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CITY OF CUPERTINO
BUILDING DIVISION PERM*
BUILD NG ADDRESS: rPERMIT NO.
2080 WALLACE DR 4 I)Imoegk) ) j � - 07050257
OWNER'S NAME: ISSUE DATE
COFFER NORMA /Z7/ 05/25/2 07
PHONE: SANITARY NO. CONTROL NO.
M,
sr
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LI a 0 0
Z LICENSED CONTRACTOR'S DECLARATION
0 lob Description
t= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)or Division 3 of the Business and Professions Code,and my license is WINDOW REPLMNT(VINYL) , 12 RETROFIT WINDOWS, 1 NF
H in full force and effect. �+ ,� Z
? Licensc Cl s ` l Lic.p a5 _ f < WINDOW W/WALL CUT DOWN 3" , 2 ENTRY DOORS. WINDOW
p
Date Contractor Contractor Cwt �'�x—..i
f ARCHITECTS DECLARATION BROKER PD FOR BUS LIC.
I understand my plans shall be used as public records
V
F' Licensed Professional
OWNER-BUILDER DECLARATION
f I hereby affirm that 1 am exempt from the Contractor's License Law for the
0 following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
ar" prior to its issuance,also requires the applicant for such permit to file a signed statement
� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
o (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $9309
m 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 3 2 6 0 3 0 3 9 �Number Occupancy Type
not more than five hundred dollars$500).
CD I,as owner of the propeny,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 Contractors License Law docs 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 dors 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.
C]I am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
C3 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.
( ave and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance
�carries and Policy number am:
Cartier.Z1an�L1 11 olicy No.: 6 7201
CERTIFICATE OF EXEMHITON FROM WORKERS'
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
became 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.
0
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.)
QLenders Name ,
I
2 Lender's Address
I Q 1 certify that I have read this application and state that the above information is
H correct.I agree to comply with all city and county ordinances and state laws relating to
i U building consuuetion,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
t a
� L40 liabilities,judgments,costs and expenses which may in any way accrue against said City /—r
Z in consequence of the granting of this permit,
APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date aJ
SOURCGULAT NS.
6
'�T � '��ZZ� 07 Re-roofs
Signature of ApplicantlConuactor Mic
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as damned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Sec6on2553i(a)? �y All roofs shall be inspected prior to any roofing material being installed.
[3 Yes rano
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?
0Yes C3No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Safety Code,Sections 25505,25533 and 25534.1 understand that if the.building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements w ust tprior toisso e�ofaCertlfucatcofOccupancy. Signature ofApplieant . Date
t�`�'—t. �J All roof coverings to be Class "B" or better
Owner or authorized agent T Date—
, *CITY OF CUPERTIN*
ai oF` PERMIT APPLICATION FORM
CUPEkTINO
APN # 3 6_� j 3 UL3 2 Date:
(p �5 f2s o�
Building Address: Mailing Address (if different from building address):
2 090
Owner's Name: Phone#:
fl,rvhQ C ro e,.
Contractor: /,1 ` 1 License#:
�\r% C0%o Sroe✓ -�Ine V�T�,..-Iaff- \011c\o•i C. 3 5 Z6 1.
Contact: Phone: Cupertino Business License#:
Fax:
Buildi g Pe it Info:
Bldg Elect ❑ Plumb ❑ Mech ❑ II
Job Description: ccp cme,_e" fov, "C" V;"_1,
1 >
Residential ,,-&U c A A"" 3" 2 6-I ttmmercial ❑
Sq.Ft. Floor Area: Sq.Ft..
Cost of Project: 513
3 Occupancy oup�
"�,
Type of Construction: Please check this box if the project is a
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> 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
Community Development
sm10300 Torre Avenue
• Cupertino CA 95014
Telephone(408)777-3228
CIT$OF Fax(408)777-3333
CUPEKTINO
Building Department
JOB ADDRESS: PERMIT#
22 g �QAI.
OWNER'S NAME: r,,t� �. ✓ PHONE # Wk? 24f-- e4
GENERAL CONTRACTOR: [AJ ,, rb e FAX#
I am not using any subcontractors: 05- .Z O
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
fl
Owner/Contractor Signature Date