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09060078 CITY OF CUPERTINO BUILDING DIVISION PERMIT ZION. PERMIT NO. BUILDING ADDRESS: 20091 NORTHWO D DR AIR A IT 090600 R PERMIT ISSUE DATE ^WNER'S NAME: SA A CONTROL NO. PHONFTJN BUILDING PERMIT INFO ARCHITEcTIENGINEER: BLDG ELECT PLUMB MECH ADD A/: INSTALL IN REAR YAR D O O D O p LICENSED CONTRACTOR'S DECLARATION Job Description U C I 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 y in fullforce and cf[ Z License Cl SS Lle•+� n t p Date Contractor RCHMLTS DELLA O I understand my plans shall be used as public records �uJ 4 Q y Licensed Professional ti 3 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the Q O following mason.(Section 7031.5,Business and Professions Code:Any city or county $�u 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 zc that 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 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(5500). ❑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 Conuactoes 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 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.). ❑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 u. cense Caw 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. ❑1 am exempt under Sec B&P C for this mason ^wner 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- sation,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 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 Workees Compens tion Insurance carrier and Policy number am: Cartier. Polity No.: FROM ORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less) I cenify 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 Qforthwith comply with such provisions or this permit shall be deemed revoked. Z"' CONSTRUCTION LENDING AGENCY [~+ I hereby affirm that there is a consu action lending agency for the performance of (x> the work for which this permit is issued(Sec.3097,Civ.C.) WCI.A Lender's Name Z Gender's Address V C) I certify that I have read this application and state that the above information is V.r"' correcu 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 W above-mentioned property for inspection purposes Lar (We)agree to save,indemnify and keep harmless the City of Cupertino against „F,t liabilities,judgments,casts and expenses which may in any way accrue against said City / /�_ O U^Z in consequence of the granting of this permit. Date 7V1 APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: SOUR E EGU ON Re-roofs Sig um o App icant/Con Da T Of F.00f HAZARD S 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 rode,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. [:]Yes Yes No Will the applicant or future building occupant use equipment or devices which If a roof:s installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes 'frio 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 d not currently have a tenant. it is y responsibility to notify the occupant f the a Certificate ora panty. Signature Of Applicant Date D All roof coverings to be Class'J `r or better �. n r au orizcd agent - —- L Community Development 10300 Torre Avenue afro, Cupertino CA 95014 Telephone(408)777-3228 tin OF Fax(408)777-3333 �;UPEkTINO Building Department JOB ADDRESS: PERMIT# za® �t/or�-�� 0906G6 79 OWNER'S NAME: & - PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors:_-��' 4- cI Sig ature 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 CITY OF CUPERTINO FUIViACE/AC CUPEkTINO PERMIT APPJLICATION FORM APN # � Date: Buildin �r ss: /I/D�1.77trt/cr�� orL�v� Owner' &. �� - Contractor: Phone#: Mit Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: �� — Fax#: Building Permit Info: Elect Plumb\Q Mech Residential Commercial Job Description: 1.(// A)A1 Ve4 For Residential Installations: Attic El1st floor\ 2"d floor ❑ Adhere to minimum setback requirement ❑ For Commercial Installations: Replacement same weight ❑ Additional weight(structural calcs) ❑ Structural Calculations required for new installation. ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): Strapped On Platform ❑ Bon ed F New Location Replacement Project Size: Express ❑ Standard ❑ Large ] Major❑ Valuation- OCyr) Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, inc zde in plan set & the sheet index. Revised 01/07/09 CITY OF C UPERTINO aM FURNACE/AC CUPEI,TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group FURNACE FURN/AC 1 MCRAA Commercial-Rep-,.ir/Alteration/Add to M ea heating appliar.ce,refrigeration unit, cooling unit,absoiption unit,or ea heating,cooling,al)sorption or evaporative cooling system,incl installation of cor trols regulated by this code. 1 MCREPALT Commercial for the repair of alt/add to M ea heating appliwLce,refrigeration unit,cooling unit,VAV boxes, absorption unit of ea heathing, cooling absorption,or eva')orative cooling sys, incl install of controls regulated by this code. 1 MCSUSHTR Commercial InstE.Il/Relocate ea M suspended heater recessed wall htr, or floor mounted unit heater. 1PGASCOM Commerical for ea gas piping System P 1-4 outlets 1BPGAS For each gas pipi:ig system of 5 or P more per outlet. 1MCAPPVNT Commercial for the install/relocate/ or M replacement of ea appliance vent installed & not incl in an appliance permit. 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICO Commercial Seismic B 1MRRAA Residential Repair/Alteration/Add to M ea heating appliance,refrigeration unit, cooling unit,abscrption unit,or ea heating,cooling,obsorption or evaporative cool:ng system,incl installation of controls regulated by this code. 1MRSUSHTR Residential Instad/Relocate ea M suspended heater,recessed wall htr, or floor mounted unit heater. CITY OF CUPERTINO FUWIACE/AC CUPE�TINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Group 1MRAPPVNT Residential for the install/relocate/or M replacement of ea appliance vent install &not it cl in an appl permit. FURNACE FURN/AC 1 PGASRES Residential for ea gas piping system of P 1-4 Outlets 1 BPGAS For each gas piping system of 5 or P more per outle . 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 1BSEISMICR Residential Se.smic B 1 MECPLNCK Mechanical Plan Check M 1 MFR=<100 Furnace Syst =100k BTU install or M relocate ea forced-air/gravity type furnace/burnei-, incl ducts/vents attached to such appliance up to and include 100,000 Btu/h 1 MFRN>100 Furnace Syst 100k BTU install or M relocate ea forced-air/gravity type furnace/burneincl ducts/vents attached to su,;h appliance over 100,000 Btu/t: 1 EPERMITFEE Electric Perm:t Fee E ' I MPERMITFEE Mechanical P,;rmit Fee M I1PPERMITFEE Plumbing Per-nit P 1 TRAVDOC Travel Documentation B 1BUSLIC Business License B