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CITY OF CUPERTINO
BUILDING DIVISION PERMIT C� ITRAT+OI� ? [ATI�N
BUILDING ADDRESS:
PERMIT NO.
10776 W ESTATES DR CRAFTSMENS GUILD INC om onl 77
OWNER'S NAME: PERMIT ISSUE DATE
1LIA jQ99P14 ANP RI-TA 11 -1-4566 .9 DE zzaizA B17_10�
PHON A O• CONTROL NO.
(408) 366-1000
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�O p LICENSED CONTRACTOR'S DECLARATION O i� o
Lie F I hereby affirm that i am licensed under provisions of Chapter 9(commencing Job Description
IZ U with Section 70M)of Division 3 of the Business and Professions Code and my license is
°may in full force and effect. CHK THE TRUSS CALCS;ORIG #07120191
34- License Class Lic.lY d I I
E-0
Date Contractor I
ARCHITECTS DECLARATION
mI understand my plans shall be used as public records
U
a
y Licensed Professional
n y
OWNER-BUILDER DECLARATION
<� I hereby affirm that 1 am exempt from the Contractor's License Law for the
y
00 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
u Z y prior to its issuance,also requires the applicant for such permit to Glc a signed statement
_< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Scction 7000)of Division 3 of the Business and Professions Code)or
y 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of 1000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500)• 36922033 . 00
❑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 Ligase Law does 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 or
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 docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law,
❑[am exempt under Set .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I 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 ca ' and Policy numberare:
Cartier, dty;ii Policy No.:
RT ICA OF EXEMPTION FRW W S'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify 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
.J Z forthwith comply with such provisions or this permit shall be deemed revcked.
'Z O CONSTRUC77ON LENDING AGENCY
.�ry)
[-��•-� I hereby affirm that there is z construction lending agency for the performance of .
ai? the work for which this permit is issued(Sec.3097,Civ.C.)
Lendces Name .
a Z Lender's Address
U C) I certify that I have read this application and state that the above information is
LL— correct.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city o enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hay) liabilities,judgments,costs and ezpensmwhich may inany way acerucagainUsaidCity )
I;)Z in consequence of the gtantin this permit. y ^
APPLICANT UN ST D AND WILL COMPLY WITH ALL NON-POINT Issued b Date S
SOURCE RE ONS
A�5
Re-roofs
Signaz of ApplicandContraclor Date
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)? o All roofs shall be inspected prior to any roofing material being installed.
❑Yes , N
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 az defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
I have read the hazardous materials requirements undcrChapter6.95 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 reibility o notify the occupant of the
requirements which must be me 'ro issu c fa Certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class' "or better
Owner or authorized age Dam� � g /T•
/oma/ 77
r
CITY OF CUPERTINO
CITY OF
CUPEk iNO GENERAL BUILDING
PERMIT APPLICATION FORM ,
07
APN# 3�' Date:
Building Address:
/d 7;?6• Gv-efT C5 -tate Cope," 1k7
Mailing Address (if different from building address):
7W ra4%4_R-
Owner's Name: ; Phone#: Lt Cc*&— 368
2c�s��� gcL 8 -7 QPW
Contractor: . Phone: .r.��_3
c eAr7-j nt�N J 6'1/ IN L
Fax: '4t 3GG --l L
Contractor License
Cupertino Business License#:
Contact: �-�� �� Phone:
Fax:
Residential Commercial ❑
Job Description: � � �f � �
(/ I
Building Permit Info:
Bldg Nr Elect R/ Plumb C Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ 1I/III/V-A ❑ 11/1I1 B, IV-HT, V-B
Valuation: `1 6Q� Square Footage:
Project Size: Express ❑ Standard Wf Large ❑ Major-F]
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgEEtn.org
Revised 10/20/08