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CITE'®F CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILI}IJiG�Ia,DRR DY WY TBD — TO BE DETERMINED 07070003
O W NE/R'SS NA4ME:N U PERMIT ISSUE DATE
CHENE MON—REN 07/24/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
K zLICENSED CONTRACTOR'S DECLARATION
U 0 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
zLu with Section 7000)of Division 3 of the Business and Professions Code and my license is GARAGE CEILING FRAMING—CRITCHFIELD CONST PAID FOR
w in full force and effect _
z Lican"sc C1. s Lie. BUS LIC.
F,p Dal ontracmr
ARCHITECTS DECLARATION
< I understand my plans shall be used as public records
aU
u.y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
a O following reason.(Section 7031.5,Business and Professions Code:Any city or county
9� which requires a permit to construct,alter,improve,demolish,or repair any structure
z I prior to its issuance,also requires the applicant for such permit to file a signed statement
=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $3500 Valuation
t— (commencing with Section 7000)of Division 3 of the Business and Professions Code or
! '4 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 ofNumber Occupancy Type
not more than five hundred dollars($500). 366170651 i��J'
❑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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of 4 P
property who builds or improves thereon,and who does such work himself or through his
own employers,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-
ccne Law dors not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a conuactor(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
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 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.
❑1 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. Policy No.:_a7 l
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complcied if the permit is for one hundred dollars($100)
or less.)
I cenify that in the performance of the work far which this permit is issued,1 shall not
employ any person in any mannerso as to become subject to the Workers Compensadon
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
.J z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
E-r i hereby affirm that there is a construction lending agency for the performance of
x. the work for which this permit is issued(Sec.3097,Civ.C.) -
W Q Lenders Name
z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
rr eerrect.I agree to comply with all city and county ordinances and state laws relating to
Q U building conswcuon,and hereby authorim representatives of this city to enter upon the
Uahovc-mcnuoncd property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rn Aconscuen
Ls,casts and expenses which may inanyway accrue againstsaid City
zhe granting of this perLnit.DERST NDS.AND WILL COMPLY WITH ALL ON-POI T Issued by: Date
TIO aff
Re-roofs
n rc App licant/Contractor DM
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.Section 25532(a)? All roofs shall be inspected prior to an roofing material being installed.
❑Ycs N P. P Y g b
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 to comamin is as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
0,cs No
I have read the hazardous materials requirements undcrChapter 6.95 of the Califor-
nia Health&Safer odc,sections 25505,25533 and 25534.1 understand that ifthc building
docs not a ave a tenant that it is my responsihility to notify the oecupant of the
requirem a must be et prior to issuance of a Certificate of Oc u ancy. Signature of Applicant Date
27 All roof coverings to be Class "Br' or better
O r au r&.ed agent I Date
- CITE' OF CUPERTINO
CUPEkTINO PERMIT APPLICATION FORM t1,2 7z9Z�3
APN# 3�R P Date:
Building Address: Mailin ddress (if different from building address):
-7 5 5 c- oa(/,,
Owner's Name: . Pone#:
Chi -��0 q 6 00Il
Contractor: License#:
It
Contact: // 1IL-F C 41's // 5 Phone: Cupertino Business License#:
Fax:
Building ermit Info:
Bldg. Elect Plumb Mech
Job Description:
Residential�, _�` e �i�Ol Commercial El
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group:
d4�,rJ�
Type of Construction: &�_ e Please check this box if the project is a
)second-story addition: ❑
Project Size: Standarisl_ .1 Large ❑ Major ❑
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 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
BELEC 1000 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
I of 3
0_ Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
`7U ?00
OWNER`S NAME: /YCo-kx _Ae,--A PHONE # t�, 8 oo!(
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: OZ
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
ile
Owner/ContractoY Signature Date