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09050075w yy? tE-C > u. F �0 rain � <j 'tz> 0C zc FA �i (da a UC wE 0 U CITY OF CUPERTINO DIVISION PERMIT�� BUILDING BUILDING ADDRESS: PERMIT NO. 22510 STEVENS CREEK BLVD TBD — T E DE ^WNER'S NAME: PERMIT ISSUE DATE PHONE: A 0 0 9 CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. EVR UPGRADE WITH VR CARBON CANI STER r REPLAC ING 4 License Class Lic. S DateContractor (E) MPD' S W/NEW 4 WAYNE OVATIONS. ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following mason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, liter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement license Law 9 Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's (Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 9 O O O O that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). 37501085 .00 0 I, as owner of the property, or my employees with wages as their sale compensation, Required Inspections fl P will do the work and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The 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 -hive the burden of proving that he did not build or improve for purpose of sale.). ,ja'fas 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 docs not apply to an owner of poorty who builds or improves thereon, and. who contracts for such projects ' a tor(s) licensed pursuant to the Contractor's License Law. 0 I son el P B& P C f this on unci r u — Date? ��' �� KER'S COMPENSATION DECL.ARATIO I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a Certificate of Consent to self -insure for Worker's Compcn- sation, 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 Compensation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be compacted if tax permit is for one hundred dollars ($100) or less.) I certify that in the performance if t vro or which this permit is issued, I shall not employ any person in any in So9�u p the Workers' Compensation Laws of California ! y Applicant it after making this Certificate of Exemption, you should become subject is Compensation provisions of the Labor Code, you must ' forthwith comply with such provisions or this permit shall be deemed revoked. " CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of y the work for which this permit is Issued (Sec. 3097, Civ. C.) Lender's Name L.endees Address r 1 certify that I have read this application and state that the above information is ' correct. I agree to comply with all city and county ordinances and state laws relating to " building construction, and hereby authorirt representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in way accrue against said City in consequence of the granting of this permit.. APPLICANT UNDERSTANDS A, MPLY WITH ALL NON -POINT Issued by. Date 1 7 SOURCE REGULATIO Re -roofs _ Type Roof sigff tNt� oriCppt,caiiuco Dateof 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 ,de. Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed. [3 Yes lallo If a roof i;; installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? 0Yes 0Nu 1 have mad the haiardo matcri 1 immcnts under Chapter 6.95 of the Califor- nia Health & Safct C 533 and 25534.1 understand that if the building does not current is my responsibility to notify the occupant of the regairements which mu ;ssnanee of a cert;fieax nr Deets Signature of Applicant Date /ancy. % `GDate All roof coverings to be Class';." or better Owncr or rizcd a ent z CUPEKrINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM �s APN # 3 7 0 GS- 00 Date: 5 /1 3/oq Building Address: az.? S7"�v� �/ S 'Gi'cEE k f�1� d� C��{��R� r'�✓o� CA. Mailing Address (if different from building address): Owner's Name: M a c<TE z A N -bb e t L -ANI ' Phone #: HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Contractor: rrgT-) Phone: Fax: Contractor License #: Cupertino Business License #: Contact: OO(CTF�-6 -1A3s Fax: Residential ❑ Commercial t~v°R L,t11�� iTu Q R e6Rac n1 CIAtj, s7-cx Job Description: �o- `'�'�' O I c �s Vf� 4Eal � ��E l CSC n+Jr P-)( ST i n/4 M (3 D -s Y Building Permit Info: Bldg 0i Elect ❑ Plumb ❑ Mech t Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B Valuation: 47qocev Square Footage: Project Size: Express ❑ Standard Q— 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.org Revised 02/05/09 x— CITY OF CUPERTINO CITY OF CUPERTINO GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1 BBOILERI For the installation or relocation of ea M boiler/compressor to & including 3 horsepower, or ea absorption sys to & incl 100,000 Btu/h (29.3kw) 1BBOILER2 Installation /relocation of ea M boiler/compressor over 3 horsepower to & incl 15 horsepower, or ea absorption sys over 100,000 Btu/h 1BBOILER3 Instal I ation/relocation of ea M boiler/compressor over 15 horsepower to & incl 30 horsepower, or ea absorption sys over 500,000 Btu/h to & incl 1,000,000 Btu/h 1 BBOILER4 Install ation/relocation of ea M boiler/compressor over 30 hosepower to & incl 50 horsepower, or for ea absorption sys over 1,000,000 Btu/h to & incl 1,750,000 Btu/h 1 BBOILER5 Instal I ation/relo cation of ea boiler or M refrigeration compressor over 50 horsepower, or ea absorption sys over 1,750,000 Btu/h 1 BAPPLOTH For ea appliance or piece of equip M regulated by this Code but not classed in other appliance categories, or for which no other fee is listed in this code. 1 ELECINSP Other Electrical Inspections (per hour) E 1 MECHINSP Other Mechanical Inspections (per M hour) 1 PLMBINSP Other Plumbing & Gas Inspections P — (per hour) 1 MEETING 1 HR Application Meeting B 2 of 5