10060039i. CITY OF CUPERTINO BUILDING PERMIT
I BUILDING ADDRESS: 22221 MC CLELLAN RD I CONTRACTOR: CITY OF CUPERTINO I PERMIT NO: 10060039 I
OWNER'S NAME: CITY OF CUPERTINO
.,WNER'S PHONE: 4087773407
❑ LICENSED CONTRACTOR'S DECLARATION
License
Contractor
Lic. #
Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, 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 provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I 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 authorize 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 accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Cignature
Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed cont ctors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, 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 provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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 Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked
W
APPLICANT CERTIFICATION
I 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 authorize representatives of this city to enter
on the above mentioned property for inspection purposes. (We) agree to save
emnify and keep harmless the City of Cupertino against liabilities, judgments,
posts, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signaturepa,tze, �,� / Date
COMMUNITY CENTER
C1 JPERTINO, CA 95014
DATE ISSUED: 06/08/2010
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
REPLACE V GROVE SIDING 500 SQ FT, ON EXISTING
WATER TOWER, REPLACE EXISTING WINDOW WITH
DOUBLE
P AIN
SSI. Ft Floor Area:
APN Number: 35706018.00
Valuation: $10000
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
I: sued by:
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
it stalled without first obtaining an inspection, I agree to remove all new materials for
it spection.
S gnature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
( alifornia Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
t:ealth & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
v ill maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
t to Health & Safety Code, Sections 25 05, 255337an
553 ,
(owner or authorized agent: r, Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
v,ork's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
bender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
I
a(-
CITY
OF
CUPERTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
APN #—�5-r7 n Lo 019, D (----
Date: 6, /cP//O
Building Address: C 114
PC/
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project?
Yes No
HOA: (Exterior work only) Yes ❑ No a--ff Yes,
provide letter from HOA
Owner's Name: ,Phone
o �v �i #� D
#:
777 3 ya
Contractor:
co ! b~o •o s �v c 7�i o -f
Phone: 3 -7 — 3 U O o
Fax: 3 l -3 qbl
Contractor License #: C'3 5/ ;- 2
Cupertino Business License #: .
�
Contact: /?0j
�je2 W1 /.�3 f /oma%
Phone:
Fax: o - 7 7- 3S i cl
Residential D Commercial
Job Description: V J t=
s " dy,.l,7
0 ,J PX s T w t.c 710 w ep .
�� //9 e y/ .t ;li .,i S c,.+ i .., �d c,J
t " " 0,/A C/o 46 P /7
Building Permit Info:
Bldg CK Elect ❑ Plumb
❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/IIUV-A ❑ II/III B, IV -HT, V -B [9--
u _
Valuation:
Square Footage: /
/0,, 000
"L." .
Project Size: Ex ress 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.builditgreen. c)r
Revised 07/14/09