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CITY OF CUPERTINO
BUILDING DIVISION PERMITPERMIT NO.
� 1TRACTQR INF �tMfTIaN
BUILMQfl�RESs:HELLY• DR FOREST BUILDING 08030168
OWNER'S NAME: PERMIT ISSUE DATE
HO JEAN C AND GILBERT D PO BOX 183 03/28/2008
PHONE: SANITARY NO. CONTROL NO.
(650) 862-0742
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
c p LICENSED CONTRACTOR'S DECLARATION
m_ 1 hereby affirm that I am licensed under provisions of Chapter 9(eommcncing Job Description
z8 with Section 70M)of Division 3 of the Business and Professions Code,and my license is RPLC EXSTNG WINDOWS 1 LVRM 8 'X4 ' 1KTCH 4 'X3 ' ,
t<a in full force and effecL
n Z License Class Lie.# 1 FM RM 3 X 3 r 6" .
i t-ver Date Contractor
ARCHI IECi's DECLARATION
C< 1 understand my plans shall be used as public records
:yU
'
U.y Licensed Professional
y
OWNER-BUILDER DECLARATION
< I hereby affirm that I am exempt from the Contractors License Law for the
:❑O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
e,0,� which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
FE 0< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $1500 Valuation
[— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
'WE 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 Number Occupancy Type
not more than rive hundred dollars(5500)_ 3 5911021 � P Y YP
❑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 Code:The Contractors License Law docs not apply to an owner of Required Inspections
property who builds orimproves thereon,and who does such work himself or through his
own employers,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.).
I,as owner of the property,am exclusively contracting with licensed contractors to
nstruct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts forsuch projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt nder S _ - ,B&P C for this reason
Owner Dam
��K-ER'S'COMPENSAT1O DECLARATION
1 hereby iffir n under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn-
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 Workers Compensation Insurance,as required by Section
700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Com enation Insurance carrier and Policy number are:
Carrier. Policy No.:
,CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars(S100)
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 manner so0A to become subject to the Workers'Compensation
Laws of Califomi Datc
Applicant
NOTICE TO AP CA ,7r-making this Ccru tc jc of Exemp rot,you-should
become subject o c'ampcnsation provisions of the Labor Code,you must
=O forthwith comply ' c provisions or this permit shall be deemed revoked.
7 CONSTRUCTION LENDING AGENCY
�.1
—�En I 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.)
QLender's Name .
=z Lenders Address
;)0 I certify that I have read this application and state that the above information is
►'t correct_1 agree to comply with all city and county ordinances and stare laws relating to
D U building construction.and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
'~y Co� liabilities,judgments,costs and expenses which may in any way accrue against said City
Z in consequence of the grapting of this permit. r
►� APPLICANT U ER�DSANDL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGU ATI _)_W
Re-roofs
Signature _rcant/Conuaetor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupantstom or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scene25532(a)7
❑Yes04 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 hazardaus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes [�fu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safely Code,Section 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant. at it is my responsibility to notify the occupant of the
reyuirements which must be m pn to issuance of a Certificate of Occupanc. lgnatllre Of Applicant Date
Owner r autho gem' Date'
�"' All roof coverings to be Class'"or better
r
CITY OF CUPERTINO
OF
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# l _ 0 00 Date:
Building Address:
X061q Sl-l6- c/ c `r -DR , ca 7/ 1v10_ 0-
Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor:._ C r Phone:
G0/(! t 0 il/ Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial ❑
Job Description: !
kvl X
Building Permit Info:
Bldg ®// Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1 FR, 1 1F ❑ 11, 111, V-IHR ❑ 11, 111, 1V V-N r2- 3
Valuation: v Square Footage:
Project Size: Standard Large ❑ Major ❑
t t
CITY OF CUPERTINO
CUPEI�JINO GENERAL BUILDING
PERMIT APPLICATION FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1BTEMPPER Temporary Building Permit (good for B
30 days)
1BBOILERI For the installation or relocation of ea M
boiler/compressor to &including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to &incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1BBOILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
&incl 1,000,000 Btu/h
1BBOILER4 Installation/relocation of ea M
boiler/compressor over 30 hosepower
to &incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
IELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing & Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B
Community Development
10300 Torre Avenue
Cupertino CA 95014
s
Telephone(408) 777-3228
a of Fax(408) 777-3333
CUPEkTINO
Building Department
JOB ADDRESS: l.(��� � V-/�� \� PERMIT #
So 6) 3�1�
OWNER'S NAME: J�% U /4(0 PHONE 4 !S _ a? (- t Z /
GENERAL CONTRACTOR: go 2Z S i l t t c n FAX #
(..ca
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
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Ow ontractor Signature Date