09050097 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � '` �� `
BUILDING ADDRESS: PERMIT NO.
PERMIT ISSUE DATE
OWNER'S NAME:
A CONTROL NO.
(408) 535-0420
BUILDING PERMIT INFO
ARCHr ECT/ENGINEER:
BLDG ELECT PLUMB MECH
3,11
o Z LICENSED CONTRACTOR'S DECLARATION Job Description
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 Code,and my license is
h in full force and effect 11Z STUCCO :?,E PA I R
j Z License Cl Lic•# `la/� /
C-0 Datc Contractor /
7W ARCHITECTS DECLA TION
ee 1 understand my plans shall be used as public records
;yU
4 C in Licensed Professional
y 3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
po following mason.(Section 7031.5,Business and Professions Code:Any city or county
K,�, 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
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
A 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(5500). 31644035 . 00
❑1,ss 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.70".Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
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-
eine Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractaKs)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
OwnerDate
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 Workees 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 arc:
Cartier. nj^, I Its,i Policy No.:?I we o l
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
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
0
Z"4CONSTRUCTION LENDING AGENCY
[~i rA 1 hereby affirm War there is a construction lending agency for the performance of
p;5 the work for which this permit is issued(Sec.3097,Civ.C.)
a A Lender's Name
Lender's Address
U O 1 certify that I have read this application and state that the above information is
(L n. cored 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
Uabove-mentioned property for inspection purposes.
>4 Wa (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 y
U Z in consequence of the granting of this permit
P-4 APPLICA UN ANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
Date — F,c)y
S E U NS.
Re-roofs
so.. pplicam/Contractor ato 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
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONo
If a roof
Will the applicant or future building occupant use equipment or devices which
.s installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
,tstrict7
❑Yes �(o
1 have read the hazardouss m_atcnals 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 ha ant that it is my responsibility to notify the occupant of the
reqs; nts 'c be met prior nonce of a certificate of Occu •G U Signature of Applicant Date
All roof coverings to be Class'n"or better
0w er or prize agent Date
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CITY OF CUPERTINO
C�
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
J APN# U\� Date: `' / o I
Building d ress: /� C
Mailing Address (if different from building address):
Owner's Na e: I �( Ijq Phone#:
' y
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter.from HOA
Contractor: Phone: L qr Ly 4
Dt-O( ¢�w• (/LL Fax:
Contracf6r License#: U
Cupertino Business License
Contact: �'� L .�rr�-U,'� Phone:
Fax: — J
Residential [ Commercial ❑
Job Description: sq-tx-ct O k1-zy'a X,,r
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type: / -_5
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Valuation: Square Footage:
Project Size: Express❑ Standard ❑ Lar e :j Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicabl include in plan set &the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit r 3en.or
Revised 02/05/09
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
CUPERTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
,ISTUCOAP Stucco Applications (up to 400 so B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door ea 8 windows
1 WINMEWSTR New Window-structural shear B
walUmason includes plan ck fee
lEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B
when not over counter) hourl -st;ind alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel&Documentation B
1BUSLIC Business License B
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