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09060103 CITY OF CUPERTINO BUILDING DIVISION PERMIT � 1 Q IWO �TI�N* BUILDING ADDRESS: PERMIT NO. 21 RR-) nA-KVTFW LN TBD — To> RF T)FTERMTNED 09060103 OWNER'S NAME: PERMIT ISSUE DATE A CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a p C LICENSED CONTRACTOR'S DECLARATION Job Description U ffrm that I am licensed under provisions of Chapter 9(commencing ,Z, with Section 7000)of Division 3 of the Business and Professions Code,and my license is n'Z y in fun force and effect UPGRD TO 200 AMPS FM 7 DAMPS ? License Claw Llc•N n y DateContractor ARCHITECTS DECLARATION I understand my plans shall be used as public records �yU tL y Licensed Professional y OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the is❑o following reason.(Section 703 1.5,Business and Professions Code:Any city or county K m which requires a permit to convect.alter.improve,demolish,or repair any suwum y Z} prior to its issuance,also requires the applicant for such permit to file a signed statement =c 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 $1200 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 rive hundred dollars(2500). 32619102 . 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(See.7044.Business Required Inspections and Professions Code:The Contractor's License Law docs 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 wiHJ4afe the burden of proving that he did not build or improve for purpose of Sale. s ow ). .aner of the property,am exclusively contracting with licensed contractors a construct the project(See.7044.Business and Professions Code:)The Contractor's Li. cense Law does not apply to an r of roperty who builds or improves thereon,and, who contracts for such project t a dr r>cwr(s)licensed pursuant in the Contractees License n, A ❑1am B&7 f 1his tn Owner Date WORKER'S COMPEN N DECLARATION I hereby affirm under penalty of du one of the following declaratio . I have and will maintain a Certificate of Consent to self-insure for Worker's 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 Workces 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 carrier and Policy number are: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSUR4NCE (This section need n c pletcd if the pc i s for h•dred dollars(2100) or less) 1 I card v that in the perform on Laws of Califomia Data Applicant NOTICE TO APPLICANT:If,after making this Certiricate ofV n.you should become subject a the Worker's Compensation provisions of thadc,you must Qforthwith comply with such provisions or this permit shall be doked. z 5, CONSTRUCTION LENDING AGENCY E4 1 hereby afrum that there is a convection lending agency for the performance of E4 > the work for which this permit is issued(Sec.3097,Civ.C.) WGL Q Lender's Name z Lender's Address U 0 1 certify that I have read this application and state that the above information is V.0r correct.I agree to comply with all city and county ordinances and state laws relating to 0 E—' buildingconvection,and hereby authorize representatives of this city to enter upon the Uabove-mentioned property for inspection purposes (We)agree to save,indemnify and keep harm)t the City of Cupertino against uH,h liabilities,judgments,costs HAZARDOUS MATERIALS DISCL R Type of Roof Will the applicant or future building occupant store or ndle hazardous material as defined by the Cupertino Municipal C Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. C]Yes Will a roof is installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which it hazardous air contaminantas def by the Bay Area Air Quality Management all new rr aterials for inspection. uict? ❑Yes contaminants; Iha re hazardous materials quircme under Chapter 6.95 of the Califor- nia Hcalth& y ode,Sections 25505 533 ary12S534.1 understand that if the building does not cu n ve a tenmy ihinty a notify the upant f the requirements cy- Signature of Applicant Date All roof coverings to be Class" ''or better Owner or authorized agent Date a3 CITY OF 1rL. TINO CUPEkT1NO GENERAL BUILDING PERMIT APPLICATION FORM APN# 132-/o^ — ICA _ 1c) Z,. O O Date: Building Address: �, Q 9� QAy-V t E Mailing Address (if different fro building address): Owner's Name: � ` � � � � Contractor: Phone: ��&C�. �c��1�C'etSl Fax: Contractor License#: 799 90 6 Cupertino Business License #: Contact: Residential Commercial ❑ Job Description: faA& 2-0 c 0,V1 Building Permit Info: Bldg ❑ Elect Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: I-A, 1-B ❑ II/IIIN-A ❑ II/III B, IV-HT, V-B [--- Valuation: N I © Square Footage: Project Size: Ex ress E9--Standard ❑ Lar e ❑ 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: Z'7- For help, contact Build it Green at www.buildit -een.oriz Revised 02/05/09 CITY OF 1�UPERTINO aC10F GENERAL BUILDING APPLICATION CUPEi;,TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Des-.ription Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application I WINREP Replacer ient windows/sliding glass B door ea 8 windows 1 WINMEWSTR New Window-structural shear B wall/mason includes plan ck fee IEPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechani-,al Permit Fee M 1 PPERMITFEE Plumbin.;Permit Fee P 1ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Al one Mechanical Pln Ck(hrly) M 1 PLMBLNCK Stand A]one Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly- Land alone / 1 BCBSC Cal Bldj; Standards Commission Fee B ALL PERMIT TYPES / 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B / ITRAVDOC Travel Ci Documentation B 1BUSLIC Busines3 License B 2pc 5 of 5 Community Development 4" 10300 Torre Avenue n Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ''UPEkTINO Building Department JOB ADDRESS: ZA � '�LL PERMIT # � ` OWNER'S NAME: iE� 64�v \ PHONE # GENERAL CONTRACTOR: -�, FAX # I am not using any subcontractors: Si,mature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical .� G 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 f *Owner/' o` actor Signature E&e