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CITY OF CUPERTINO =
BUILDING DIVISION PERMIT IQRMATI®lY
X911 SAN JUAN RD ARTISAN BUILDERS 08100095
BUILD N DD ESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
WM HALL 771 CLEMENTINA ST 10/16/2008
PHONE: (415) 863-2232 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O
Z LICENSED CONTRACTOR'S DECLARATION
L4
F I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
zwithSection7000)ofDivision3oftheBusinessandProfessionsCode,andmylicenseis KTCHN RMDL, MDFY CBNTS, ADD OPNING INTO LVRM &
a
in full force and eIT _
License Class Lic.# �� ADD
FDate v. Contractor A v t '
�W ARCHITECTS DECLARATION � MICROWAVE (115SQ)
ci�< I understand my plans shall he used as public records
aU
N Licensed Professional
15
rn OWNER-BUILDER DECLARATION
N 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
Z which requires a permit to construct,altar,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
za
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Va uatlon
= 20000
f— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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 Q,� Number Occupancy Type
not more than five hundred dollars(5500). 3 4217 089:t7
❑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 forsale(Sec.7044,Business
and Professions Code:The Contractor's 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.).
[11.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 does 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.
E]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 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 arc:
Carrier.9*T_AfVt�' J `rd n PolicyNo.:b b
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars(5100)
or less.)
I certify that in the performance of the work for which this permit is issued,t shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificatc of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
•. Cn I hereby afTirm that there is a construction lending agency for the performance of
, the work for which this permit is issued(See.3097,Civ.C.)
Jct Q Lender's Name ,
,+ Lender's Address
7z
J 0 1 certify that I have read this application and state that the above informatiun is
correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding conswction,and hereby authorize 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 Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
J Z in consequence of the gra ti of this permit.
'—' APPLICANT UND ADS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE, A
Re-roofs
Signature of Ap cant/Contractor 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
Code,Section25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ago
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?
❑Yes
1 have read the hazardous materials requirements undcr Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if the building
does not curter� ha�lenant,that it is my responsibility to notify the occupant of the
mquimmertt�whi in be mel prior to issuance of a Certificate of Occupancy.
`A��,° � Signature of Applicant Date
Oent Date
-
All roof coverings to be Class".'or better
wner or au&ri-red ag
ohoo
CITY OF CUPERTINO
A.-a,
ADDITION/REMODEL
CUPEkTINO PERMIT APPLICATION FORM
APN# �%R, 00 Date:
Building Address: �
YZI L S.,<r V v/� (Lt
Mailing Address (if different from building address):
Owner's Name: Phone#
Contractor: Phone#: b W 7-TA-52—
L
A-3vL Fax#: 4t5- t,Ls L
Contractor License#: r!>
Cupertino Business License#:
Contact: . Phone#: �5- 3- u.-3
f�cM1Sor,! Fax#:
Building Permit Info:
Bldg. Elect. 9— ' Plumb. ❑ Mech. D Hillside ❑
Job Description: rk+-ars
Addition-What is.being added?(Be Specific):
What is being remodeled(not including addition)? ,�,
Remodel Includes Re-Roof: Yes ❑ No ❑ If yes list number of squares
Remodel Includes Structural: Yes [ No ❑ F.`p.=>t_
Do you have the pre-application planning approval? Yes ❑ No [�—_
If yes, please provide a copy of your plannig approyal letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen l5 Bath Other
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A. ❑ IUIII B, IV-HT, V-B
Valuation: Please check this box if the project is a
second-story addition ❑
Project Size: Express ❑ Standard ❑ Large ❑ Major❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved•
include in plan set & the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 10/01/08
CITY OF CUPERTINO
ADDITION/REMODEL
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit 'Type
Sq Ft
ADDITIONS 1R3SFDADD
PLLONGRNGR Long Range PL
Planning/Residential _
1R3INSP Dwellings Inspections B
1 R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection _
1R3REPPLNC • Dwellings Repeat Plan B
Check: _
1 R3HINSP Dwellings Hillside B
inspection
1R3HPLNCK Dwellings Hillside plan B
check _
1R3HREINSP Dwellings Hillside B
Repeat Inspection _
1R3HREPLNC Dwellings Hillside B
Repeat Plan Check _
1 R3ALTINSP Dwellings Alternate B
Materials•Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check _
1PCESS Cesspool P
1 PPRSEWG Ea. Private Sewage P
Disposal System
1 PRSEWER Sewers P
1 BPSPRINK • Lawn Sprinkler/Backflow P
1BPWSVCS Main Water Service P
f 1BSEISMICRE. Seismicgesidential B
1REROOFRES Residential Re-roof Each B
100 SF
DECKS 1R3SFDADD OR
1R3SFDREM
1DECKWOOD Deck (Wood)-Each B
(Each) _
1 DECKRAIL Deck Railing-Each B
(Each) _
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
V2- v S/cri
OWNER'S NAME:Wi til-i o*. -PHONE #,-l<,. $6'S_1-1-3 ti
GENERAL CONTRACTOR:p4xrtcoc� f�jvi _ FAX# f—
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
Owner/Contractor Signature Date