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CITY OF CUPERTINO T
BUILDING DIVISION PERMIT �11C7fGTOR 1 �1t�N
BU"5Ip(CtyQDJ2P,%ODRIDGE CT TBD — TO BE DETERMINED 07110118
OWNER'S NAME: W PERNQ'rISSUEDATE
04/09/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o a a a
o p LICENSED CONTRACTOR'S DECLARATION
U E= I hereby affirm that I am licensed under previsions of Chapter 9(commencing Job Description
<i with Section 70W)of Division 3 of the Business and Cessions Cod d license is S FD RMDL KTCHN, LAUNDRY, DINING & MSTR BATH.
C y in full force and effects
j 2 License Class r Lie.It
;90 Date Contractor t
ARCHITECTS DECLARATION
e a I understand my plans shall be used as public record&
�yU .
L t"' Licensed Professional _
ch.r
OWNER-BUILDER DECLARATION
� I hereby affirm that 1 am exempt from the Contractor's License Lew for the
Z20 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
<m 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 file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
9 C( commencing with section 7000)of Division 3 of the Business and Professions Code)or $80000
8 0 0 0 0
'2r3 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 T
not more than five hundred dollars(5500). 3 4 215 0 61 .Aff Number Occupancy yPe
0 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 Inspections
and Professions Code:The Contractor's License Law does ne nsot 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 oroQered 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 I,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-
cense Law dors not apply to an owner of property who builds or improver thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec ,B&P C for this reason
Owner Date
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 Worker's Crimper-
Italian,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the tabor Code,for the performance of the work for which this permit is issued. '
My Worker's Compensation Insurance carrier and Polity number ale:
Carrier. Polity 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 terrify that in the performance of the work for which this permit is issued.I shall not
employ any persany m, as to be s ifto W rs'Compensation
Laws of Califo
Applicant
NOTICE TO P ANT:If,after making this Certificate of—Exemption. should
become subject to the Worker's Compensation provisions of the labor Code,you must
Oforthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
r..� I hereby affirm that there is a construction lending agency for the performance of
7.t> the work for which this permit is issued(Sec.3097,Civ,C.)
p Lender's Name
=Z Lender's Address
I eerily that I have mad this application and state that the above information is
y. correcL I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
�.t liabilities,judgments,costs and expenses which may in any way accrue against said City
J Z in consequence of the granting of this permit.
APPLICANT UNDERSTLNDS AbW W L COMPLY WITH ALL NON-POINT Issued by: Date
SOUR EGULA S.
PGS Re-roofs �y
St na tum 7 Applicant/Contractor Da—�l
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,Seeccttion 25532(a)? o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or f tbuilding 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?
C]Yes 0�
I have read the hazardous mm`a�tcrials rcquirements under Chapter 6.95 of the Cali for-
niaHcalth SafetyCodc,seetioas25505,25533and 25534.1understandthat ifthe building
dors no u •ntly have a tenant,that it" m ponsibility to notify the occupant of the
requi Certificate of Occu anry ignature of Applicant Date
® All roof coverings to be Class `'or better
Owner or authari-rcd agent Date" g rr
o� si olid
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM .
CUPEkTINO
APN# /� ^�/ o O Date *difEit—
Building
Address: �(®7IJ � ailing Address(ifrom building address):
Owner's Name-,,— i Phone#: , i
Contractor: License#:
Contact, Phone: 1011PT•X-0 Pqwupertino Business License#:
Fax: - -
BuildingPermitlnfo: ,l ` �`
Bldg Elect Plumb TA, Mech
Job Description:
Residential � L--- Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.: AT
Cost of Project: Occupancy Groin
Type of Construction: Please check this box if the project is a
second-story 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<= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of 3
Community Development
10300 Torre Avenue
Cupertino CA 95014
`> Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDR SS: - PERMIT #
W0010 o
OWNER'S AME:
GENERAL CONTRACTOR: /K AX#
4OK—' 779-
I am not using any subcontractors: U �.
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
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature 6ate