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09060091 CITY OF CUPERTINO BUILDITNG DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. 10678 FARALLONE DR TBD - TO BE DE09060091 OWNER'S NAME: PERMIT ISSUE DATE VTTT�T(` HO ('HU NG, (eH�d6��lf� INE: S A CONTROL NO. BUILDING PERMIT INFO ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH 0 L___J 0 app LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing 02with Section 7000)of Division 3 of the Business and Professions Code,and my license is c y in fullforceandeIII L �yi> FILL PCOL, 400SQ - JIA JIA INC HAS BUS LIC#31051 z License Class Li e•i c Date / GOOD TH RU 7/31/ 10 gg t' 'Altcfirmcm DECLARATION d< 1 understand in plans shall be used as public records �yU L OH Licensed Professional H OWNER-BUILDER DECLARATION I herchy firm that I 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 4 a ff 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 cthat he is licensed pursuant to to provisions o[the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation nt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $3000 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 man five hundred dollars(SM. 36934015 . 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 Contractors License Law does not apply to an owner of q p 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.). ❑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- ccase 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. ❑I am exempt under See. B&P C for this reason 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- ,ation,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 Workers Compensation Insurance carrier and Policy number are: S� Cartier &A./_I Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for ooe hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,1 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 2CONSTRUCTION LENDING AGENCY (~-e iii 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 A Lender's Name z Lcndees Address U 0 1 certify that I have read this application and state that to above information is LL 1� correct.I agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorim representatives of this city to enter upon the w above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against hH-e liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. y1 �. APPLICANT UNDERSTANDS AND WILL COMPLY WITHALL NON-POINT Issued by: Date l SOURCE REGULATIONS. Re-roofs Signature of Appl ontr 1.3 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(x)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes GK If a roof is installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which it hazardous air contaminants as defined by the Bay Area Air Quality Management all new IT aterials for inspection. .strict? ❑Yes awu 1 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 to 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 Oc / Signature of Applicant Date 7 / oL All roof coverings to be Class'n"or better Owncr or authorized agent Date �� 0 0q i CITY OF CUPERTINO DI-TIMO COF CUPEM kTINO PERMIT APPLICATION FORM APN# Date: Building Address: m rtc r itc, 1"-)r. Mailing Address (if different from building addrCss):' Owner's Name: Phone: V,a Contractor: Phone : cy- -7 , M Fax: Contractor License #: Cupertino Business License #: c' C Phone: Contact: C J Fax: Residential 5] Sq Footage 4,-&& Commercial 0 Sq Footage Job Description: 4J Valuation: Project Size: Express ❑ Standard F-1 La--geE] Major 0 Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type IDEMORES Demo-Residential B 1SFDWL-DEM IDEMOPRES Pool Der10-Residential B 1SFP00L-DEM- IBCBSC I ---�-alffld& Standards B ALL PERMIT Commission Fee TYPES IBSEISMICRE Seismic -.Zesidential B Revised 01/07/09 CITY OF C'UPERTINO DEMO CUPEkTiNO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group Permit Type 1DEMOCOM Demo-Commercial B 1COMML-DEM 1DEMOPCOM Pool Demo Commercial B 1CPOOL-DEM 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICOM Seismic Ccmmercial B 1BUSLIC Business Li,-ense B Revised 01/07/09 Community Development 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 C1T1f OF Fax(408)777-3333 UPEkTINO Building De artment JOB ADDRESS: PERMIT # /6 6 F?' 006,00 61, / OWNER'S NAME: u PHONE # 44- z t- - GENERAL CONTRACTO IVI % ,- - FAX # I am not using any subcontractors: S4 gnatufe �� 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