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CITY OF CUPERTINO
BUILDING DIVISION PERM* CQIOTTIZA,GTC1l[tIIVJEQRM N
3.
BUILDING ADDRESS: PERMIT NO
03090043
OWNER'S NAME: PERMIT ISSUE DATE
DAVID CHAD
PHONE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT'/ENGINEER: BLDG ELECT PLUMB MECH
p LICENSED CONTRACTOR'S DECLARATION Job Description
q P I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
1W with Section 7000)of Division 3 of the Business and Professions Code,and my license is
yin fun fume and erreeL
Z License Class Lic.p ADD 571 SQ. FT. /KITCHEN REMODEL
�
_a Date_ Contractor
ARCHITECT'S DECLARATION
a 1 understand my plans shall he used as public records
yU
y Licensed Professional
1 OWNER-BUILDER DECLARATION
a 1 herehy affirm that I am exempt from the Contractor's License Law for the
0 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
n which requires a permit u)construct,alter,improve,demolish,or repair any structure
z prior In its issuance,also requires the applicant for such permit to file a signed statement
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of 37529029 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than rive hundred dollars($500).
M 1,as owner of the property,or my employees with wages as their sole compensation, '(�7
will do the.work,and the structure is not intended oroffered forsale(Sec.7044,Business — Ted Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of 102 — PIERS 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 forsale.If, 103 — OF ER
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 104 — REBAR
sale')' 105 - ANCHOR BOLTS
1]I,as owner of the property,am exclusively contracting with licensed contractors to 10 6 - SEWER & WATER
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. 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contracter(s)licensed pursuant to the Contractor's
i ense Law. 203 - UNDERFLOOR MECHANICAL
I am exempt under Sec. ,B&P C for this reason 204 - UNDERFLOOR FRAME
Date
GW��-SWORKER'OMPENSATIONDECLARATIRF 0 205 - UNDERFLOOR INSULATION
T hereby affirm under penalty of perjury one of the fol awing declarations: 301 - ROUGH PLUMBING
❑T have and will maintain a Certificate of Consent to self-insure for Worker'sCompen- 302 - TUB & OR SHOWER
sation,as provided for by Section 3700 of the Labor Code,for the performance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
304 - ROUGH ELECTRICAL
F1 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. 3 05 — FRAME
My Worker's Compensation Insurance carrier and Policy number are: 306 — HOLDOWNS
Carrier._ CERTIFICATE OFEXEMFInONFROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(This section need not he completediftheperrnitisforonchundreddollars($1(K)) 309 - EXTERIOR LATH
or less.)
1 certify that in the perfarmancc of the work for which this permit is issued,1 shall not 310 - INTERIOR LATH
employ any person in any manner so as to become subject to the Workers'Compensation 311 - SCRATCH COAT
Laws of California.Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become:subject to Ne Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed mvokcd. 502 — F I NAL PLUMBING ENERGY
^� CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
1 hereby affirm that there is a construction lending agency for the performance of 504 - F I NAL BUILDING ENERGY
> the work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name 505 - F I NAL ELECTRICAL
a�
Lenders Address
z - - 506 - GAS TEST
0 1 certify that 1 have read this application and state that the above information is
'—' 507 - FINAL PLUMBING
correct.I agree to comply with all city and county ordinances and state laws relating to
j U building construction,and hereby authorise representatives of this city to enter upon the FIN MECTN
AL
U ahove-mentioned property for inspection purposes.
r
(We)agree to save,indemnify and keep harmless the City of Cupertino against 0 9 F I �(�)
y fn/j liabilities,judgments,costs and expenses which may in any way accrue against said City 5 `�
Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bY:5 ORKS Date
-SOURCE R[i(,ULATIONS.
Re-roofs
nature of of Appltca—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,S25532(a)?
[]Yes:)Yes y,.,. 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 materials for inspection.
District'?
E]Yes No
I have mad the hazardous materials requirements under Chapter 6.95 of the Cal ifor-
niaHcalth&Safety Code,Sections 25505,25533 and 25534.1undcrstandthat ifthc building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
mquircmcntsoch must qE met prior to issuance of a Ccnificatrtiof Occup O I Signature of Applicant Date
o� -ad dried agent \\\ t� � All roof coverings to be Class "B" or better
� CITY OF CUPERTINO 3
CITY of PERMIT APPLICATION FORM D
CUPEI�TINO
APN
Building Add ss:
Owner's N e: Phone #:
Ant i
17
Contractor: License #:
Contact: Cupertino Business License#:
Li
Building Permit Info:
Bld, Elec Plufnb�LJ Mech ❑
Job Description:
Residential ❑ ! /Comhi-etci
u!�q
Sq.Ft. Floor Area: S/Sq.Ft.:
Cost of Project: ] ccupancy Group:
Type of Construction: `
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permit sq. foot BUILDING
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<= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
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