09060168 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � QR +�k �� '
BUILDING ADDRESS: PERMIT NO.
7552 ERIN WAY TBD — TD BE D
OWNER'S NAME: PERMIT ISSUE DATE
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_.,7 SXIhyAi 2809 CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
acd Z
pp LICENSED CONTRACTOR'S DECLARATION Job Description
U F l hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
<e. in full force andcffect. RMV WOOD SHNGLS FM EXTERIOR OF HOUSE & REPLC WITH
z License CI Lie.8 1 '� .l.
,�'-, o Date Contra��•l T� X22.4 STUCCO — CENTURY REMODELING PD FOR BUS LIC 6/30/9
RCHI7ECT S DECLARATION
i I understand my plans shall be used as public records a EA, /Z) <
d
U E i'arl
`c H Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y s Pi 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 Valuation
sthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $9200
y 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 APN Number Occupancy Type
not more than five hundred dollars(S=. 35921030. 00
❑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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q
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.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-
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 Caw.
❑I am exempt under Sea B&P C for this reason
Owner 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-
.don,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 Worker's Compensation Insuranc/e�grrcr and Policy number are:
Cartier. C)t_�``' Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Trot 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.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 Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z"' CONSTRUCTION LENDING AGENCY
E~.t I hereby affirm that there is a construction lending agency for the performance of
p!> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Lender's Address
U O I certify that I 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
O Vbuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
indemnify and keep harmless the City of Cupertino against
CL (We)agree to save,
c,n liabilities,judgments,toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit Date
APPLICANT UNDERSTANDS AND-WTtbCOMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
0.4- (o J 4 U Q Re-roofs
Signature of Applicant/Contractor Dara T Of F.00f
HAZARDOUS MATERIALS DISCLOSURE Type
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)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes 411.
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
nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
istrict?
❑Yes 14 No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
docs not currently have a reranresponsibility to notify the occupant of the
mquiregLents which mu met prior to iss ra Certificate of Qc pan
C, Signature of Applicant Date
Owner or autho�nAoaagcnl
Date All roof coverings to be Class in"or better
ogocp of(oe
CITY OF CXPERTINO
CITY OF
CUPEkTINO GENERAI__j BUILDING
PERMIT APPLICATION FORM
APN # .� �vDate: . 30-01
,,_�5aA3 0 , p�
Building Address: S'S 2 F R I !v (/V A Y
Mailing Address (if different from building address):
Owner's Name: (ZAT �( !ti J-�, /1 Zf jZ Phone#: �'G _`T_7'7_ Q7
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: j Q e- F--, KA J Phone: q d L 36 Lp ` y 0 cC e of
Fax: t/0 a27 2-- 3 6-7 V
Contractor Lice se#:
!377 �-
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial El
Job Description: �1r� ue
R
Building Permit Info:
Bldg N Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): OccupancyType:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT,V-:3 N;
Valution:_ Square Footage:
Project Size: Expressi2n Standard ❑ Large 1] 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.buildit2r�!en.or
Revised 02/05/09
C CITY OF C.UPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPE(�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
IGENCOM
.._ I STUCOAP Stucco A plications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Wir.dow-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing;Permit Fee P
I 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 Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 1 BSEISMICR Seismic:tesidential B
1BSEISMICO Seismic Commercial B
I 1 TRAVDOC Travel & Documentation B
1BUSLIC Business License B
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