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CITY OF CUPERTINO $
BUILDING DIVISION P ) CTOR NF.0
BUILD MIT NO.
JNQ��D,p�EsPER
JOHANSEN DR TBD TO BE DETERMINED 07050160
OWNER'S NAME: PERMIT ISSUE DATE
JUDY LIN 05/30/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Z LICENSED CONTRACTOR'S DECLARATION
g Job Description
F- I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
UW with Section'7000)of Division 3 of the Business and Professions Code,and my license is REVISION-REMOVE S HEARWALL @ DEN. OR I G #06110037-
in full force and effect
N
z License Class Lic.It NO
p Date Contractor
ARCHITECTS DECLARATION NEW PERMIT.
f I undersand my plans shall he used as public records
U _
v Licensed Professional
a OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
"' prior ht its issuance,also requires the applicant for such permit to file a signed statement
a that he is licensed pursuant to the provisions of the 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 $0
m
.r ,That he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty ofNumber Occupancy Type
not more than five hundred dollars($500). 3 7 5 3 6 013"�
❑1,as owner of the property,or my employees with wages az their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
property who builds or improves thereon,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 he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the.project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law docs 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 Contractor's
License Law.
❑I am exempt under Sec ,B&P C fo5 this reason
Owner /jam Y�� /` <"'� - Dale
WORK S COMPENSATION DECLARATION/
t
y en:by amtm/u 6cr penalty of perjury one of the following declarations:
❑I have and will ma" Win 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.
❑I 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:
Cartier._ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify the!.in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as tote omcs bject to the Workers'Compensation
Laws of Califorti Date
Applicant—
NOTICE TO CART:If,�ljerri'naking this Certificate of Exemption,you should
become subje to the Work�s/"�Compensation provisions of the Labor Code,you must
z fmrthwith co p,
with suet 1—visions or this permit shall be deemed revoked.
p U Iii
CONSTRUCTION LENDING AGENCY
r.
1 hereby affirm that there is a construction lending agency for the performance of
r.
the work for which this permit is issued(See.3097,Civ.C.) -
Q Lender's Name ,
Z Lender's Address
C) I certify that 1 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
Ubuilding construction,and hereby authorize repmsen unives of this city to enter upon the
W above-mentioned property for inspection purposes.
G>•c (We)agree to save,indemnify and keep harmless the City of Cupertino against
V2 liabilities,judgments,costs and expenses which may in anyway accrue againstsaid City
Z in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R GULATIONS. �—
O�2 Re-roofs
Signatur `Applicant/Co r Dific
HAS. DOUS MATERIALS DISCLOSURE Type of Roof
ill the applic fpr future building occupant store or handle hazardous material
az dF6med by the Cup rfino Municipal Code.Chapter 9.12,and the Health and Safety
CoqVS-1 Yes r_1 No 5532(aj?
❑ All roofs shall be inspected prior to any roofing material being installed.
Yes
.Will the applicant or future building occupant use equipment or devices which If a roof.is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
El Yes ❑Nu
I have read the hazardous materials requirements under Chapter 6.95 ofthe Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requi�nts which must be met prior to issuance of a Crgificatc of Oc ancy. . Signature of Applicant Date
�� 06/ - All roof coverings to be Class "B"or better
Ow or aulhorircd pXcnt a
t
Ci 'OF PERMIT APPLICATION FORM
APN# Date:
Building Address: Mailing Address (if different from building address):
I<S 60 o JCI
Owner's Name: Phone#:
�r--Ontl-actoi-7 License#:
Contact: Phone:e4,69)44 C--r'7 8L Cupertino Business License#:
b'AV I C�> PSR Fax: (-d-a,S) c�-,6 -780
Building Pen-nit Info: .*. r—>z "6U r.- 5 4 iC-+'�NR.WnLL (-i� 'b-7---Y1
Bldg 1Z Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
Sq.F1:. Floor Area: Sq.Ft..
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
Iv— Ai. second-stor addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/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 Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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