09050038CITY OF CUPERTI.
BUILDING DIVISION
BUILDING ADDRESS:
OWNER'S NAME:
ARCHITECT/ENGINEER:
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
in full force and—�
License Class '� Lic. 8 1f).L
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I 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 to its issuance, also requires the applicant Cor such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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 Professions Code: The Conuacmes 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 arc not intended or offered for sale. U.
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 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 Contnaor's
License Law.
❑ lam exempt under Sea B & P C for this reason
Owner Date
ORKER'S COMPENSATION DECLARATION
I by anrm under penalty of perjury one of the following declarations:
ve and will maintain a Certificate of Consent to self -insure Ca Worker's Compen-
.on, 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 Compel fation Insurantie c}rri~licy number am:
Carrier ( (X PolickNo.:
CERTIFICA OEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or Icss.)
I cenify that in rform of work for which this permit is issued. I shall not
employ any pe n any subject to the Workers' Compensation
Laws of Cali( D
Applicant
NOTICE TOA fee making this Certificate of Exemption, you should
become subject to the W ' Compensation provisions of the Labor Code, you must
forthwith comply with suc visions 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
I certify that 1 have read this application and state that the above information is
ZteeCI
to comply with all city and county ordinances and state laws relating to
co tion, and hereby authorize representatives of this city to enter upon the
ave menti ed property for inspection purposes
(We) ice to save, indemnify and keep harmless the City of Cupertino against
liabili es, jud mems, costs and expenses which may in anyway accrue against said City
in co ate a of the granting of this permit.
APP UN NDS AND WILL COMPLY WIfH�A�L NON -POINT
SOU EGUL N
Signature V APA' ;V on for Date
OUS MATERIALS DISCLOSUR
Will the applic t Cuturc building oceupan or handle hazardous material
as defined by the Cu o Municipal apter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes o
Will the applicant or future building occupant use equipment or devices which
hazardous air contaminants as defined by the Bay Area Air Quality Management
,rict?
❑ Yes ❑ Nu
4083777512
PERMIT NO.
PERMIT ISSUE DATE
S A CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
a 0 0
Job Description
REPAIR ]IREPLACE FM EXT SHELL UP
Sq. Ft. Floor Area
362070116.00
Issued by:
Re -roofs
Type of Roof
Required Inspections
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 maerials for inspection.
Aread the hvaMous materials requirements under Chapter 6.95 of the Califor-
nia tit Safely Cttdo, Sections 25505.25533 and 25534.1 understand that if the building
docs t rcndy have a tenant. that it is my responsibility to notify the upant of the
requi crus w ' h muss be mel prior to issuance of a Ccnificatc o eap Signature t If Applicant Date
All roof coverings to be Class 'W' or better
CITY Of
CUPEkTINO
CITY OF C UPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
CqoS0o3k
A PN # � j � —7o ( � ,J v
Date: -
Building Address: / l�z
. LG�rZr/I
Mailing Address (if different from building address):
Owner's Name:6, '/ —'*? '/v cK-
Phone 4:3� 3 — /5 97
Contractor: . I� �Z
Phone:
S./i? bpi
Fax: a 77 7-5/.3
Contractor License #: 3 'S--
S--Cu
ertino Business License #: —2 1,2
Cupertino
Contact:
Phone:
Fax:
Residential Commercial ❑
Job Description: �- .pezile
Building Permit Info:
Bldg Pr� Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ 1I/111 B, IV -HT, V -BR=
--3
Valuation: 65 300 ,cg--
Square Footage:
Project Size: Express Standard 0 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.buildiit reen.or
Revised 10/20/08
ax CITY OF (�UPERTINO
CUCITY
TYOF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
I ACOUSFDW
SFDWL/I)uplex New
B
IACOUSRESAD
SFDWL/I)uplex-Addition/Alteration
B
1 ACOUSCOM
Multi-Far.lily/Commercial
B
CHIMNEY'S
1 CHIMNEY
Chimney
B
1 CHIMNEYR
Chimney Repair
B
FENCES
1 FENCE>6FT
Non -masonry, over 6 ft in height
B
I FENCEMAS>6
Masonry, over 6 ft in height
B
FIREPLACES
1 FIREPLMAS
Fireplace Masonry
B
1 FIREPLFAB
Fireplace Pre-Fabricated/Metal
B
1 FLAGPOL>20
Flag pole (over 20 ft in height)
B
1 MODUSTRU
Modular ;Structures
B
FOUNDATIONS
1 FOUNDREP
Foundatic n Repair
B
I PILECAST
Pile Foun lation Cast in place concrete
B
1PILEDRIV
Pile Founlation Driven (steel, pre-
stressed c :)ncrete)
B
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ae�
CITY OF
CUPEkTINO
CITY OF C."UPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1 STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea :3 windows)
B
1WINMEWSTR
New Winlow-structural shear
wall/masonry (includes plan ck fee)
B
1 EPERMITFEE
Electrical 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
when not over counter)
Standard Plan Check (when no E/M/P)
hourly-st�Lnd alone
B
1
1 BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
I BSEISMICR
Seismic F.esidential
B
1 BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
1 BUSLIC
Business License
B
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