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08110061fooI'do Z U,, �Z �e F W S d i7MU .tea rtq�..t i in K2K r7 •"y EFC 0z Z� r. a �rti r7 UO LL F, O U ►�-t G/1 UZ r --t CTIA' OF CUPERTINO BUILDING DIVISION PERNUI' �f} � �� �I� BUILDING ADDRESS: PERMIT NO. 19750 2TEVENS CRFEK RTATD TRn- OWNER'S NAME: PERMIT ISSUE DATE PHO SIR AA38CONTROL NO. ARCHITECTlFNGTNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 a a LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70011) of Division 3 of the Business and Professions Cade, and my license is in full force and cffccL COMML TI , NON— STRCTRL INC LD E / P / LI GHTNG , License Class Lic. p Date Contractor (4 2 6 SQ)-MURUKI ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records Licensed Professional OWNER-BUTLDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License law for the fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to consuuct, alter, improve, dcmoiLsh, Or repair any structure 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 (commencing with Section 70D0) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy P Y Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars (5500). 3696000 8 MRKI ❑ 1, as owner of the property, or my employees with wages as their sole compensation, . Required Inspections will do the work, and the structure is not intended or offered forsalc (Sec. 7044, Business and Professions Code: The Contractors 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 employers, provided that such improvements are not intended or offered for We. 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.), t 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li- ccnse 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. ❑ 1 am exempt under Sec , B & P C for this reason Owner P ' _. - ��—Dale S.' WORKER'S MPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the fallowing 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. (:11 have and will maintain Wonkces Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ' My Workees Compensation Insurance carrier and Polity number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is forone hundred dollars (5100) or less.) I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any maboer soffit to bccprtte subject to the Workers' Compensation Laws of Calif, Date •Y a -= Applicant J:L �r 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 I hereby aMrm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) - Lendces Name ' Lender's Address 1 certify that I have read this application and state that the above information is ' correeL 1 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 ahove-mcmioned property for inspection purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilides,judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON Issued by: -POINT Date V SOURCER •G TI PtS. Re -roofs a — Signature ofAplilicant/LibnErIctor 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)? All roofs shall be inspected to any roofing material being installed. El Yes �o prior 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? ❑ Yes _ jI ivo I 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 does not currently have a tenant that it is my responsibility to notify the occupant of the require en hi usi be met Or to issuance of a Certificate of Occup cy. Signature of Applicant Date All roof coverings to be Class'n" !'►�" or better � g Owner or authorized age Date ' CITY OF CUPERTINO CITY OF CUPERTINO TENANT IMPROVEMENT PERMIT APPLICATION FORM APN # -3 (,� `l `/A 00 6 I I ► fes. 4q Building Address: Mailing Address (if different from building address): Tenant (If tenant please provide a letter from the building owner approving the tenant improvement.) Building Owner ❑ Tenantsuilding Owner's Name: one #: r - Contractor/ T ` Phone #: (� % 3 4 6 C'' (f _T 4 Z., i�C Jo Fax #: 6 Contractor License #: '?0-9_7q0 Cupertino Business License #: Contact: 2 Phone #: (XSo) S-3 —7�3 Dd oa L/e% Fax #: Alternate Contact: `�� �{ Phone #: NOF 96,3 _C19'6__A_ Fax #: `iv ?-- Valuation (cost of project): So k -v 3S k Job Description (be specific): --� plL b %�n Tenant Improvement Includes Re -Roof. Yes ❑ No ei yes, number of squares Tenant Improvement Includes Structural Yes ❑ No [ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/IIIN-A ❑ IUIII B, IV -HT, V -B Project Size: Express ❑ Standard Large ❑ Major El Green Building: Please complete Leed for commercial interiors checklist & attach it to the application or if applicable, include in plans & sheet index LEED Points Achieved *** For Office Use Only*** Over The Counter ❑ Revised 8/08/08 CITY OF CUPEf�TINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building Department JOB ADDRESS: 7,rC S-fbvers G?e-eek 61vA. PERMIT #Q OWNER'S NAME: PHONE # ( Vo % 3 —er 7 di - GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Signature Date Please check avvlicable subcontractors and comvlete the following information: v Owner/ Contractor Signature Date RI�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 v Owner/ Contractor Signature Date