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CITY OF CUPERTINO
BUILDING DIVISION PERNIIT
BUILDING ADDRESS: PERMIT NO.
10481 SCENIC BLVD TBD — TO BE DETERMINED 07100058
OWNER'S NAME: PERMIT ISSUE DATE
TIM & EMILY MASLYN 03/27/2008
PHONE:. SANrrARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 o LICENSED CONTRACTOWS DECLARATIONJob Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70DU)ofDivWon3ofthe Business and Professions Code,and mylicense is ADD-1 , 002 'MASTERSUITE,LIVING,DINING,CLOSET, ADD
H to full form and effect..;Z 2_.R45(?
�? LicenacC% a uc.xGARAGE 242 ' —REMODEL ENTIRE HOUSE 1, 452 '
ra o Date ARCHITECTS DECLARATION 3/17/08 PERMIT APPLICATION EXTENDED TILL 5/30/08 .
aZ 1 understand my plans atoll be used as public records
..Licensed Professional
y OWNER-BUILDER DECLARATION
< 1 hereby affirm that I am exempt from the Contractor's License Law for the
:00 following mason,(Section 7031.5,Business and Professions Code:Any city or county
l^l which requires a peril to construct,alter.improve.demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
Ic that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor AreaValuation
(commencing with Section 7000)of Division 3 of the Business and Profras%ons Coder)or $374730 374730
Oust be is exempt therefrom and the basis for the alleged exemption Any viOladon of
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of �p N Number Occupancy Type
not more than five hundred dollars(s . 3 5704035 .IM
[]L 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
and Professions Code:The Comitctor's License Law does not apply to an owner of Required Inspections
property who builds or improves themon,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 be did not build or improve for purpose of
Sale.).
❑L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec 7044,Business and Professions Code:)The Contractor's Li-
=rise 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 m the Contractor's
License Law.
I am exempt under Sec B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Worker's Compensation Insurance carrier and Policy number are
Carrie �,5ZA7Z Calff S, PolicyNo.: J!SW 6 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be c(mplcted if the permit is for one hundred dollars(S IOD)
or Icsa.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject tope Workers'Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the work es Compensation provisions of the Labor Code,you must
0 Q permit forthwith comply with such provisions or this pit shall m
be deeed 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.)
W 0 Lander's Name
Z Lender's Address
U Q I certify that I have read this application and state that the above information is
IL " cormcL 1 agree to comply with all City and county ordinances and state laws misting to
Q V building construction,and hereby authorize representatives of this city to enter upnn the
abovc-mentioned property for Inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r.y l) liabilidea,judgments,costs and expenses which may in arty way accrue against said City
(„)Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:%12fl Date
S R DONS. Z7 p� Re-roofs
Signature of Applic an ontractorrF Da
OUS MATERIALS DISCLOSURE Type of Roof
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
Code,Section �No
zss32(a)?
E]Yes - All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use If a roof is installed without first obtaining an inspection,I agree to remove
aPP 8 P equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
E]Yes UQlvo
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does t cunend a tenant.that it is my responsibility to notify the occupant of the
req crits her ipriorroissuance a of Occupancy Signature of Applicant Date
�' tVJ7V 3 Z$,e11Y
0 er or,authorized agent Date All roof coverings to be Class' '`or better
:F Y OF CUPERTI
CIT �.
NO
CUPEkTINO REVISION/DEFERRED
PERMIT APPLICATION IC ON FORM
APN # Date:
3S7 - 0q — o3S , c� v �(i3lo
Original Permit#: �8
071 poo
Building Address:
C qoo Scenic
Mailing Address (if different from building address):
Owner's Name: Phone #:
Tt +4-k �o Zs�S q�r2
Contractor: Phone: zjv g�, -3!56 5-7go
C �- Q Fr,erf �i,r.�1c�c'�w, �°o Fax: IfV8 3S (.- 57R-2
Contractor License #: g��► '-7
Cupertino Business License #: Z 1 (o ( (�
Contact: Tn M T4s r Phone: qo g 3 7 8 2
r Fax: q68 378 !f 6o z
Building Permit Info:
Bldg fid Elect ❑ Plumb ❑ Mech ❑
Residential Commercial
Job Description: ems,s-a� k�r d) T `'h�� — (-Vew
Fo 8c�-\-L c)"t
Is the project in the Wildland- Urban Interfacce Fire Area? Yes ❑ No
Type of Construction (Usage Class): * Occupancy Type:
1-A, 11-B ❑ 11, 111, V-A ❑ 11, 111, lV V-B
Project Size: Standard arge 0 Major D Valuation (cost of project):
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
CITY OF CUPERTINO
CITY of REVISION/DEFERRED
CUPER,TINO
PERMIT' APPLICATION FORM
FEESCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
1 REVCOMNEW Revision Commercial New B 1
1REVCOVITI Revision Tenant Improvement, B 1* TI
1REVSFDWL Revision SFDWL B 1R3SFDW
1 REVRESADD Revision Addition B 1R3SFDADD
IREVRESREM Revision Remodel B 1R3SFDREM
1DEFINSP Deferred Submittal not R-3 B 1*
Inspection
1DEFPLNCK Deferred Submittal not R-3 Plan B 1* OR
Check 1* TI
1 DEFR3PLNCK Deferred submittal R-3 Plan Chk B 1R3SFDW
1R3SFDADD
1R3SFDREM
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