09060086 +I��Q� '�Ia►N,
PERMIT NO.
CITY OF CUPERTIN PER T
BUILDING DIVISION PERMIT LcisUEDATE
BUILDING ADDRESS: F H
CONTROL NO,
S A
OWNER'S NAME:
BUILDING PERMIT INFO MECHO
� BLDGELECT PLO
ARCHITECT/ENGINEER
: Job Description
ACTOR'S DECLARATION OUTLET TO NEW CEILING
5 a Z LICENSED CONTR provisions of Chapter 9(commciicing WALL SW
FM
u O o t I am licensed under p and my license's R E_TOUTE
m I hereby affirm! .
U wits Section 7000)of Division 3 of the Business and Protcssions LIGHT •� LIGHT BOX
n. in full force and effect. Lic.�[ pANELL IN HALLWAY W/4
vi i License Class��Contractor LIGHT
G—an Dam ARCHITECTS DECLARATION & REPLC
3 t:md as Public records
tt
2:J l understand mytj
plans shall be used
Eft
W F Licensed Professional OWNER-BUILDER DECLARATIONfor the
O< t from
the Contractor s Lac City
wo coumy Valuation
n , I hereby afTtrm that 1 am exempt air any structure
p o following reason.(Section 7031.5,Business and Professions Calc:Any Y ;q Ft Floor Area
1.m which requires a permit to c t liter-ant t i nliit t o i rep signed statement
rmittofile s
"y riot w its issuance,also requiresenvisions of the Contractor s License law(Chapter 9 Occupancy Ty
Prior he is licensed pursuant to the p violation of APN Number
and rte basis for the alleged exemption.Any
Y F G (commencing with Secuon 7000)of Division 3 of the Business and Professions C or
a that he is exempt therefrom permit subjects the applicant to a civil penalty of •O 0
Section 7031.5 by any applicant for a pe 3 2 6 4 3 0 8
s as their sole compensation. Required Inspections
not more than five hundred dollars(y employees
with wage 7044,Business
�I,as owner of the property,or mY employees
The Contrxwt I License Law does not apply w an owner of
iJlll do the work and the structure is not intendede a w do for sale(See,It or through his
and Professions Code: ves thereon,and who does such workhorse for age-If.
property who builds a impro improvements are not intended or the owner-
own employees.provided that such imp ar of completion.for purpose o[
however,the building or improvement g that within not build or improve
builder will have the burden of proving
to
sale.). with licensed contractorses Li
(]I,as owner of the property,am exclusively contracting ,�Conuacto
(Sec.7044.Business and Profvessions ho bui,dsor improves Hereon,and.
construct the project n1 w an owner of Property licensed pursuant w the Contractor's
cense law docs not appy.cI3 with a contrxtor()
who contracts for such Prole g gr,p C for this reason
License Law.
C]I am exempt on er�
Dam
OwnerW ORKI;IYS OMPENSATION DECLARATION
I here y affirm under penalty of Perjury one of the following declarations:
Certificate of Consent w self-insure for Worles Compen
I hs+e and will maintain a -
cation.as provided for by
Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued tion Insurance
as required by Section
performance of the work for which this Permit is issued.
(]I have and will maintain Workers Compo number are:
3700 o[the labor COde.for the pe
My Workers Compensation Insurance Cartier and Polity
Policy No.:
Carrier. CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE dollars($100)
MIA section need not be completed if the permit is for one hundred
or less) permit is issued.I shall not
performance of the work[or hich thio Wow,Compensation
1 certify that inn in in anY manner
employ any Pc
Laws of califomi a tion.You should
Applicant ng this Ccrtificam of ExemP Coda You must
A
NOTICE TO er's mpcnsation provisions of the Labor
become subje Work
with such provisions or this permit shall be domed revoked.
Z forthwith coin Ip Y
CONSTRUCTION LEtNDlend ng agency for the performance of
(A 1 hereby affirm that tiers is a constcuc
permit is issued(Sec.3097,Civ.C.)
ice.+ rte work for which this pe
W Lender's Name
Lender's Address
1 certify
that I have read this application and sate that the above information is
U agree to comply with all city And co reesentat vies of this cityand t to enmlaws dupon tic
►+ cortcct.l ag
O V building conswction.and hereby authofi7t
coon Purposes. n[Cupertino against Date
above-mentioned penperty for inspe harmless City
�+W (We)agree to save.indcmnif which may in any way accrue against said City
E''p liabilities.judgments,costs and expensesPermisned by*t-in consequence of the granting of this pc
V APPLICANT UNDERO S NDS AND WILL COMPLY WITH ALL NON-POINT Re roofs
SOU CE U
Oj�/D#a _ Ty�e of Roof
S' o Ate; ontracO ALS DISCLOSURE aterial being installed.
HpypRDOUS MATERIALS
store or handle hazardous material y TOOfIn m
Will the
applicant or future building occuP9.12•and the Health and Safety ected I agree to remove
Al roofs shall be insp prior to an
the Cupertino Municipal Code,Chapteran ins inspection,
as defined by without first obtaining P
Cove,section 25532(x)1 No If a roof is installed
❑Yeavices which materials for inspection.
Occupant use equipment�i al l new
Will the applicant or future building by tthC Bay Area Air Quality Managcmcm
fait haiafdnus air contaminants as defined by
District? [x Nu
0 Yes T ter 6.95 of the Califor-
�usmaterialsrequiremcntsunvcrCha�d�mifahc building Date
I have read the hazard, 25505.25533 and 25534.1 undo dte occupant of the — Applicant
niaHcalth&SafetyCodc,Secuons responsibility to notify rt "UT better
docs not curtanty have a tenant,twat f t i u��of a Cerufi a Signature of App
requ' m is which must be met p O All roof coverings to be Class .
Dam
or authonagent
2l
C)�0 C)�
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # � � Date:
�2t c v
Building Address:
IO 6 3 a CRsTimf: Ave-Nuc-
Mailing Address (if different from building address):
Owner's Name: Phone#:
JEF F N v L--r-GL I s,_
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 ❑
Job Description:* (?F te0j)T-C UALLL ZWrTGH f-ROM
T_o Nf Vj C L 1 tJG0C H T
° RCFLA CC- Lla)-j i PRtjrt-- IA) HAIL WAY
Vol L-4 GH T--
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Valuation: 2 Square Footage:
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicab:e, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.budditg een.or
Revised 02/05/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPERTINO
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)
IEPERMITFEE Electrica. Permit Fee E
1 MPERMITFEE Mechani:al 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 Standarc. Plan Check (when no E/M/P) B
when not over counter) hourly-s:and alone
1 BCBSC Cal Bldg, Standards Commission Fee B ALL PERMIT
TYPES
l BSEISMICR Seismic Residential B
—4- 1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1 BUSLIC Busines 3 License B
5 of 5
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF
Fax(408)777-3333
rUPEkTiNO
Buildipi De artment
JOB ADDRESS: PERM_
f o 6 3 o CA�6-"�£ - b 13b
OWNER'S NAME: � �, t .�T'- P ONE # '?3 Z 3 Z.
GENERAL CONTRACTOR: FAX #
------
I am not using any subcontractors:
Sif ature D to
Please check applicable subcontractors and complete the following ' 0 tion:
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
owner/Contractor Signature Date