilities, judgments, costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERWANDS ANQ WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni' al Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
Cl Yes o
Will the applicant or future building occupant use equipment or devices which
nit hazardous air contaminants as defined the Bay Area Air Quality Management
istrict?
❑ Yes
1 have read 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 tensyyt,� that it is my responsibility to notify the occupant of the
.muuitatmcntt which must br/Ihgf prior tg4ssuattcc of a Ccnifcate of Occupancy.
or authorized
408)367-1660
REPAIR --HIMNEY
. Ft. Floor Area
362Q2030.00
Issued b,
Re -roofs
Type of:Zoof
Number
Job Description
Required Inspections
Valuation
Occupancy Type
l�
All roof: 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 fnaterials for inspection.
Signatur; of Applicant
All roof coverings to be Class" ' or better
Date
PERMIT NO.
PERMIT ISSUE DATE
A O. 9 9
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB MECH
Job Description
Required Inspections
Valuation
Occupancy Type
l�
All roof: 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 fnaterials for inspection.
Signatur; of Applicant
All roof coverings to be Class" ' or better
Date
att----
CITY OF
CUPEkTINO
CITY OF C.UPERTINO
GENERAI� BUILDING
PERMIT APPLICATION FORM
o
APN # �, r „ ar� 0 � /�, �� ,�� (.'� (�
Date:
MCI
Building Address:, r /�-6
Mailing Address (if different from buildifig address):
's Name:
OrL
44 k t &W
Phone #:
_
iia - q1 y �qy �
HOA: (Exterior work only) Yes ❑ No �/
If yes, provide letter from HOA
Contractor:
Phone: 3 �S-- /6z',
Lo " v� ,ti%�✓C
Fax: l
Contractor License #: 6 2- t 3 cl
Cupertino Business License #:
Contact:
Phone: CO
uv vrZ
Fax:
Residential Commercial
Job Description:
Al/Vex
Building Permit Info:
Bldg a Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
/�
1-A, 1-B ❑ II/IIUV-A ❑ II/III B, IV -HT, V. -B U4-"'lam
"
Valuation:
Square Footage:
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:;
For help, contact Build it Green at www.builditgreen.or
Revised 02/05/09
atv�__'
.�'
CITY OF
CUPERTINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE S(�HEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
IACOUSFDW
SFDWL'Duplex New
B
1 ACOUSRESAD
SFDWL'Duplex-Addition/Alteration
B
1 ACOUSCOM
Multi-Family/Commercial
B
CHIMNEY'S
1 CHIMNEY
Chimnev
B
/
1 CHIMNEYR
Chimne- Repair
B
FENCES
1 FENCE>6FT
Non-ma;;onry, over 6 ft in height
B
1 FENCEMAS>6
Masonry, over 6 ft in height
B
FIREPLACES
1 FIREPLMAS
Fireplac ,- Masonry
B
I FIREPLFAB
Fireplac,- Pre-Fabricated/Metal
B
1FLAGPOL>20
Flag pol-_ (over 20 ft in height)
B
1 MODUSTRU
Modular Structures
B
FOUNDATIONS
1 FOUNDREP
Foundation Repair
B
IPILECAST
Pile Foundation Cast in place concrete
B
1PILEDRIV
Pile Foi;ndation Driven (steel, pre-
stressed concrete)
B
3 of 5
CITY OF
AUK TINO
Buildim
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: �,V PHONE #ria — ci I it - 7 VVI
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: Signature I `D� ��
Date
r ? _1_ - _t_ anrq rnmrdpi-p the following information:
Please
elicit
app.L.Kauic----
SUBCONTRACTOR
BUSIrtESS 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
Owner/ Contractor Signature
Date