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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
22292 BUILDERS
OWNER'S NAME: PERMITISSUEDATE
PHO Y�EA CONTROL NO.
(650) 948-1077
ARCHI'fECI7ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
3 O�p LICENSED CONTRACTOR'S DECLARATION D D D
U P 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
:may in full Come andcff:CL REVISE,MOVE EXT IN 1ST&2ND FLRS,REMOVE INTERIOR
�M? License Class Lic.q
e Date Contractor WALL IN BASEMENT,FAMILYRM & TRNSFR LOAD TO
ARCHITECTS DECLARATION
wI understand my plans shall be used as public records BASEMENT WALL S—1, S—2&S—3 ORG#0 7 0 9 012 4 NO NEW
a
LU.ya Licensed Professional
n0 J OWNER-BUILDER DECLARATION
+� 1 hereby affirm that I am exempt from the Contractors License Law for the
E 0 o following-reason.(Section 7031.5,Business and Professions Cole:Any city or county
K m which requires a permit to construct,alter,improve•demolish,or repair any structure
y z} 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 Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
EC F (commencing with Section 7000)of Division 3 of the Business and Professions Cale)or
y .. that he is exempt therefrom and the basis for the alleged exemption.My 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(5500).
36647015 . 0 0
❑1,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 does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
awn 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.).
❑L as owner of the property,am exclusively contracting with licensed contractors to
Construct the project(Sec.7044•Business and Professions Code:)The Contractor's Ld-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractar(s)licensed pursuant to the Contractors
License Law.
1 am exempt under See ,B&PC for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 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 Insurance,as required by Section
3700 of the Labor Calc,for the performance of the work for which this permit is issued
My Workers Compensation Insurance artier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPE14SAT ION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
1 cenify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so o be tame. b'ct to the Workcrs'Compensation
Laws of California Dao
Applicant Lrt�s•-e _
NOTICE TO APPLI NT:If,after making this Certificate of Exemption,you should
become subject to the orkees Compensation provisions of the Labor Code,you must
Q forthwith comply with such provisions or this permit shall be deemed revoked.
Z Cn CONSTRUCTION LENDING AGENCY
E"s""' 1 hereby affirm tut there is construction lending agency for the performance of
<Y.5 the work for which this permit is issued(Scc.3097,Civ.C.)
CWn Q Lenders Name .
Z Lenders Address,
U C) 1 certify that 1 have read-this application and state that the above information is
ly cormcL I agree to comply with all city and county ordinances and state laws relating to
0 V building convection,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
N (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
U Z in consequence of the granting of this permit.D L
APPLICA UNDERSTANDS ANL OMPLY WITH ALL NON-POINT Issued by: Date 0
SOURCE R ULAT10
Re-roofs
Signatu a! ppliraniContnctor 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
cone, es 17]No
z553z(a)7
0 Yrs All roofs shall be inspected prior to any roofing material being installed.
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 mterials for inspection.
District?
❑Yrs Qy�No
1 have mad the halm dmus materials requirements under Chapter 6.95 of the Califor.
ria Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not curerrrfly have a tenant,that it)s my responsibility to notify the Occupant of the
requirements 9(hich mus met prior�)a/jhssu race of a CcrUfhcate of Occrypancy Signature of Applicant Date
Y(orizcd t, w-r '�RR//AA��_�t-- �/ 6� All roof coverings to be Class'A"or better
Owner of auyjtOmcd agent Dam
U � i
067D
CITY OF CUPERTINO
Cin Of
CUPEVINO REVISION/DEFERRED
PERMIT APPLICATION FORM
APN # 7 U 1 0 Date:
Original Permit#:
p`)-ocj o lZ4
Building Address:
222 2 6--E 6,,J 491-
Mailing
-Mailing Address (if different from building address):
Owner's Name: Phone #:
JA��V�c k V.KP(� YDS Aa'o
Contractor: Phone: ,,.5V
cr,tC..
Fax: 650
Contractor License #: 7Dt -90115-
Cupertino
90115-Cupertino Business License
Contact: Phone: ��2 CA-o 4-
Fax: 1+0 (�
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Residential Commercial ❑
Job Description: WK t
.rJ w Mcn . 24A. k
19-1 ,S-2. cq,-3
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction{Usage Class): * Occupancy Type:
1-A, 11-B ❑ 11, 111, V-AE] 11, 111, 1V V-B
Project Size: Standard Large ❑ Major ❑ Valuation (cost of project.
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help,contact Build it Green at www.builditgreen.org
CITY OF CUPERTINO
CITY of REVISION/DEFERRED
CUPE1Q:INO
PERMIT APPLICATION FORM
FEE SCHEDULE .
Quantity Fee ID Fee Description Fee Group Permit Type
Sq Ft
IREVCOMNEW Revision Commercial New B 1*
IREVCOMTI Revision Tenant Improvement B 1* TI
` IREVSFDWL Revision SFDWL B 1R3SFDW
IREVRESADD Revision Addition B 11F:3SFDADD
IREVRESREM Revision Remodel B 1R3SFDREM
I DEFINSP Deferred Submittal not R-3 B 1* ,
Inspection
IDEFPLNCK Deferred Submittal not R-3 Plan B 1* OR
Check 1* TI
IDEFR3PLNCK Deferred submittal R-3 Plan Chk B 1R3SFDW
1R3SFDADD
1R3SFDREM
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