09030220 (2) CITY OF CUPERTIINO -
BUILDING DIVISION PERVIITCO vTR�CTCIR`II�TRORNIATION: .`
sr ,-wroF � � au
BUILDING ADDRESS: PERMIT NO.
19500 PRUNERIDGE AVE RLDG 1 DRAEGER
OWNER'S NAME: PER.MITUSUEDATE
PHO A 8 9 CONTROL NO.
408) 536-0420
ARCHf1ECnENGiNEQI: BUILDING PERMTTINFO
BLDG ELECT PLi MS MECH
0 0 0 0
u o o LICENSED CONTRACTORS DECLARATION Job Description
id u t- I beach,afOm our 1 am liccnxd umlur pmvicimu of ChapWr 9(commencing
-Zw 07
with section 7O)Of Division l of Ate Buses
iok and Profecamo Codc.and my liceae is
^,C.,aw in full ferccand urce ^1 0 SHORE UP DECKS & STAIRS #309, 305&301
Y,v%Z Lice CI Lie.• /,
F W Dau: Conmcrar 1" �g,q
A CHITECTS DELLA ON
?w v 1 documented my Photo shall W hand u public mmrtls
g u.N I.iarumd P.rooda.l
c0� OWNER-BUILDER DECLARATION
F I hereby air,.Nat I an exempt form Ne Canvanoes Lk.Law for the
t o R following msuon.(Srsuun 7031.5,BusL¢ss and Pmlceumd Code:My city or.un,
which Iryuinm a permit W conmacL allot,improve.demolish,m repair any amcrort
Zt pricrut itsiamumcc.aBamg111re3Neapplicam rof.hpmmitm Elcaiigneda wrcnl
< at he u Bmu
eced purmano Nn provisions of Nc
e ConuWrne s Lic Law(Chapter 9 Sq.Ft. Floor Area Valuation
YFG N(communing with S¢uon 7000)of Division 7 of the BusinemandProfessiamCodc)or
-
i 3 3 Nss he W esemps denefrom and!Ne w:.for Ne alleged...,..peon My riolaudn of
section 7W 16 by any appimat for a Pamir mbjma Ne-"91am W a civil penalty of APN Number Occupancy Type
trot more Nan rive hundred dollars(S500).
❑LarnwncrofthnProperty.Ormyemployeeawith wages atheir saWmmpemaum, 31606037 .BLDG1
will do Ne work.and the srmcram ra.1Intended orbRccd for sale(Sce.70M.Runtiness Required Inspections
and Porfemiom Code crs Li
The ConuW U.law does asst"Ply W riot e an. of q P
property who Wildsm imporves thermal,and who dao such work himuelf or through hu
owes employe,prnrldcd that smh impro einem arc not intended motional for sale If.
bwcm.the Wilding or improvement u said within one your of wmpkdo 1.We owrm-
builder will have the burden of proving that he,did ms Wild Of improve for Priam of
❑I.m w.of the property,an udmively contracting with literati.nuacmra b
mcuoct the pmjm(See 7014.Business bbd Pnefeamand Code:)The Coameor's l-
on—Law dor:not apply W an owner of preauty who Wilds or improv Nems,and.
who canoacia for surd projucrs with a.ntnemr(s)licestmd pummbt to the CmUrnou ',
Lieen"'Law.
❑I me mampt unde ser. .B R P C rm Nie mmon
Owner Date
. WORK S COMPENSATION DECLARATION
I hereby aDbm under penalty of perjury ors of the following dcdaradam
❑I hs.e aM will mainWa a CutiOcaW of Comms W relf-Imam(a WmkcfsCampcn-
sa on,as provided for by section 3700 of the Labor Code,for Ne pufomanor of the
work for which Nu permit is hand.
I lune and will maintain Workcea Gampemauon Inmran¢.as cgwreS by Section
37ODof the La ear Code.for the performance of the wmrk for which Nu pcmii u round.
MY Wcome, mCq pemyov rano mcie abut Pull 1 tm,.-: \ I'
Canriv j5ry .•'wN, PoIIry No',(J
CERTIFICATEO EMPTION FROM WORKERS
COMPENSATION INSURANCE
(This xainto need Out bu canpteted His permit Is for oon,hundred dollar($LOB)
or let)
1 certify Nu in the perfomabce of Nc work for which Nis permit is iaacd.I uhall not
employ any permn in my mannerau u to become mbjeci to Ne Worluc 'Comperoauon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If.after making Nu Cnrinom of Exemption.you danoW
baerm mbjm m Nc Worml`3 CaM)COlu n providma of the Lmor Cade.You mea
0 Z forthwith comply with such pmvimans or Nis permit shall bu deemed muted.
Z O1 CONSTRUCTION LENDING AGENCY
IWmb,.T.dot there ita.mrmcunn lading agency for the put...c of
x RW work for which Nis Peoul W issued(Ser.109'1.Civ.C)
{f] Q Lenders Name
= Z tandeh Addaca
U 0 1 cvtify that I have rad Nix applicauon and sum that the above infacnau.u
U. P carrot 1 age In mmPIY with all city and county cadinanec and rum laws dating W
0 U Wilding construction.and hereby mthbrim reprcee gives of Nu city to amt upon Um
above-m.tioncd Property for inclined.Pure.
F1 (We)ages W am indemnify and tree,harmlrsu ate City of Cupertino aCaimt
rn Hahnium,judgmeme.cow and experam which may in my way meme ULma said CRY
U Z in eamegWnee of the granting of Nis permit.
^ APPLICA UNDERST4NDS AND W COMPLY WITH ALL NON-POINT Issued by:9 Date
so lRc R u n Q
C--j— S J� R Re-roofs
aipvpR or pli Ramat �a I .
HAZARDOUS MATERIALS amDISCLOSURE Type of Roof
Will y the
C.,nt m forum Wilding e.Clan vert orandhandle r Mrandom material
u
defined by Um Cupcnino Mumcigl Code.Chapmr 9.12,and Ne HeaIN and Sa&ry
Cade.section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
CTes Yb
will Nc applinntar f ..m building caeupum,.epuipmenr m devices winch If a roof is installed without first obtaining an inspection,l agree to remove
emit hmardom air comvaimnu u defined!by the Bay Area Air Quality Managcmam all new materials for inspection. t
Disc e7
E3 Y. No
1 have mad Ne haaNwTm wnctlr c4uim+nmss umkr Cupmrd.95 of Nc Califm-
Na HcI"Safmy Cute Sections 25505.25533 am125534,1 uMeraamd Nvift a Wilding
doe net c Y K a mmol that It u my rmpbmilrility W motif"the b¢uPant Of the
I uw uvbumet paior aracwrmWors 64 Signature of Applicant Date
nthaa dagenR am. All roof coverings to be Class'n"or better
003 0..) o
5«C CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # �O� 03� n ��I Date: J 01
Building Address—
/ 5cr�
Mailing Address (if different fro building address):
Owner's Name: �P�' r1- � Phone#: yQ91_ -)-3_
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from MOA S 3
Contractor: I ' Phone: yU C,_ 'I
D i e �-S c �,' C Fax: W 9-- S 3 U 3
Contractor License#: (Q j-7 (e U
Cupertino Business License#:
Contact: To P-k , Phone: ` jt- ?-6 Y- Cn J
Fax: 537 y
Residential 9 Commercial n
Job Description: Pr1 VJ e- r(1" '3 ()�� I
I
v� t,4 cQ�.-0 -6 -f
Building Permit Info:
Bldg 4 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 U —
Valuation: 16 3 5 u 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:
For help, contact Build it Green at ivww.buildit reen.ora
Revised 02/05/09