08010029:)z
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
19772 STEVENS CREEK BLVD
KEEN ON CONSTRUCTION CO
08010029
OWNER'S NAME:
PERMIT ISSUE DATE
FRED CHAN
1426 DE LA CRUZ WAY
01/14/2008
PHONE:
SANrrARY NO. CONTROL NO.
(510) 913-1818
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
1 hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 700X)) of Division 3 of the Business and Professions Code, and my license's
REV , OR I G # 0 7 0 5 0 0 6 0 - COMM ' L TI- REV IS DRYWL T- BAR
in full force and effect.- / i/ y >
License Class Lie. p — ! /
CEI LNG GRID
Date Contractor _ /1— Ln l 12.t r f n �
I'DECLA
ARCHr1'EC"q
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
to the of the Conimclur's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant provisions
section 7000) of Division 3 of the Business and Professions Code) or
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(commencing with
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
y�
�(
Occupancy Type
section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofNumber
not more than five hundred dollars (16500).
3 6 9 0 6 0 0 9
❑ I, as owner of the property, or my employees with wages as they sole compensation,
Required Inspections
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
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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) Ile 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 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 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 Worke Compensau Insurance carrier and Polity number are,
Carrier. (' � ^1 Polity No.:
CERTIFICATE EXEMPTION FROM W ERS'
COMPENSATION INSURANCE
,
(oris section need not be completed if the permit is forone hundred dollars (5100)
or less.)
I cer ifv that in the performance of the work for which this permit is issued, 1 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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work fur which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
'
cored. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
ahovc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UE }ANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE] s.
Re -roofs �—
Type of Roof
Signature of pp icanU ontractor Date
HAZARDOUS MATERIALS DISCLOSURE
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, Section2ss3z(a)?
[3 Yes No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining P g an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air comaminams as defined.bylle Bay Area Air Quality Management
all near materials for inspection.
District?
71 Yes fl u
1 have read the hazardoL materials requirements under Chapter 6.95 of the Califor-
nia Health &SafetyCode, Sections 25505,25533and25534.lunderstandthatifthe building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements whi usl be mel prior to issuance of a Certificate of Occup%,ty.
Signature of Applicant Date
�� y' ` at
All roof coverings to be Class "B" or better
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Owner or authorized agent Date
OF
CUPEf�TINO
CITY OF CUPERTIlNO
REVISIOlN/DEFERRED
PERMIT APPLICATIOlN FORM
APN #o5Ap n
Date: , ^ C) 08
Original Permit
Building Address:
CA CR
Mailing Address (if different from building address):
Owner's Name:
Phone #:
Contractor: a
Phone:
Fax:
Contractor License #:
Cupertino Business License #:
Contact:
Phone: 5ti oP CA' k f
Fax:
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Residential ❑ Commercial S
T L T a.
J V U "ese11p i.on:
L '
�Y „J� 1 1 �— 4�4� c� t l°rpicc Gvv-A v2
Type of Construction (Usage Class):
* Occupancy Type:
1 FR, 11FR ❑ 11, 111, V-lHR ❑ 11, 111, 1V V -N
Valuation (cost of project):
Project Size: Standard E] Large ❑ Major ❑ Valuation:
aPYF
CITY OF CUPERTINO
REVISION/DEFERRED
CUPEI�?INO
PERMIT APPLICATION FORM
FEE SCHEDULE
Quantity';
Sq Ft,
Fee ID
Fee Description
Fee Group
Permit Type
1REVCOMNEW
Revision Commercial New
B
1*
1REVCOMTI
Revision Tenant Improvement
B
1* TI
1REVSFDWL
Revision SFDWL
B
:lR3SFDW
1REVRESADD
Revision Addition
B
1R3SFDADD
1REVRESREM
Revision Remodel
B.
1R3SFDREM
IDEFINSP
Deferred Submittal not R-3
B
1*
1DEFPLNCK
Deferred Submittal not R-3
B
1* OR
1* TI
IDEFR31NSP
Deferred Submittal R-3
Inspection
B
lR3SFDW
1R3SFDADD
1R3SFDREM
1DEFR3PLNCK
Deferred submittal R-3 Plan Chk
B
1R3SFDW
1R3SFDADD
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