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09060159 CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING)ADDRESS: PERMIT NO. 'TA PT.TTMRTT'n' ncmrni ;q WNER'S NAME: PERMIT ISSUE DATE PHO SA CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO COPPER REF IPE THROUGOUT BLDG ELECT PLUMB MECH Liao LICENSED CONTRACTOR'S DECLARATION U I hereby affirm that I am licensed under provisions of Chapter 9(commencing HOUSE 1 FIXTURE Job Description with Section 7000)of Division 3 of the Business and Professions Code,and my license is y in full force and ]'�2 License Class e G Lic.* 9 i:4-z�if Date if— 1 Contrutor jdg!2d-A ARCHITECTS DECLARATIO- V� UI understand my plans shall be used as public records Lit6 C y Licensed Professional n y OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county e m� which requires a permit to construct,alter,improve,demolish,or repair any structure Z yy 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 S Ft.Floor Area 1:2 c p p ( P q. Valuation c h (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 6 .. 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 API J Number Occupancy Type not more than five hundred dollars($5001 ❑1,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 sale.). [-11.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. ❑1 am exempt under Sec. B&P C for this reason vner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,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 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 are: Carrier./St7ifpYl La o /0/1 Policy No.: i G'0�/ G7,9 7 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 manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Ccrtilicate 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. 7 CONSTRUCTION LENDING AGENCY I hereby atfinm that there is a construction lending agency for the performance of i> the work for which this permit is issued(Sec.3097,Civ.C.) ALender's Name z Lenders Address 0 I certify that I have read this application and state that the above information is V► 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 W above-mentioned property for inspection purposes t p h (We)agree to save,indemnify and keep harmless the City of Cupertino against t 0A liabilities,judgments,costs and expenses which may in any way accrue against said City Z in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. .LG'o Re-roofs Signature of licant/Contractor Date 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 Safely de.0Yeess 25532(a)? 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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes dNo I have read the hazardas materials requirements under Chapter 6.95 of the Califor- nia Health&Safcty 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 be met prior to issuance of a certificate of Occupancy. Signature of Appl:cant Date All roof coverings to be Class"A•ar or better r'"' - �authorized agent Date' g Community Development a 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 CUPEkTINO Buildin ; Department JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # ,t o 2 G 6 ' GENERAL CONTRACTOR: ft-,�- �,► FAX # Sfa Z6 I am not using any subcontractors: Signat ire Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINES,3 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 µ CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPEi�TINO PERMIT APPLICATION FORM ()96U l APN# 3 2to O 1 a Date: — 2 G Building Address: jg�AR Owner's Name: Phone#:yr p g -7-X'> ,-6,, 6 1-1 01 r bot. G f ✓ Contractor. t Phone#: So. 246 S-1 r--5 9 v Fax#: Contact: Phone#: /til c ,,( Fax #: Contractor License#: q t2-,LqLr Cupertino Business License#: Job Description: GprwR,- ,r.c,i, -tl....aL-�Lk V4-i;--� 1 <1 Residential Cor.unercial ❑ Valuation: 14 s Project Size: Express Standard ❑ Large major Green Building: Please complete relevant portion of tb a Green Building Checklist& attach it to the application or if applicable, include in plan set& the slieet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 11CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial Gas Pip]ng System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY OF CUPERTINO REPIPE/SEWER/NUIIN SERVICE CUPEk ANO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1 BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Cutlets P 1PPERMITFEE Plumbing Permit Fee Is;;uance P 1 PLMBLNCK Plumbing Plan Check P 1 PLMBINSP Other Plumbing/gas Ins-?. P 1TRAVDOC Travel &Documentation Fee B 1 BUSLIC Business License B