09060089 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � �
BUILDING ADDRESS: PERMIT NO.
1328 PRIMROSE WAY SUZUKI 140EL KAaD
PERMIT ISSUE DATE
OWNER'S NAME:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
a p Z LICENSED CONTRACTOR'S DECLARATION Job Description
IU 01 hereby affirm that I am licensed under provisions of Chapter 9(commencing
_Z tar with Section 70(10)of Division 3 of the Business and Professions Code,and my license is UPGRD E�ECTRC L PANL FM 12 5 AMP TO 2 0 0 AMP
A- in full force and effect
j rt2 Z License Class Lic•ff
Date Contractor
ARCHITECTS DECLARATION
aI understand my plans shall be used as public records
�yU
`O I- Licensed Professional
y
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractofs License Law for the
r a O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K Pi 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 Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 S q
xFS- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $600
y that he is exempt therefrom and rho basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than Bre hundred dollars($5W). 36618009 . 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:TU Contractor's License Law does 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)Tbe Contractor's 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
following declarations:
I 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.
❑I 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier. 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 Icss.)
I certify that in the performance of Joe work fojwhich this permit is issued,I shall not
employ any perso
Applicant
NOTICE TO P CAM:If, or making this Cc of Exemption,you should
become subject to the Workces mponsation provisions of the Labor Code,you must
Q forthwith comply with such provisions or this permit shall be deemed revoked.
Z. CONSTRUCTION LENDING AGENCY
1 hereby affirm that thele is a construction lending agency for the performance of
a
the work for which this permit is issued(Sec.3097,Civ.Q
ALender's Name
ca. fender's Address
U C) 1 certify that I have read this application and state that the above information is
LL F correct.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
U above-mentioned property for inspection purposes.
a (We)agree to saw,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►+ AP ERSTANDS COMPLY ITH ALL N-P NT Issued b)
SOURCE
i� 0? Re-roofs
Signature f Applican ontractor Dai T Of I:OOf
HAZARDOUS MATERIALS DISCLOSURE Type
W(II 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 Safely
Code,Section 25532(a)? o All roofs shall be inspected prior to any roofing material being installed.
❑Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new r iaterials for inspection.
.Istria?
❑Yes VN.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
Health& afcty Code,Secti .2 533 and 25534.1 understand that if the building
d
crtificgtSignaturcofApplicant Date
All roof coverings to be Class'"or better
Owner o thorizcd agent Date
o(4D �a
,.., CITY OF (.UPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date: ,J-r-4
Building Address:
f 3�g rimrase. Wa Cc,� ��n� CA `fn(
Mailing Address (if different from building address):
Owner's Name:
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: oM a pXX,->,O.e,Y7 Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial ❑
Job Description: Upgraof e, epc,a� �'t'�e� - f-0m t2�
Building Pen-nit Info:
Bldg ❑ Elect [01 Plumb ❑ Mech ❑
Type of Construction (Usage Class): ,Occupancy Type:
I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Na/
Valuation: Square Footage:
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
[6r-e�enBuilding: 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.builditg een.or
Revised 02/05/09
G CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEi�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Al plications (up to 400 sf) B
additional stucco application
1WINREP Replacem.-nt windows/sliding glass B
door (ea O windows)
1 WINMEWSTR New Window-structural shear B
wall/masc my (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
IMPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
I ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK 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-stand alone
1 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 1 BSEISMICR Seismic lZesidential B
1 BSEISMICO Seismic commercial B
IT AVDOC Travel & Documentation B
1 BUSLIC Business License B
5of5
Community Development
_ 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�'UPEf�TINO
Buildi:n De artment
JOB ADDR PERMIT #
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
Signafdre Date
Please check a licable subcontractors and complete the following information:
SUBCONTRACTOR BUSI VESS 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