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09050146 CITY OF CUPERTINO BUILDING DIVISION PERMIT G�1 ' `RAC? Z �U 'T��1 • BUILDING ADDRESS: PERMIT NO. 20800 VALLEY GREEN DR #464 TBD — TO BE DETERMINED 09050146 OWNER'S NAME: PERMIT ISSUE DATE 'ONE: SA AR CONTROL NO. ARCHITEC IENGiNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 (� a o p LICENSED CONTRACTOR'S DECLARATION Lu I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is =y in full force and effect INSTL VASHR & DRYR UNITS IN SIDE COMM'L APT BLDGS Z License Class Lic.M n F, Date Contractor ARCHITECTS DECLARATION a U 1 understand my plans shall be used as public records L u.y Licensed Professional OWNER-BUILDER DECLARATION t I hereby affirm that I am exempt from the Contractor's License Law for the LOO following reason.(Section 7031.5,Business and Professions Code:Any city or county m BZg which requires a permit to construct,alter,improve,demolish,or repair any structure y Z prior to its issuance,also requires the applicant for such permit to rile a signed statement _ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation X f-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or f R E that he is exempt therefrom and the basis for the alleged exemption.Any violation of $100 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than rive hundred dollars(5500). 32609040 .464 p y yp [11,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 Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections 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 sa 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 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. ❑I am exempt under Sec. B&P C for this reason Owner MJAZA r--\n.tJLl1J', Date 15 �Z WORKER'S COMPENSATION DECLARATION I 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- ..rn,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Workces 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. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or Icss.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manpt elO uWJic�roosuhicct to the Workers'Compensation Laws of Califorid to .i7 1 LL 1 CJ�C Applicant 7m-- -- - ^-✓�'�— NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must .J C:) forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction tending agency for the performance of �i the work for which this permit is issued(Sec.3097,Civ.C.) W�.Q Lender's Name ]Z Lender's Address U C) I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. L1. (We)agree to save,indemnify and keep harmless the City of Cupertino against �..�rA liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUrtRCEREfLATIO S 11 �r l�.t.t..t,� L5 12-2-1 0�'i Re-roofs Signature of Applicant/Contractor I lbate HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? / ❑Yes [$No All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices which If a roof is 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 mi.terials for inspection. .trict? ❑Yes �1u 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 tenant,that it is my responsibility to notify the occupant of the requirements which must tic mme'l P'or to uance of a Certificate of c7ap�n Signature of Applicant Date *Iyn I must "` ac, ` s�`"`' All roof coverings to be Class'A"or better Owner or authorized agent DW EFS CITY OF C.UPERTINO CUPEI�TINO GENERAL BUILDING PERMIT APPLICATION FORM APN# , I (� Date: OC Building Address: �/ l / f z� <W(50 E.� 1 e 6,/Cec.� �� L4 6 l Mailing Address (if different fr �n building address): 7,cU-L Owner's Name: S Phone#: U i? HOA: (Exterior work only) Yes U No �Ip -OZ60 If yes, provide letter from HOA Contractor: Phone: Teo Fax: Contractor License#: _T_ Cupertino Business License#(� Contact: Phone: qdg, Fax: 8- 25 Residential Commercial El Job Description: 1-7,ra 5�� W r.c1.e, P Building Permit Info: Bldg V Elect M� Plumb Mech L� Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Rf 14- 2— Valuation: Square Footage:. Project Size: Express ❑ Standard N 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. Ants Achieved: For help, contact Build it Green at www.builditg .n.or Revised 02/05/09 I . CITY OF CUPERTINO CUP TOF NO YGENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additionE.1 stucco application 1 WINREP Replacer.lent windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1EPERMITFEE Electrica. Permit Fee E / 1 MPERMITFEE Mechanical Permit Fee M / 1 PPERMITFEE Plumbing;Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK 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) hourly-st ind alone 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES / 1 BSEISMICR Seismic l:esidential B IBSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1 BUSLIC Business License B eO Gfl E(Z 5 of 5 OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child)will perform: A. All the work autho:-3zed by this permit B. A portion of the we-rk C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hirec L to do: A. Vf All of the work B. A portion of the work (complete section below) Contractor Address/City. Phone# State License # Type of work to 3. _ I will utilize unlicensed person(s) other than my immediate fanvly to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City . Phone Number Type of work to be performed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owners Signature: QDate: 21 D _ job Address: .20ODo -#V I Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CIV OF Fax(408)777-3333 ''UPEkTINO Building Department JOB ADDRESS: PERMIT # 10,8n Vc�11e free OWNER'S NAME: PHONE # ' 0 -2S3—QZD(D GENERAL CONTRACTOR: FAX # I am not using any subcontractors: �Q �r1-v►-.%� S 2 2 b 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 2,211 Owner/Contractor Signature Date