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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10148 JUDY A
OWNER'S NAME:
VE:
ARCHITECT/ENGINEER:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic• g
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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 We a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(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
not more than rive hundmd dollars ($500).
0 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
and Professions Code: The Contractors License Law docs 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. 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 Contractors 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 Law.
❑ [am exempt and r Sec. Q B & P C for this mason
Owner �� llt>~ � C/f Dau 161-1-
WOO KER'S COIMTNSATION 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 Workers Compen-
sation, 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 Workers 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:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not 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 subjec to the Workers' Compensation
Laws of Califomi a
Applicant
NOTICE TO APP : If. after making this Certificate of Exemption, you should
become subject to the'Worker's Compensation provisions of the Labor Code, you must
0 O forthwith comply with such provisions or this permit shall be deemed revoked.
Z - CONSTRUCTION LENDING AGENCY
[.r V) I hereby affirm that there is a constructinn lending agency for the performance of
p: the work for which this permit is issued (Sec. 3097, Civ. C.)
W ALender's Name
�
Z
Lenders Address
U 0 1 certify that I have read this application and state that the above information is
iY h"r correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
p.4 to liabilities, judgments, toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
►'h APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE E ONS.
�y o
Signatu plicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
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)?
O Yes f3No
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
0 Yes 0•Nb
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 the building
does not currently have a tenant, that it is my responsibility to notify the occupant or the
requirements whichjinusA met prior to issuance of a Certificate of Occupancy.
Owner or asst agent
- ` `Date
TBD - To09060137
POOL DEMO
Sq. Ft. Floor Area
umber
37511006.00
Issued by:
Re -roofs
Type of Roof
Job Description
500
Required Inspections
Occupancy Type
Date C-1
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new riaterials for inspection.
Signatur; of Applicant
All roof coverings to be Class" ' or better
Date
PERMIT NO.
PERMIT ISSUE DATE
A A O.
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB
Job Description
500
Required Inspections
Occupancy Type
Date C-1
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new riaterials for inspection.
Signatur; of Applicant
All roof coverings to be Class" ' or better
Date
)() 9 D (,D 0 1 -f>1
CITY OF CUPERTINO
.:'` DEMO
CUPEkTINO PERMIT APP=LICATION FORM
APN# 3767j �` o o ,6 U 0
Date:
"June_ ooh
Building Address:
Fee Group
Mailing Address (if different from building ad&-ess):
Owner's Name: e'A t l J A y S� N� tv I
Soy L -/,N / SoHc5l'W
Phone:
�os� lli4&
Contractor:Phone
X1`7 C3Ry�E C� . Mct_FiT-J\-s 5035
: ( g� 3 �3— 171 1 -;S��S�uiu�R�
Fax:
Contractor License #:
Cupertino Business License #:
1 DEMOPR.ES
Contact: SCG a �,L 6 Ire
J
Phone: LZ p 2
Fax: (4tl-35/-
Residential ❑ Sq Footage Commercial ❑
Sq Footage
Job Description: - o O L E /M o L T I o',1
Cal Bldg Standards
Commission Fee
Valuation: I f
ALL PERMIT
TYPES
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Greon Building Checklist & attach it to the application
or if applicable, include on the plan set & thf sheet index.
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1 DEMORES
Demo -R esidential
B
1 SFDWL-DEM
1 DEMOPR.ES
Pool De no Residential
B
1 SFPOOL-DEM
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICRE
Seismic Residential
B
Revised 01/07/09
CITY OF
7UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS: ( 0 I $ 7tj (�
AV f'
PERMIB#/� da�3
OWNER'S NAME: S k L ci ,,c Sa H ' c�.
BUSINESS LICENSE #
PHONE # If 0,9 ra 5 2 - t 9 4
GENERAL CONTRACTOR: T o�j P->
FAX #
I am not using any subcontractors:
S ignature
P1PacP r-hPrk annlicable subcontractors and corr.vlete the following information:
Date
Owner/ Contractor Signature
Date
SUBCONTRACTOR
BUSIN- ESS 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