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09060141 CITY OF CUPERTINO BUILDING DIVISION PERMIT CtINTRAt Z ` I ' PERMIT NO. BUILDING ADDRESS: 10439 BONNY DR CONNELLY PERMIT ISSUE DATE O'VNER'S NAME: SA CONTROL NO. INE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH SERVIE UPCRADE TO 100 AMP T Z 0 LICENSED CONTRACTOR'S DECLARATION 200 AMP Job Description cd U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 70(10)of Division 3 of the Business and Professions Code,and my license is y in full force and effect. ? License Class Lle•8 C Dam Contractor ARCHITECT'S DECLARATION I understand my plans shall be used az public records aV w Licensed Professional < OWNER-BUILDER DECLARATION the1 hereby affirm that I am exempt from the Contractor's License Lawar 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county m Pi which requires a permit to construct.alter,improve,demolish,or repair any structure y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation C that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9 Sq.Ft. Floor Area t- (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 penalty of APr l Number Occupancy Type not more than five hundred dollars(5500). ❑I,as owner of the property,or my employees with wages az their sole compensation, will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections 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.It. 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 themon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑lam ex under Se ,B&P C for this reason Owner_ Date WORKER'S OM TION DECLARATION I hereby am under penalty luperjury one of the following declarations: I 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 arc: Cartier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($1110) or less.) I certify that in the performance of theork for which this permit is issued.L shall not employ any person i y manift so az become subject to the Workers'Compensation Laws of Califon' -'- Applicant NOTICE TO APP :If.-afterlmakift&fi Certificate of Exemption,you should become sub—jecflS the Workces Compe 'on provisions of the Labor Code,you must `Z forthwith comply with such provisions or Ihis permit shall be deemed revoked. Z O 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.) W ALender's Name az Lender's Address (�0 I certify that 1 have read this application and state that the above information is LL�" correct.I agree to comply with all city and county ordinances and state laws relating to 0 Vbuilding construction.and hereby authorim representatives of this city to enter upon the U above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against � In liabilities,judgments,costs and expenses which may in any way accrue against said City U z in consequence of the granting of th' permit. Date r-- APPLICANT DER NDS D WILL COMPLY WITH ALL NON-POINT Issued by: SOUR GULATI N . Re-roofs awre pelican onlnc Dare T of Roof HAZARDOUS A ALS DISCLOSURE Type Will the applicant or future ti !ding occupant store or handle hazardous material as defined by the Cupertino Munici I Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall t e inspected prior to any roofing material being installed. ❑Yes o he applicant or uture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove Will t it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. JISII1Cl? ❑yes YN. 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 15505.25533 and 25534.1 understand that if the building docs not cu have a ant, it is my responsibility to notify the occupant of the requiremc hich m met r to issuance of a Certificate of Occupancy. Signature of Ap�licant Date orizcd agent Date All roof coverings to be Class'R'or better a CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM 0 bWO/4 APN # Date: icy I 3� 1� DIs-�� Zalo q Building Address: j0q ,3q 2 cup _ (�4 , c7_1_-),a/ Lt Lt Mailing Address (if different from building address): ` Owner's Name:��S�� �o������ Phone#: HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Contractor: Phone: Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial ID Job Description: Building Permit Info: Bldg ❑ Elect M– Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: I-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B IV Valuation: i L5C(1) — Square Footage: Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of thy: 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.builditgreen.o N Revised 02/05/09 am-11 CITY OF CUPERTINO CITY OF GENERAL BUILDINI i APPLICATION CUPEkTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-:structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Perrr.it Fee E 1 MPERMITFEE Mechanical Pe:-mit Fee M 1 PPERMITFEE Plumbing Perna t 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 PlanCheck (when no E/M/P) B when not over counter) hourly-stand alone / 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES I BSEISMICR Seismic Residontial B 1 BSEISMICO Seismic Commercial B I 1 TRAVDOC Travel &Documentation B 1 BUSLIC Business License B 5 of 5 OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (pare-it,spouse or child) will perform �� U A. t' All the work authorized by this permit B. A portion of the work C. — None of the work If B or C is checked,comp ate 2 or 3 below. 2 A state licensed contractor will be hired to do: A. _ 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 utilizeunlicensed person(s) other than my immediate family 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' compens ation must be on file at the City of Cupertino Building Department office. PersoryTirm 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 yOwner's Signature: ' z � Date: Job Address: �G y�� UD/,Z�Z�/ QI�. � . Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department.