09060013BUILDING DIVISION
BUILDING ADDRESS:
10387 AVENI
OWNER'S NAME:
ARCHITECTIENGINEER:
PERMIT
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(X0) of Division 3 of the Business and Professions Code, and my license is
in full force and effect, 4 L6 Q
License Class t� Lie. p (i
cyt
Date Contractor ti J
ARCHITECTS DECLARATIO e_A-^-^/(
1 understand my plans shall be used as public recor
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 for 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 any applicant for a permit subjects the applicant to a civil penally 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 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.).
❑ I, 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.
cerise Taw 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 Date
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-
.on, 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 Workees 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 Compensation Insurance carrier and Policy number am:
Cartier. S (AJ fl" 'Q -Lf %k S IC fkicy No: V a -3w K 0 Z -�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis 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, 1 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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS77RUC ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lender's Address
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
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, toss and expenses which may in any way accrue against said City
in consequence of the grantingis permit.
APPLICANT UNDERSTA AND WILL COMP IT11 ALL NON -POINT
SOURCE REGULATION
Signature of Applican tractor Sam
HAZARDOUS MATERIALS DISCLOSURE
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 We
Will the applicant or future building occupant use equipment or devices which
It hazardous air contaminants as defined by the Bay Area Air Quality Management
.trio?
❑ Yes Nu
1 have read the outs materials requirements der Chapter 6.95 of the Califor-
nia Heallh & Safety C +tions 25505, 25533 and I understand drat if the building
does not currently h L.
that it is my tcspo hi ty to notify the occupant of the
requirements ich be met prior to issuance a crtificate of Oce pan
2 0
Owner or authorized aecnt Date
650) "77-7104
PERMIT NO.
09060013
PERMIT ISSUE DATE
S A CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
-RO" WTR DAMGD SECT (BK OF HSE) 48SQ WDFRM,
YWOOI) & SIDING REPAIR
Sq. Ft. Floor Area
3424504:0.00
Issued b}
Re -roofs
Valuation
Type
Required Inspections
Type of Roof
All roofs shall be inspected prior to any roofing material being installed.
If a roof s install d without first obtaining an inspection, I agree to remove
all new nlateri r inspection.
e
1210 �f
Signature of Applicant Date
All roof coverings to be Class'W' or better
I an CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #13 L-10.9- '/ 5- !� y 0 6
7"
Date: 612
/2 / O
Building Address:'?
I 036-4 )q I c( a�-
Mailing Address (if different from building address):
Owner's Name: S ktPhone
#:
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor:
Phone: b _ ?/
to CA 1610.4
Fax:
Contractor License #: 76 o
Cupertino Business License #: 3 j 0,0
Contact:
Phone: C, c> - (p
mark
Fax:
Residential 14Commercial ❑
Job Description: da I'L4 a q eC� S LL {,0 �'A
(90C K o -614,e h L't S (2 )-
Lt,, o o C �1-a &t -e e w c, c3(
I ,
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
'
1-A, I -B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B
Valuation- Square Footage:
,-6� 3oo0, c�,;,
Project Size: Express 2L,-S'fandard ❑ 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.builditstreen.orgLs�
Revised 02/05/09
�'�� ., CITY OF CUPI;RTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
11GENCOM
PARTITION WALLS
1 SIDEOTHER
1111LG1 1v1 / %+n w1 •v1
Siding all other
B
1 PARTICOMM
Partition Interior Commercial
B
IPARTICOMM
1PARTIR
Partition Interior Zesidential
B
1PARTIR<=30
RETAINING
B
WALL(CONCRETE
Skylight greater than 10 sf or
structural
B
OR MASONRY
ISTAIRS
Stairs -first fligh /ea addt'l
B
1 RETSTN
Standard (up to 5 3 ft)
B
1 RETSP310
Special Design, 3-10' high (up to 50 `)
B
1 SRACKS<=8
1 RETSP 10
Special Design, over 10' high (up to
B
1 SRACKS>8
50')
1RETCRB<
Gravity/Crib Wall, 0-10'high (up to
B
50 ft)
1RETCRB>
Gravity/Crib Wall over 10' high (up to
B
50 ft)
SIDING
1 SIDEST/BK
Siding, Stone & Brick Veneer
B
`7
1 SIDEOTHER
1111LG1 1v1 / %+n w1 •v1
Siding all other
B
SKYLIGHTS
1 SKYL<10 SF
Skylight less than 10 sf
B
1 SKYL>10SF
Skylight greater than 10 sf or
structural
B
ISTAIRS
Stairs -first fligh /ea addt'l
B
STORAGE RACKS
1 SRACKS<=8
Storage Racks (,-8' high (up to 100 sf)
B
1 SRACKS>8
Storage Racks over 8' high (up to 100 B
st)
4 of 5
aE--,
CITY Of
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows)
B
1 WINMEWSTR
New Windovi-structural shear
wall/masonr}- (includes plan ck fee)
B
1 EPERMITFEE
Electrical Permit Fee
E
1 MPERMITFEE
Mechanical Fen -nit Fee
M
1 PPERMITFEE
Plumbing Peimit Fee
P
1 ELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1 MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
1 PLMBLNCK
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 -stand z1one
B
/
1 BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
/
l BSEISMICR
Seismic Residential
B
1 BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
IBUSLIC
Business License
B
5 of 5
�w
X `
CITY OF
`.UPE�TINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building; Department
JOB ADDRESS:
ld�32 4 r9ueLf( 14-
PERMIT # 4J C> 00 I
`P
OWNER'S NAME: kU t- -
PHONE # 6 - W o `r
GENERAL CONTRACTOR: S -
FAX #
4 ('fA 0- L
I am not using any subcontractors:
Signature T Date
Please check annlicable subcontractors and complete the following information:
6-12LO 9
Owner/ Contractor Signature Date
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 ;
6-12LO 9
Owner/ Contractor Signature Date