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CITE'OF CUPERTINO
BUILDING DIVISION PERMIT �fi1TRATQRINQRT(I�T
BUILDING ADDRESS: PERMIT NO.
20333 NORTHCOVE SQ I .C.R. CONSTRUCTION 07120116
OWNER'S NAME: PERMIT ISSUE DATE
JOSE & ELY GOMEZ 5817 FALON WAY 01/08/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 561-7690
ARCH1TECTIENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 a 0
u0p LICENSED CONTRACTOR'S DECLARATION
�U U I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
.U m with Section 7000)of Division 3 ofmc Business and Professions Codc,and my license is ADD 1 SKYLIGHT, 1 WINDOW
a a. in full farce and effect. —z t� �/�r
3,-14 License lass Lic.p J l
s—a Date '—'MW -4 Contractor �_G �.
ARCHITECTS DECLARATION
o�C< 1 understand my plans shall be used as public records
�yU
U,F" Licensed Professional
t7 OWNER-BUILDER DECLARATION
I 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
-4 which requires a permit to construct.alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
S
G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y f— (commencing with Section 7000)of Division 3 0[the Business and Professions Code)or $2000
y 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 anC mber OCCU
not more than rive hundred dollars(x500). 316 410 6 8 V'NuOccupancy Type
❑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 for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner or 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 or
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractols Li.
cense Law docs 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 See. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
11-1 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 are: .
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
or less.)
I certiry that in the performance of the work for which this permit is issued,1 shall no
employ any person fn any m rus sr ccI to the Workers'Compensation
Laws of Califolaie�Dhltc - 'S "D
Applicant �� s
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z r'" CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
G:> the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Lender's Name
z Lender's Address
V Q 1 certify that I have read this application and state that the above information is
LL P correct.1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representatives of Utis city to enter upon the
a above-meouoned propeny for inspection purposes.
(We)agree to save,indcmniry and keep harmless the City of Cupertino against
►F-r liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date dt �
SOURC S.
2��
Re-roofs l'
Signature of Applicant/Contractor Date /�J
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 any roofing material being installed.
❑Yes 9
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,.1 agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Pg.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
reyui Bich must be mel prior to issuance of a certificate or Occupancy. Signature of Applicant Date
rc�,
Owner or a zegent Date
All roof coverings to be Class"B"or better
10,
CITY OF CUPERTINO
ADDITIOloT/REMODEL.
affi
CUPEKrINO PERMIT APPLICATION FORM
APN# Date:
l � - cf / � 96 � , O(D ! Z ! z Buil ding Address: 2 0 373 N� C> o v e
Mailing Address (if different from building address):
Owner's Name: Phone#
Contractor: Phone#:
Fax#: S-0 ?a
Contractor License#: 5 — �/ C( y 3 Z
Cupertino Business License#: .Z c -3 'F 7Z—
Contact: Phone A 3 Z
Fax #:
Building Pen-nit Info:
Bldg. �� Elect. ❑ Plumb. ❑ Mech. ❑ Hillside ❑
Job Description:
What is being added?
f S 7-
o .
LV a � ®
What is being remodeled?
Remodel Includes Re-Roof: Yes ❑ No M If yes list number of squares
Remodel includes Structural: Yes ' TTo
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath Other
Type of Construction (Usage Class): Occupancy Type:
1 FR, 11FR ❑ 11, 111, V-lHR ❑ 11, 111, WV-N a�
Valuation: Please check this box if the project is a
2 C7-0
second-story addition ❑
Green Building Check list must be completed and
attached to the plans. Green Building Points Achieved:
***For Office Use Only***
Over-the-Counter ❑
CITY OF CUPERTINO,
a-6,
ADDITION/REMODEL
CITY CUPEFRTINO 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
1R3PLNCK Dwellings plan check B
1R3REPINSP Dwellings Repeat B
Inspection
1R3REPPLNC Dwellings Repeat Plan B
Check
1R3HINSP Dwellings Hillside B
inspection
1 R3HPLNCK Dwellings Hillside B
plan check
1R3HREINSP Dwellings Hillside B
Repeat Inspection
1 R3HREPLNC Dwellings Hillside B
Repeat Plan Check
1R3ALTINSP Dwellings Alternate B
Materials Inspection
1R3ALTPLNC Dwellings Alternate B
Materials Plan Check
1PCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
Disposal System
IP RSW
EER Sewers " P
1BPSPRINK Lawn P
Sprinkler/Backflow
1BPWSVCS Main Water Service P
1BSEISMICRE SeismicResidential B
DECKS -IR3SFDADD OR
1123 SFDREM
1DECKWOOD Deck (Wood) B
1DECKRAIL Deck Railing B
sa
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT# Z6 r 1
2 3 3 3 A)061� C d ve a0-7�
OWNER'S NAME: -Y-o5 e G-0"^-e PHONE # '6 ,/ -6 Z 3
GENERAL CONTRACTOR: C P— FAX # - Z Z- JL ?-c'
I am not using any subcontractors: / 2 &-e— o ix-
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