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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
"I'L-DiT AIFtALVERT DRIVE TBD — TO BE DETERMINED PERMIT07120263
OWNER'S NAME: PERMIT ISSUE DATE
BILL SULLIVAN 05/28/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 c UCENSED CONTRACTOR'S DECLARATION Job Description
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
U� with Section 7000)of Division 3 of the Business and Professions Code,and my license is REMOVE EX STNG 800 S Q HOUSE & CONSTRICT NEW 2344 S Q
y in full force and effect
Z License Class Lk.M SFDW
F,a Date Contractor
ARCHTTECPS DECLARATION
I understand my plans shall be used as public records -
yU
C y Licensed Professional
y
OWNER-BUILDER DECLARATION
t g I hereby affirm that I sea exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to Construct.alter.improve,demolish,or repair any structure
z y prior to is issuance,slso requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisionsof dee Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $400000
3r- that he is exempt therefrom and the basis for the Alleged exemption.Any violation of
Section 7031.5 by arty applicant for it permit subjects the applicant to a Civil penalty of 375 1 8 0 Q�N Number - Occupancy Type
not more than five hundred dollars(5500).
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
and Professions Coda:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such impmvememts 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 he did not build or improve for purpose of
sale.),
0 L as owner of the property.am exclusively contracting with licensed conuactom to
convect the project(Sec.7044,Business and Professions Code:)The Contractors U-
cense 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 to the Contractors
License Law.
❑I am exem/Pj��der Sec .B&P(C for this reason
Owner / Data 5 z G
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers 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 Workers Compensation Imurana,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:
Carrier. Polity No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compacted if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any mannoses as w becomsubject to the Workers'Compensation
Laws of California.Date f ) ,SO
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Codc,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
"" CONSTRUCTION LENDING AGENCY
M r�r 1 hereby affirm that there is a construction lending agency for the performance of
:4.7' the work for which this permit is issued(See.3097,Civ.C)
4 0 lenders Nam
1 z Lenders Address
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
U building construction,and hereby authorirs:representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
„r (We)agree to save,indemnify and kap harmless the City of Cupertino against
tn liabilities,judgments.Coss and expenses which may in any way accrue against said City
Zin consequence of the granting of this permit (' 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date J '
SOURCE REG TIONS. A�l - -
tw/ � --- � " z s - °S Re-roofs
Signature of ApplianLIContntctor Date �'-
HAZARDOUS 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 25532(5)?
❑Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I'agree to remove
croft hazardous air contaminants as detned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ONO
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety CodC,Sections 25505.25533 and 25534.1 understand that if the building
does not curendy have a tenant,that it is my responsibility to notify the occupant of the '
requirements P7 be el prior to issuance of a Certificate of Occupancy. S Signature Of Appl Kant Date
Gam— 5.—
Owner or authorized agent Date All roof coverings to be Class'j 'r or better
• CITY OF CUPERTINO
NEW SINGLE/MULTI FAMILY DWELLING
CUPEkTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
1 0 4 C .A i P-k i
Mailing Address (if different from building address):
3 �-2-, �. Q5LnaJ , f- L� ckn , Slt C /k SS
Owner's Name: Phone#
Contractor: Phone#: (4A)48b 6 $o 2
Fax #:
Contractor License#:
Cupertino Business License#:
Contact: - M �;�.y� Phone
�ab)
Fax #:
Alternate Contact: Phone#:
Fax#:
Single-Story ❑ Two-Story ❑ Three-Story ❑ Basement ❑ Hillside. ❑
Multi-family ❑ Apartment ❑ Condo ❑ Townhouse ❑
Sq.Ft. Living Area (Including Basement &Attached Garage: Sq. Ft. Garage (Detached Only):
'23 _ty
Valuation:
Gob
Job Description:
1&-_0
�& __ \ S
Y&-'�"U •Q�I s:-s',v ` co O c �- v a-<�v- Z %4
Type of Construction (Usage Class): Occupancy Type:
1 FR, 11F ❑ 11, 111,V-1HR ❑ 11, 111, 1V V-N
Project Size: Standard LI' Large❑ Major❑
Green Building: Must attach completed Green Building Checklist to the plans
Green Building Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
-- 071 Z b 2, In3
OWNER'S NAME: PHONE # D Q r Q Z
GENERAL CONTRACTOR: pVFAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper N
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
e
Owner/Contrac or Signature Date