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CITY OF CUPERTINO 7
BUILDING DIVISION PERI
BUILDING ADDRESS: MASTER BUILDER & CONSTRACT PPMIT N904080235
10455) BANDLEY DR
OWNER'S NAME: PERMIT 155UE DATE
M & LM
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Z O O LICENSED CONTRACTOR'S DECLARATION
X U(- I hereby affirm that 1 am licensed under provisions of Chapicr 9(commencing Job Description
?Z uu with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and effect. .,
j y Z License Class Lic.# TI--LEARNING CENTER
Z�,w Date k ContractorLiI
M ARCHITECTS DECLARATION
ce 11 undcrstanJ my plans shall ire used as public records
7
,U
7
3 WO H Licensed Professional
»z�
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
FCC following mason.(Section 7031.5,Business and Professions Code:Any city or county
X m ti which requires a permit to construct,alter,improve,demolish,or repair any structure
prior m its issuance,also requires the applicant for such permit to file a signcrIstatement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9 Sq.Ft.Floor Area Valuation
ez Y- (commencing with Section 70D0)of Division 3 of the Business and Professions Code)or
'CIL' 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 3 � j-��rp 0 Occupancy Type
not more than five hundred dollars($500).
❑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 Cade: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
own 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.).
❑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 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.
❑1 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 o(Consenl 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 am: r
Carrier: Policy(6V Vii: t�"'=' Policy No.:--t
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in(he performance of the work for which this permit is issued,I 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:1(,after making this Certificate 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.
Z O CONSTRUCTION LENDING AGENCY
[—+►� 1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lender's Address
aZ
U 0 1 certify that I have read this application and state that the above information is
"'—' correct.I agree to comply with all city and county ordinances and state laws relating to
0 V 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
rF-t to liabilities,judgments,costs and expenses which may in any way accrue against said City
V 2 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date f�
SOURCE REGULATION)
«-is Re-roofs l
Signature of Applicant/ tractor Date
HrCZARDOUS 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,Section 25532(a)?
C3 Yes LINo All roofs shall be inspected prior to any roofing material being installed.
�
C
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 ONO
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code,Sections 25505,25 533 and 25534.I understand that if the building
does not currently have a to ant, at itis my responsibility to notify the occupant of the
requirements which muss -met r to issuance of a Certificate of Occupancy. Signature Of Applicant Date
Owner or authorized agent Date
All roof coverings to be Class "B"or better
`f
CITY OF CUPERTINO*
��YY of PERMIT APPLICATION FORM " o 3`
CUPERTINO
APN # 32- / 33 l e Z Date:
Building Address: Mailing Address if di ent from building address):
Owner's Name: t /',� Phone #;/ ,/ 2��,r
Contractor: L9 License#:
Contact:,�a Phone:(0g) Cupertino Business License#:
A-!®/i-4 S. 4eJ Fax: 9 -
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description: ,{'
Residential El �E'O�Vi�-f C�^��'�/l� Commercial
Sq.Ft. Floor Area: S;- ! ZZ2 $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: ,�__^ Please check this box if the project is a
-�� /l 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> I OOK 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
BCOIVSTAXBQ 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
ao
lof3 � /� � O
Community Development
10300 Torre Avenue
'3✓ Cupertino CA 95014
Telephone(408)777-3228
CIT1f OF Fax(408) 777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
v-=,"5 $ Vi!-- ey a&kq23S-
OWNER'S NAME: >e-t PHONE #
GENERAL CONTRACTOR: nam L FAX #
I am not using any subcontractors: 4
Si e Dat
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
0 to