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CITY OF CUPERTINO
BUILDING DIVISION
PERMIT GJEtGTGIR INFORMATION
BUILDINGADD ESS: PERMIT NO.
2212 WALLACE DR MICHELLE & RICHARD 07090187
OWNER'S NAME: PERMIT ISSUE DATE
MICHELLE & RICHARD MATKOVICH 22129 WALLACE DR 11/06/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 a 0 0
Ica LICENSED CONTRACTOR'S DECLARATION
v P 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
i e a with Section 7000)of Division 3 of the Business and Profession.%Code,and my license is ADDITION 480 ' BDRM, BATH.
in full force and effect.
j ? License Class Lic,a
❑ Date Contractor
ARCHITECTS DECLARATION
w U 1 understand my plans shall he used as public records
a
O y Licensed Professional
s rn OWNER-BUILDER DECLARATION
e I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5.Business and Professions Code:Any city or county
e li which requires a permit to construct.alter,improve,demolish,nr repair any structure.
a'–y prior to its issuance,also requires the applicant for such permit to file a signed statement
othat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $48360
$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of e�,y Number Occupancy
not more than five hundred dollars($500). 3 2 6 02 044 l�: P Y Type
❑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 Code: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 f)imself orthrough 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.
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such proje ith a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt un c ,B&P C for this mason
Owner Date.�(� .
W¢RK 'S NS TION DECLARATION G�'
7 he cby affi under penalty 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 or the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 or 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.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permi(is for one hundred dollars($100)
or Ifs%.) .
I certify that in the performancC'ot the w ich this permit is issued,(shall not
employ any person in anyarrncr so as nm st ' t to the Workcrs'Compensation
Laws or California.Date
Applicant
NOTICE TO APPLIQA :If, to making this cniticatc of Exemption,you should
become subject to/hie Wo ker s Compensation provisions or the Lahor Code,you must
.J O forthwith comply with su++h provisions or this permit shall be deemed revoked.
Z 0 -INSTRUCTION LENDING AGENCY
[� I hereby affirm that there is a construction lending agency for the performance of
�+ 7 the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name .
Z Landers Address
U 0 1 certify that I have toad this application and state that the above information is
LT~ '—' cormct.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
L>a above-mentioned property for inspection purposes.
HLL (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expeges which may in any way accrue against said City
U Z in consequence of the Fnti n9�ffittsrpermiAPPLICANT UNDE �IQDS YD ILL 0 L WITH ALL NON-POINT Issued by: DateSOURCER
4-0 Re-roofs
Signature cf AppIkandCont{ctor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will�pplilant or future building occupant store or handle hazardous material
as derrncd by the C ertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553 (a)? All roofs shall be inspected prior to any roofing material being installed.
[3 Yes o
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?
❑Yrs LAS
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health&SarctyCode,Sermons 25505.25533 and 25534.1 understand that if the building
dors not currently have a,lenan4 that it it my responsihility to notify rite occupant of the
requirements which mt(s` r issuance ora C/cote pc ar pane. Signature of Applicant Date
�JAll roof coverings to be Class"B"or better
Owner or Thor` agent 1 Data g
CITY OF CUPERTINO 07oc of E-7
CITY of PERMIT APPLICATION FORD
CUPEk iNO
APN#3;�(PO oZ 414. Date:
Building Address: Mailing Address (if different from building address):
Owner's Name: r� Phone_#:
i 41111 ,L�c14J v( � e'r�/,� /W)
Contractor: License #:
Contact: Phone: V,00 Cupertino Business License#:
Building Permit Inf :
Bldg Elect Plumb Mech'[`-
JobDescription:
Residential 2 Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: d90 e) del- Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard 39 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
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
1 of 3
w4,, Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
F
CITY O
O Fax(408)777-3333
CUPERTINO
Building Department
JOB ADDRESS: PERMIT#
-2Zi z ;� C72- 0 D D
OWNER'S NAME: z i?+c t(a � ,.'!/J�y/ di�/1 PHONE #(L/03) 9'E,- —O l`f j
GENERAL CONTRACTOR: Qi :/ v' -O' 4 3;
I am not using any subcontractors:
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 6ignature Date