09060046 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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PERMIT NO.
BUILDING ADDRESS:
1 441 PHAR TBD — To
PERMrr ISSUE DATE
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u O
ZS CONTRACTOR'S DECLARATION Job Description
V 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 Cede,andy license is
=y in full force and effey (/G'', �J CONNECT GAS METER & ELECTRIC METER
Z Licenlass i Lic•8
n F G Datc - Contractor
ARCHITECTSDECLARA N
tGJ-UJ I understand my plans shall be used as public records
?y
`U.rF„ Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
a O following reason.(Section 7031.5,Business and Professions Code:Any city or county
429 which requires a permit to conswct,alter,improve,demolish,or repair any structure
4 prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
Y. (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
it 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 fire hundred dollars(M). 32635042 . 00
0 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.70".Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves hhercon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sato 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.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See.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 contractors)licensed pursuant to the contractors
License Law.
0 I am exempt under Sec B dt P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
..hon,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
(01(0
have and will maintain Workers Compensation Insurance,as required by Section 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 EXEMPION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor ono 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 irraq manner so as to become subject to the Workers'Compensation
Laws of t
Applic
NOTICE TO A009CANT.If,aftEt makingthis Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Codc,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
'" CONSTRUCTION LENDING AGENCY
[~—h ham. I hereby affirm that there is a construction lending agency for the performance of -
R�t> the work for which this permit is issued(Sec.3097,Civ.C.)
w Q Lender's Name
aZ Lenders Address
U 0 1 certify that I have read this application and state that the above information is
GL►" corecL 1 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.
a (We)agree to save,indemnify and keep harmless die City of Cupertino against
On liabilities,judgments,costs and expenses which may in anyway accrue against said City
U Z in consequenee the granting of this permit. Date
h-" APP ANTU DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
S
Re-roofs
Signature ofAliplicant/Co6ektor Data Type of Roof
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)? All roofs shall be inspected prior to any roofing material being installed.
0 Yea
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
't hazardous air contaminants as defined by the Bay Area Air Quality Management all new n iaterials for inspection.
uict?
0 Yes
I have mW the hazardous materials requirements under Chapter 6.95 of the Califor-
nia
a Certificate of Occupancy•�'T Date
!/ All roof coverings to be Class'A"or better
Owner oiauthori7zd agent Date
n
cg, oc-�,
CITY OF CUPERTINO
CUPEkTINO GENERAI_j BUILDING
PERMIT APPLICATION FORM
APN # 5b 4 ;?, - J Date: J _ Y^
co
Build' Address:
a,,,- 441n dr -j zz� �-�o
Mailing Address if different frombuilding address):
Owner's Name: , �, Phone #:
HOA: (Exterior work only) Yes ❑ No
If yes, provide letter from HOA
Contractor: c417 ►A Al)!'0,� Phone: / � (� � �
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone: 410Y
Fax:
Residential Commercial ❑
Job Description: re ✓1 n--e,c, -5 W-e--fr PCe Ct 10 n n e e_7'
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B ❑
Valuation: �/ Square Footage:�e
Project Size: Express ❑ 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:
For help, contact Build it Green at www.builditgreen.or
Revised 02/05/09
j CITY OF CUPERTINO
CU
CITY
Of O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additiona stucco application
1 WINREP Replacers.ent windows/sliding glass B
door (ea 3 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE PlumbinE Permit Fee P
I ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-st3und alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
I BSEISMICR Seismic 1Zesidential B
1 BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
IBUSLIC Business License B
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�' 5 of 5
Community Development
10300 Torre Avenue
w ; ... Cupertino CA 95014
Telephone(408)777-3228
C1T1(OF Fax(408)777-3333
1UPE�TINO
Buildi�n Delartment
JOB ADDRES • PERMIT # , f I
0 CIO
OWNER'S NAME: #
GENERAL CONTRACTOR: C ` G�� (!4 t g-`It`n i� FAX#
//
I am not using any subcontractors
)�
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
ontractor Signature Date