07100138 CITY OF CUPERTINO ' `
BfU[LD1NG DIVISION PERMIT �������� ����������*
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PERMIT NO.
BUIL a ���� ES �TEVENS CREEK BLVD TBD — TU BE DETERMINED 07100138 .
PERh9T LSSUE DATE
IER'S NAME:
BYRNE AVE HOMEOWNER'S ASSN � 10/18/2007
SANiTARY NO. CONTROL NO.
PHONE:
BUILDiNG PERMIT INFO
ARCHITECilENGINEER: BLDC ELECT PLUMH MECH
� 0 � �
j p Q LICENSED CONTRACTOR'S DECLARAT[ON JOb D2SCTlpt101]
: V� I hcccby afGrm that I am liccnscd undcr provisions of Chaptcr 9(commcncing
:ZW withSccuon70o0)ofDivision3ofiheBusincssandProfcssionsCodc,andmylicenscis RE �F CEDAR SHINGLES OVER SKIP SHEETING,TEMP
?� y in fuu foece and cttec�. POWER P( )LE
� v� Z Licensc Class L�. #
p Dam Conuuwr
: F' � ARCHiT'ECI'S DECLARATION
j a 4 1 undcrstand my plans shali 6c used as public rccords
)aU
' a y Licensed Pro(cssional
: � a OWNER-BUILDER DECLARATION
� a� 1 hcrcby alflrm U�a� 1 am excmpt Crom ihc Contractor's Liccnu Law for thc
p O Collowing rsazon. (Section 703I.5, Business and Professians Code: Any city or county
��� which requires a pccmit to conswct, altcr, improve, dcmolish, or �cp�ir any suucture
prior ui ils issuance, alsu requires the applicant for such pertnit to file a signed stalement �, � 0 Valuation
� Z< that hc is liccnscd pursuan� �o thc provisions oC thc Conuacwr's Liccnsc Law (CAaptcr 9 , r Ft. Floor Area
� h �(commencing wi�h Scction 7000) of Division 3 of �hc Busincss and Profcssions Codc) ur
L�� ihat he is exempt thccefrom and Ne bazis for the alieged exemplion. Any violauon of
Section 703I.5 by arry applicant Cor a permit subjecu the applicant to a civil penatty at 3 5 710 0 0 7�� Number Oeeupaney Type
not more than five hundred dollars (5500)•
❑ I, u owner of tl�e property, or my employces with wages az iheir salc compensadon,
wili do thc work and the suuaure is not intendcd or offeced [arsale (Sec. 7044, Business Required Inspections
and Professions Code: The Conuactors License Law daes not apply to an owner of
propeny who 6uilds or improves thercon, and who das such work himselC or through his
own empioyces, provided that such improvements are not imended or ollered for sate. I[.
however, the building or improvement is sold within one year of compledon, ihe owner-
builder will have �he burden of proving ihat he did not build ar improvc tor pu�pose of
salq.).
I, as owner o[ the property, am exclusively conuuting wiW licensed convaccors to
nstnut the project (Sec. 7044. Business and Professions Code:) The Contnctor's Li-
cense Law dacs not apply to an owner of propeny who builds ar improves �hemon, and ,
who contracu (or such projec�s wi�h a con�ractor(s) licensed pursusnt to �he Contnetafs
License Law.
Q I am ezempt under Sec , B 8c P C for ihis �cuon
ier 171`i� Date ld'f�� _.. -
W KER' G PEN ATION DECLARATION
I hereby �rm under penairy ol perjury one o[ �he foliowing declaradons:
❑ i hsre and will main�ain a Cenificate of Consent lo self-insurc for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the perfarmancc of the
work for which Ihis permit is issucd.
1 havc and will maintain Workefs Compensadon Insunnce, az rcyuired by Scction .
J of the Labor Cade, Cor the pcA'ormance o( �he work for which this pertnit is issued. �
..�y Worker's Compensauon Insurance carricr and Policy number are:
Carrier. Policy No.:
CERTIFICATE OP EXEMP'I'ION FROM WORKERS'
COMPEPISATION INSURANCE
(ihis section necd not bc completeJ iC the pccmit is for onc hundred dollacs (5100)
or Icss.}
[ cenify thxt in �he performance af �he work for which Ihis pertnit is issucd, 1 shall not
employ any person in any manncr s az w` mc su� to U�e Workcrs' Compensation
Laws of Califomia. Datc
Applicant
NOTICE 7'O APPLICA , aftcr making t�is CcniCcatc of Excmption, you shaulJ
become subjcct to thc Workcr's Compensation provisions of thc Labor Cadc, you must
� O forthwith comply with such provisions or this pecmit shall bc dccmcd �cvokcd.
z '—' CONSI'RUCTION LENDING AGENCY
H i-�. 1 hcs6y alTirm �hat thcre is a consuuetion Icnding agcncy for thc performancc uf
�� thc work fur which �his pertnit is issucd (Scc. 3097, Civ. CJ ,
a Q Lendcr's Namc
L.ender's Addrcss
(� � 1 certify thal 1 have read Ihis applieation and su�e lhat U�c above info�matiun is
w ► - " correct. 1 agree to comply with all city and coun[y arelinariccs and sw�e laws relating �o
� U buildiog conswction. and hcicby authori�e rcprcscn�ativcs of this city to cntcr upon thc
� W abovc-mcntioncd property for inspcction purEwses.
a (Wc) agrce to save, indcmnify and kecp harmless the City o[ Cupcnino against
�� liabilitiu, judgmcnts, costs and expenses which may in any way accrue against said City
V z in consequcncc oC �hc grandng of ihis permit. DSLC ,� I�'C�
�'-+ APPLICAM UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATION .
'���„ ,�2 Re-roofs ^ /
Sign�it f ApplicanU ontracwr
oa� T e of Roof
HAZARDOUS MATERIALS DISCLOSURE YP �
Will ihc applicant or futurc building accupant storc or handlc harardous matcrial
dcfincd by lhe Cupenino Municipal Code. Chaptcr 9.12, md thc Hcalth and Safety
Ic. Scction 25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
� Ycs �J No ,
Will thc applicant or fulurc building occupant usc cyuipmcnt ar dcvices which
If a roof i� installed without first obtaining an inspection, I agree to remove
cmi� harardous air con�aminan�s az cicGncd by thc Bay Arca Air Quality Managcment all new m aterials for inspec*ion.
Disvict?
Q Ycs Q�'Nu
1 havc rcaci the hvard<ws ma�crials rcquircmcn�s undcr Chap�cr 6.95 o(ihc Califor-
Hcalth & Safcty Code. Sections 25505, 25533 and 25534.1 undersund thatiCU�c huilding
aocs not cumenily havc a tcnan4 Wat it ia my rcaponsibiliry io naify thc occupant of �hc
rc cniswhic `n����o�a�u���orac�Nr�a�oro���p��r. SignatureofApplicant Date
,��,�� �.�j'-^ "------ ��''-' �- � 7 All roof coverings to be Class "B' or better
Owncr or authorizcd agcm Datc
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= x �{_� CITY OF CUPERTINO
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� ��� �F pERMIT APPLI CATION FORM
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APN # Date:
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8uilding Address• Vlailing Address (if diffe, ent from building address):
� � / U -��T �.�, �� � ,,� t�. l31��: � � �=r� �c � �: s' �? .J
Owner's Name: Phone #: . � � ! � � �� �
� �,�.t E"c c.xJ 1N ti2S � S/� �v
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Cont actor: License #:
I 7,
Contact: Phone: �/d8 �= t' j� 7 Cupertino Business License#:
--' f ,�l/11 Fax: �d8 2��-br6�o
Building Pe � it Info: ���� ���r9� ��tf. c� G t�s L��- S K� P s�-{� �� � j��;c.�c /-'
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Bldg l�" Elect � F'lumb ❑ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group: �
Type of Construction: Please check this box if th project is a
�_ ,��' _ second-stor addition:
I Project Size: Standard ❑ Large ❑ Ma� or ❑.
Quanti Fee ID Fee Descri tion Fee Grou
BAPPLOTHER ��ther Ap liances MECHANICAL
BBOILERI Boiler <= 100,000 Btu MECHANICAL
BBOILERZ Boiler > 100K to SOOK Btu MECHANICAL
BBOILER3 Boil er > S OOK to 1 M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS B oiler > 1.75M Btu MECHANICAL
BCONSTAX ��onstruction Tax BUILDING
BCONSTAX In 3/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax - Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec: Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD :�nergy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
� �� �f pERMIT APPLI CATION FORM
CUPEI�TINO
Quantit Fee ID l�ee Descri tion Fee Grou
BMISCELL IV:iscellaneous Fee BUILDING
BMITIGATC Comn. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP N�w Comm Plumb PLLTMBING
BOVERTIME In:;pection Overtime BUILDING
BPBACKFLOW Atrnospheric Vacuum - PLLJMBING
BPCESSPOOL Cesspool PLITMBING
BPERMFEE B ld Permit Fees BUILDING
BPFIXTURE Pbl Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLIJMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plal Check Add Multi � BUILDING
BPLANCKREP Plaii Check Repeat Fee BUILDING
BPREPIPE Rc i e Of Fixtures PLUMBING
BPSEWAGE '�ewa e Dis osal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn Sprinkler/Backflo PLLTMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Tra PLUMBING
BPVENT A: t of Drain & Vent PLUMBING
BPWATER Inst<<IVAlter Water Pi e PLUMBING
BPWHEATER W ater Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT lteins ection Fee BUILDING
BREMACOVER A/C Unit > 10,000 cfin MECHAI�TICAL
gRElVIAIRHAN A/C Units <= 10,000 cfm MECHAlvICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUS�VAY R_emodel Busways ELECTRICAL
BREMFIXT l�ighting Fixtures ELECTRICAL
BREMFURN Re'�.ocation of Furnace MECHANICAL
BREMFURNOV Rel�� Furnace > l OK btu MECHANICAL
BREMHEAT �[eater Installation MECHANICAL
BREMINHOOD In �tallation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREl��INRApp Rerr Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Powcr Device/A aratus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Rf;pair/Alter Heating MECHANICAL
BREMRESAPP Reniodel Res Appliance ELECTRICAL
2 of 3
� k' v CITY OF C'UPERTINO
� ���Y�� pERMIT APPL:[CATION FORM
�UPE�TINO
�uantit Fee ID Fee Descri tion Fee Grou
BREMSIGNAD Rmctl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Mar uee ELECTRICAL
BREMTHEATR The atrical Lighting Fix ELECTRICAL
BREMVENFAN Ve�it Fan Sin le Duct MECHANICAL
BREMVENSYS Vf ntilation S stems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Sei smic Commercial BUILDING
BSEISMICRE ��eismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP T em orar Power ELECTRICAL
BTEMPPERM Tem orar Bld Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC �:usiness License BUILDING
ELECTRIC l:lectrical sq foot ELECTRICAL
EPERMITFEE Ele c Permit Issuance ELECTRICAL
MPERMFEE M echanical sq. foot MECHANICAL
MPERMITFEE Me�;h Permit Issuance MECHANICAL
PPERMITFEE Plu�nbin Permit Issue PLUMBING
PPLBG Pltimbing Fee sq foot PLiJMBING
PLLONGRNGC Plannin LR Comme/ Multi-Fam PLANNING
PLLONGRNGR Plannin Lon Ran e Residential PLANNING
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