09060105 7777
77777777777
CITY OF CUPERTINO SIN:
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: ,
PERMIT ISSUE DATE
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
v p Z LICENSED CONTRACT'OR'S DECLARATION Job Description
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
_Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
nay in full force and effect REPLACE GAS VALVE FOR .GAS FIREPLACE
-z License Class co tractor CHARLIE' S PLUMBING PD FOR BUS LIC. 0 6/18/2 0 0 9
y ul Date ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
�yU
4 C y Licensed Professional
rn 1 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
pO following reason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
_ prior to its issuance,also requires Ilse applicant for such permit w file a signed statement q,Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of Contractor's License law(Chapter 9
rH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $200
y that he is exempt therefrom and the basis for the alleged exemption Any violation of APN Number Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500). 3263503 ) . 00
❑1,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 dors 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.).
1110,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 contractors
License Law. B&PC far rcascln
E]I am exempt der Sec
Owner Date S�
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 Workers Compen-
_tion,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Codc,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 be Rome ect to the Workers'Compensation
Laws of Califoynjrl -
Applicant IJ/C Y
NOTICE TO APPLICANT: f,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you mast
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F.t rA 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 QLenders Name
0Z
Lcndees Address
U C) I certify that I have read this application and state that the above information is
LL H corccL 1 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
above-mentioned property for inspection purposes
t a (We)agree to save,indemnify and keep harmless the City of Cupertino against
HrA liabilities,judgments,costs and expenses which may in any way steric against said City
U Z in consequence of the granting of this permit Date
�. APPLICANT UNDERSTA DS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOURCE
Dam 'j' Of R oof
RDOUS 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 Iro
If a roof is installed without first obtaining an inspection, agree to remove
Will the applicant or future building occupant use equipment or devices which
1 hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
rict?
❑Yes
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
does
Ccrtificale of Occupancy. Signature Of Applicant
All roof coverings to be Class'A.'or better
Owner or authoriz d agent Date
,. CITY OF CIUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Memeal06—
APN # Date: `,1 - /
Z� 35 034. l0 b �5 9_ Vq
�"
Building Address: 10!�I' H A �_6 .D Q,, W qSD 14
Mailing Address (if different from building address):
Owner's Name:
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: r1 j `S , (1r1 Phone: U
Fax:
Contractor License#:
Cupertino Business License#:
Contact: LU 01 T Phone:
Fax:
Residential Commercial ❑
Job Description:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ��"� Mech ❑
Type of Construction (Usage Class): Occupancy Type:
I-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Eq � V_r�s
Valuation: $ )_00 — Square Footage:
Project Size: Express [J-- Standard ❑ Large ❑ 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: -6-
For help, contact Build it Green at www.builditr een.or
Revised 02/05/09
M7�(��.� CITY OF �.UPERTINO
CITY
GENERAL BUILDING APPLICATION
CUPE�TINO
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 Wir dow-structural shear B
wall/mas)nry (includes plan ck fee)
1 EPERMITFEE Electrica: Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
r 1 PPERMITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand Al ane Electric Pln Ck (hourly) E
1 MECPLNCK Stand Al ane Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Aline Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-s1 and alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
I BSEISMICR Seismic Residential B
1
1 BSEISMICO Seismic Commercial B
' 1 TRAVDOC Travel &; Documentation B
1BUSLIC Business; License B
5 of 5
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`'UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: PHONE # 408- � l
GENERAL CONTRACTOR: C�f t l tFs UIII N FAX # p _ ' 2 3
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSI14ESS 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/Co tractor Signature Date