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09060132 CITY OF CUPERTINO BUILDING DIVISION PERNIIT BUILDING ADDRESS: PERMIT NO. N 'RESIDENTIAL OWNER'S NAME: SERVICES OF CA PERMIT ISSUE DATE ^HO A 0 9 CONTROL NO. 82-0405 ARCHCIECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a Op LICENSED CONTRACTOR'S DECLARATION O (� m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is 'may in full force andeffecL SPOT REPAIR UP TO 5FT & INSTALLING BLDG. CLEAN OUT j Z License Class Lic.S p Date_ Con e AR HDECLARATION DEC1-AR ON �y I understand my plans shall be used as public records U a L Wo Licensed Professional 3 OWNER-BUILDER DECLARATION MI hereby affirm that 1 am exempt from the Contractor's License Law for the a following reason.(Section 7031.5,Business and Professions Code:Any city or county K Pi which requires a permit to construct,alter,improve,demolish,or repair any structure y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement F=`e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation y F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y that he is exempt therefrom and the basis for the alleged exemption.Any violation of 8-4500 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($500)_ P Y YP ❑I.as owner of the property,or my employees with wages as their sole compensation, 36923028 . 00 will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Conuactoes 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 sak.). ❑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. r� - cense Law does not apply to an owner of property who builds or improves thereon,and. a who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's R License Law. ❑1 am exempt under Sec ,8&P C for this reason p !Ai 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- .ron,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 Insurance �race carrier and Policy number am: Cartier. 4e✓ Tn/5 Policy No.: � o f 'CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed it 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 Ccnificatc of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. z r'" CONSTRUCTION LENDING AGENCY E.r 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.) aA Lender's Name z Lender's Address U 0 I certify that i have read this application and state that the above information is Vw►" correct.I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the a shove-mentionc y for inspection purposes (We) ice to sa ,indemnify and keep harmless the City of Cupertino against f� liabilities,j gmews,co is and expenses which may in any way accrue against said City V z in conseq race oC the g ung of this permit A •+ APPLIC NT UNDE ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date l/7 SOUR REGULA Re-roofs Signature pplicanUCon 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 Safety Code,Section 25532(a)? _ / ❑Ya No All roofs ihall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices which If a roof i;installed without first obtaining an inspection,I agree to remove t hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection. rict? ❑Yes No 1 have ad the ardous maten Is requirements under Chapter 6.95 of the Califor- nia Hcalth& afety C ,Sections 25505,25533 and 25534.1 understand that if the building does not cu ndy ha a tenant that it is my responsibility to notify the occupant of the mquiremc which in t be met prier to issuance of a certificate of occupancy. Signature of Applicant Date Owner or au horize agent p Date All roof coverings to be Class or or better CITY OF CUPERTINO REPIPE/SEWF,R/MAIN SERVICE CUPEkTiNO PERMIT APPLICATION FORM APN#g vI D te: 2-3 0 Building Address: Owner's Name: Phone#: U �� U _p (�V✓� Contractor: Phone#: �q�eScu — ZU0� Fax #: Contact: Phone#: L109- 2 f09- Fax #: Contractor License#: Cupertino Business License#: Z f a L Job Description: ��-- Residential Commercial ❑ Valu tion: V!�W �- Project Size: Express R Standar La-ri­eEl Major Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary Sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping 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 C'UPERTINO "` RIM REPIPE/SEWEAIN SERVICE CUPEI�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1 BCBSC Cal Bldg Standarc s Commission B ALL PERMIT Fee TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential buildi:lg P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pip:per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1 PGASRES Residential Gas P iping System P 1-4 Outlets 1BPGAS Gas Piping System 5+ Outlets P / 1PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Insp. P / 1TRAVDOC Travel & DocumEntation Fee B 1BUSLIC Business License B Community Development V F':• 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 #'UPEkTINO Building Department JOB ADDRESS: PERMI /a (o WS ,�,— Y OWNER'S NAME: Gevv PHONE # 17 GENERAL CONTRACTOR FAX # I am not using any subcontractors: Z 3 G C( §nAture Date Please check applicable subcontractors and complete the following information: 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