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CITE'OF CUPERTINO
BUILDING DIVISION pE CQla1TI�ATC�I2INJECaI� ��1�% :<
BUILDING ADDRESS: MASTER BUILDER & CONS TRACT MMIT NO0 5 0 1 0 0 5 1
OWNER'S NAME: PERMIT ISSUE DATE
LITTLE MUSTARD SEED 2003 ABBEY LANE 01 /07/2005
PHONE: SANITARY NO. CONTROL NO.
(408) 866-0999
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1 O p LICENSED CONTRACTOR'S DECLARATION
L U{= I hereby affirm that I am licensed under provisions.of Chapter 9(commencing Job Description
_z with etit>a7D(B))of Division 3 of the Business and Pr sions ode,and my license is
' in fall force and effect. ✓ �� _ 7 REV I S I ON- -IN HOUSE USE ONLY
j Z License Class !� Lic.#
;moo Date — Contractor.17-D--7,y-� r li irx NO NEW PERMIT ISSUED/ORIG. #04080235
a AR ITECTS DECLARATIOLL!1
,stand �
W< Lurtf my plans shall be used as public rccKas
JaV
` H Licensed Professional
y OWNER-BUILDER DECLARATION
a 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
O O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
<,�, which requires a permit to construct,alter,improve,demolish,or repair any structure
u—'m prior to its issuance,also requires the applicant for such permit to Glc a signed statement
za
_-< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation$4 5
is 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 APN Number Occupancy Type
not more than five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sole compensation, 32633102 . 00
will do the work,and the structure is not intended oroffered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law docs no(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.
❑I am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally 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 tcaarrrier and Polic number are: T
1
AP% Poli No.i. l.?���
CERTIFICATE OF EXEMPTION FROM WOR
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
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 so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.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.
OCONSTRUCTION LENDING AGENCY
r--c 1 hereby affirm that there is a construction lending agency for the performance of
3i > the work for which this permit is issued(Sec.3097,Civ.C.)
it 0 Lender's Name
z Lender's Address
J Q 1 certify that 1 have read this application and state that the above information is
1, correct.I agree to comply with all city and county ordinances and state laws relating to � s
V building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
y
(We)agree to cast,indemnify and kith harmless aCupertino against
..r(/) liabiliLies,judgments,costs and expenses which may in any way
accrue
e against said City
J in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date
SOU�P®ULATIONS.
1
_Z_7
ignature of Applicant/Con ractor Date Re-roofs ,
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,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ENO
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 Arca Air Quality Management all new materials for inspection.
District?
❑Ycs E No
I have read the hazardous materials requirements under Chapter 6.95 ofthc Califor-
niaHealth&Safety Code,Sections 25505,25533 and25534.I understand that if du building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
req it ems which must be met prior to issuance of a Certificate of Octupanty.- Signature of Applicant Date
`Owner or authorizeda ent ' art All roof coverings to be Class "B" or better
0
CITY OF CUPERTIN
�7Y of PERMIT APPLICATI®N FORM o kV ( o
CUPERTINO
APN 32-1� 33 / oZ Date: /
Builchg Address: _ Mailing Address (if diff rent uilding a ress):
Owner'sPhone #:
Contracto . License #:
Co ct: Phone: Cupertino Business License#:
Fax
Building Permit Info:
Bldg ❑ Elect ❑ lumb ❑ Mech
Job Description:
0,/ rv,
Residential El �oeal '
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Larg ] Ma'or
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1 M 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
Z�z�
-7
Community Development
W
10300 Torre Avenue
Cupertino CA 95014
:r Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEI�TINO
Building Department
JOB ADDRESS: PERMIT #
WNER'S NAME: -V4,-�5 , PHM # 9-Lp D� 9
GENERAL CONTRACTOR: ,4-� fN-72- Y,�;,V 1 1_>PpFAX
I am not using any subcontractors:.
ignature e
Please check applicable subcon ors 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
1 � 7,,��-5��/ � �
Contrac or Signature Date