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BUILDING DIVISION` � 1��� v
C ® �RAINFORM
BUILDING ADDRESS: PERMIT NO.
OWN PER I
PHONKENNY FU SANI(�k3yM/2 0 0 7 CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
n o 0 0
ZLICENSED CONTRACTOR'S DECLARATION
oI hereby affirm that I am licensed under provisions of Chapter 9(commencing FROM 8 ' TO 10 ' —ROOF 1°b Description
U with Section 70(1))of Division 3 of the Business and Professions Code,and my license is
, in full force and effccL w �•� � ✓ //�-��`�J �oC,1 �/�`/D f ��1 /,�5� .,1 1/
? License Class Lic.#
O Date Contractor
a
ARCHITECTS DECLARATION �L7 ( �(CI I N�'��/G•{� �(J�F/��/�/J�
•-� I understand my plans shall be used as public records /g�
I.icenseJ Professional ___-- __- C.���CT�/✓"C�� C- =/�A�� �♦/�r///�w�/ -- ��/V�z O C F--•oi✓�
<, OWNER-BUILDER DECLARATION
I hereby alfirm that I am exempt from the Contractor's 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
prior to its issuance,also requires the applicant for such permit to Glc a signed statement
o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
e (commencing with Section 7000)of Division 3 of the B usiness and Professions Code)or
m that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑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 Required fired Ins ecti o ns
and Professions Code:The Contractor's License Law does not apply to an owner of 9 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 J.
I,as owner of the property,am exclusively contracting with licensed contractors to
nstmcl the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractors)licensed pars rirto the Contractor's
License Law.
❑I am exempt der Sec. .B&PC fo this re n
Owner ' ' Date
WORKE MPE 3ATION DECLARATION
1 hereby affirm under penalty of ury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen.
sation,az 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,az 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 he completed if the permit is for one hundred dollars($100)
or less.)
1 eenify that in the performance of the work for whi this pe i is issued,1 shall not
employ any person in any m cr so az t ccomc su I ct c Workcrs'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLI ,after making this eniGibatc of Exemption,you should
become subject to the Worker's Compensation p visio s of the Labor Code,you must
Oforthwith comply with such provisions or this per all be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructinn lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name
Z Lender's Address
0 1 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
Ubuilding construction,and hereby auiborne representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cu fl,insl
Cn liabilities.judgments,costs and expenses which ay in any way accrue msl said City
Z in consequence of the granting o this permit.
APPLICANT UNDERSTAND AND WI COMPLY TH ALL NON-POINT Issued by: Date
SOURCE REGULA`ONS. _
Ac��kL
Signatu f rcanUCo ratio Datc Re-roof
HAZARDOUSMA A S DISCLOSURE Type of Roof
Will the applicant or future buildi g oceu ant store or handle harardous material
az defined by the Cupertino Municipal ode,C pter 9.12,and the Health and Safety
Code,Section 25532(¢)? All roofs shall be inspected prior to any roofing material being installed.
E]Yes No
Will the applicant or�f ,re 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 Arca Air Quality Management all new materials for inspection.
District?
❑Yes u
1 have read the hazardous materials requirements under Chapter . 5 of the Califor.
nia Health&Safety Code,Sections 25505,25533 and 25534.1 d that if the building
docs not currently have a tenant,that it i y responsibil' to lify the occupant of the
requirements which mu be met prior W is of crtiri of occupancy. Signature of Applicant Date
Owner or authorized¢gem Date All roof coverings to be Class"B" or better
CITY OF CUPERTINO
C
�1 All
IkJCuPE1N0 PERMIT APPLICATION FORT
ADDITION/REMODEL
APN Date:
lo-1
Buildinu Addi-ess: �b CANIailin- Address (ddifferent from building; address):
,,\)f-) I _ . Cut,4-q 6ciq La
L "A
Owner's tame: wi Phon
Contractor: j License.4":
V4
1 Contact: Phone: Cupertino Business License',-:
Fax:
Building PeMlit ITlf0:
BldCy Elect ❑ Phimb 0 .,\,ICCh 0
Job Description:
What. is beilia at-'Ided?
f
gfsLA-6m i;b�a vJ ,9 tl e,�a16 r4 Fla
+0 to
ro ef
W11,11t is beilit" I-elliodeled?
• 3
AA
Remodel Includes Structural: Yes W No
Residential Commercial El
Square Footatze:
Moll:
Ciai-ac:
1�elllodej.- 2-0 '�;.F . 110Z
Deck: othel-:
Cost of Project: i Occupancy Group:
Tvl)e Of COTIStRICti011: Please check this box if the project is a
second-story addition: D
Project Size: Standard Large 0 iMajor C) i
*For Office use 0111y",
Over the Counter
_Qt�L111tity Fee ID Fee.Description Fee Group
BAPPLOTHER Other Appliances 'i\,l ECI--IA NN ICA L
BBOILERI Boiler<— 100.000 Btu 'TECHANICAL
BBOIL R2 Boiler> 100K to 500K' Btu N1FCHA1JCA1..
ry
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