09060170 CITY OF CUPERTINO
BUILDING DIVISION PERMIT E� 2 ICRMTIf�IY�
BUILDING ADDRESS: PERMIT NO.
21975 SAN FERNANDO AVEELCOR ELECTRI
OWNER'S NAME: PERMIT ISSUE DATE
PHONEIT-Y S A CONTROL NO.
(408) 9E:6-1320
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p Oa LICENSED CONTRACTOR'S DECLARATION Job Description
U CI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z.ro with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'may INSTL I:LEC PANEL SWITCHES & PLUGS IN OUT—BLDG @
in full force and effect
E-a LicenseC
Class ox
tD
-p pate Contractor BLACKBERRY FARM
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Dill
U.In Licensed Professional
Z
O� OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
COO following mason.(Section 7031.5,Business and Professions Code:Any city or county
m ff which requires a permit to construct,alter,improve,demolish.or repair any structure
14 prior to its issuance,also requires the applicant for such permit to file a signed statement
E=c that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $10000
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($500). 35710006 . 00
0 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 Contractor's 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
sakJ.
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. -
cense Law does not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 lam exem t and Sec B&P for s reason
Owner Da
WORKER'S PENSATION DECI ARAT10
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 Worker's Compen-
.an,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
0 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 Workees Compensadon Insurance carrier and Policy number am:
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 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 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
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
E i►�. 1 hereby affirm that there is a construction lending agency for the performance of
(x the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U O 1 certify that I have read this application and state that the above information is
LL correct I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorim representatives of this city to enter upon the
above-mentioned property for inspection purposes
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
04
tE rt rA 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
�4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bl,:
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Comtractor Date Type of Roof
HAZARDOUS 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
Cotte,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes ,0
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
,it hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
u ict7
0 Yes _.E�
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
docs not cu oily have a tenant.tha 't is my res t dity to notify the occupant M the
re ircmens hich must be mel or to i ce of a Ce01 nifica of oc sex Signature:of Applicant Date
caner orautharircd rat All roof coverings to be Class'R.'or better
ate
ogacpo ( jo
CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERA=L BUILDING
PERMIT APPLICATION FORM
APN # Date:
3.5 C>
Building Address:
s�7--j A-j
Mailing Address (if different from building address):
Owner's Name: ( 1I 7 D-f' Cupc22 T/, 6 Phone#: 410 _ 7 7 7 _ 3 y�
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: Phone: yo? - 9 OP& 13,?o
Fax: e/of 4J'G •- /3
Contractor License#: Sd o 2 zd'
Cupertino Business License#: 0 n� cf c,aon
Contact: Phone: 4/pkp
W A
Fax: VO 7 7 7 --33
Residential ❑ Commercial tZ
Job Description: /Ns�14 // e/e c- IPA,-J(2r/ ex
r
/"1 per 7L ' bur ..�� A � 13
Building Permit Info:
Bldg ❑ Elect.., � Plumb Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-lk,/
Valuation: /o" poo Square Footage:
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:
LFor help, contact Build it Green at www.builditgreen.or
Revised 02/05/09
aFiCITY OF UUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO
FEE S(:HEDULE
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
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/mas:)nry (includes plan ck fee)
1 EPERMITFEE Electrica: Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbin€;Permit Fee P
1 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-st ind alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic l:esidential B
J 1 BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Documentation B
1 BUSLIC Business License B
2.00
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