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09060087 CITY OF CUPERTINO BUILDING DIVISION PERMIT 7 . PERMIT NO. BUILDING ADDRESS: • PERMIT ISSUE DATE OWNER'S NAME: p CONTROL NO. i ; 10 614-839 BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG EO PLUMB MECH u p p LICENSED CONTRACTOR'S DECLARATION Job Description U1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Z W with Section 7000)of Division 3 of the Business and Professions Code.and my license is boy in fuli��ARCHrrECT`S REPLC LIKE4LIKE 3X7, 7X.8 r 8X18 SECTIONS OF CONCRET vi2 Z LicenLle'M SLB —in DaleContraamr DECLARAT 1 understandmy plans shall be used as public records DyU w y Licensed Professional L. < OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law far the is p O following mason.(Section 7031.5,Business and Professions Code:Any city or County K m Pi which requires a permit to construct,alter,improve•demolish,or repair any structure a W prior to its issuance,also requires the applicant for such permit to file a signed statement ;;q•Ft.Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 y F$ (commencing with Section 7000)of Division 3 oC the Business and Professions Code)or y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500). 32631021. . 00 0 I,as owner of the property,or my employees with wages as their sole compensation, will do the work.and thestructure isnot intended oroffered for sale(Sec.7044.Business Required Inspections and Professions Code:The Conuactoes 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.). 0 I.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.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 contractor(s)licensed pursuant to the contractors License Law. 0 1 am exempt under Sec 8&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the fallowing declarations: 1 have and will maintain a Certificate of Consent to self-insure for Workers Compen- ,ation,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 Workers 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 Com rtaatt Insurance comer and Poliry�u n mc: rte 1 Carrier:E � Policy No..Z�QS/"11y� 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 Oforthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a convection lending agency for the performance of fYY,> the work for which this permit is issued(Sec.3097.Civ.C.) W Q Lenders Name Z Lenders Address U 0 1 certify that I have read this application and state that the above information is LI,H correct.I agree to comply with all city and county ordinances and state laws relating to 0 C> building construction,and hereby authorize representatives of this city to enter upon the s. W above-mentioned property for inspection purpose 0. (We,)agree to save,indemnify and keep harmless the City of Cupertino against p�q to liabilities,judgments,costs and expenses which may in any way accrue against said City 1,Z inconsequence of the granting of this pe 11 Date APPLICANT UNDERSTANDS AN ILL COMPLY WITH ALL NON-POINT Issued by: SOURCE RE A S. Re-roofs Signature of Applicant/Contrsctor Dale Type Of Roof MATERIALS DISCLOSURE yP will the applicant or future building occupant store or handle hazardous material as defhned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed. 0Yes D(No If a roof:s installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which all new materials for inspect-ion. it hazardous air contaminants as defined by the Bay Area Air QualityManagement .astrict? D Yes WN. I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Code,Sections 25505,25533 2553 1 understand that iC the building docs not curcnty�tcnan ' ty to notify the occupantof UteDate rcquiremcnts whichrtificatc of Occupancy. SlgnaturE Of Applicant •l All roof coverings to be Class'JW'or better Owner or onzed agent Date o c COU A, oq o� o�� CITY OF ("UPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # to P_ ( , v 3 Date: G . (S -Q)( Building Address: ap9gj 94EVE-.0. ClkEEV- RLgb . " &jOC.KTi�.m Mailing Address (if different from building address): Owner's Name: S ALL C i (ye Phone#: � HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Conttractor: Phone: (S.,o) 6t y, p`3l1� f ko, 1SO i i c. - Fax: 6510 61L1—-?3 94 Contractor License#: G a)9 Cupertino Business License#: a 6 5 3 Contact: H I k E KkkWo Phone: 610) Fax: (510) Residential ❑ Commercial Ex Job Description: L E Fa L iZ E E.TtdAS C) F SL��3, Building Pen-nit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B (/ Valuation- Square Footage: * X000. 00 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.builditg een.or Revised 02/05/09 i ( . . CITY OF C;UPERTINO CITY OF GENERAL BUILD[NG APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM ACOUSTICAL REVIEW IACOUSFDW SFDWL/I)uplex New B 1 ACOUSRESAD SFDWL/I)uplex-Addition/Alteration B 1 ACOUSCOM Multi-Fan lily/Commercial B CHIMNEY'S I CHIMNEY Chimney B 1 CHIMNEYR Chimney Repair B FENCES 1 FENCE>6FT Non-masonry, over 6 ft in height B 1 FENCEMAS>6 Masonry, over 6 ft in height B FIREPLACES IFIREPLMAS Fireplace Masonry B 1 FIREPLFAB Fireplace Pre-Fabricated/Metal B 1 FLAGPOL>20 Flag pole (over 20 ft in height) B I MODUSTRU Modular Structures B FOUNDATIONS 1 FOUNDREP Foundati Dn Repair B IPILECAST Pile Foundation Cast in place concrete B IPILEDRIV Pile Foundation Driven (steel, pre- B stressed ,,oncrete) 3 of 5 CITY OF C'UPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEi�TINO FEE SC EIEDULE Quantity/Sf Fee ID Fee DescAption Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacemi;nt windows/sliding glass B door (ea � windows) 1 WINMEWSTR New Window-structural shear B wall/masonry (includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E IMPERMITFEE Mechanical Permit Fee M I PPERMITFEE Plumbing Permit Fee P 1 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-st and alone 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT / TYPES I BSEISMICR Seismic'Zesidential B 1 BSEISMICO Seismic ,-'ommercial B 1 TRAVDOC Travel &.Documentation B 1BUSLIC BusinesE License B 5 of 5 Community Development 10300 Torre Avenue :. Cupertino CA 95014 kl Telephone(408)777-3228 Fax(408)777-3333 CITY OF `;UPEkTINO Buildijij& De artment JOB ADDRESS: PERMIT # am4g9 5WC%4C SOIL 0kv,� . o 0(.0og7 OWNER'S NAME: 5del o, o �L— V S PHONE # 10 GENERAL CONTRACTOR: kp kD j 4 C-e.�ll� c.RL FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and com lete the followin 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