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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21837 TERRACE DR CONTRACTOR:TBD-TO BE PERMIT NO:09080142
DETERMINED
OWNER'S NAME: JU ROBERT DATE ISSUED:08/17/2009
OWNER'S PHONE: 4083162182 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION r
BUILDING PERMIT INFO: BLDG 'ELECT PLUMB
License Class Lic.# r 'r' r—
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REVISION TO ORIG#08090040-3 X PLATE
(commencing with Section 7000)of Division 3 of the Business&Professions AT EXISTING
Code and that my license is in full force and effect. SHEAR WALL. ANCHOR BOLTS AT SHEAR WALL,LENGTH
AT
I hereby affirm under penalty of perjury one of the following two declarations: SHEAR WALL.
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35617020.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 D YS FROM L T CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued by:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 255
Section 3700 of the Labor Code,for the performance of the work for which this z�0
Owner or authorized agent: wwl1 u�- Date:
permit is issued.
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 Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.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 above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said Ci in consequence of the
P Y g City� �1 I understand my plans shall be used as public records. -- _-------=-
granting of this permit.Additionally,the applicant understands and will comply
with a)l non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
CITY OF
CUPEVINO REVISION/DEFERRED
PERMIT APPLICATION FORM v %
APN # Date: Ys
OriginalPe #:
Building Address: � f qz
Mailing Address (if different from building address):
Owner's Name: Phone #:
f� ( q-o �� 3 � b _ Z � g
Contractor: Phone:
Fax:
Contractor License #:
Cupertino Business License#:
Contact: Phone: 7, " e,
Fax: d , Ga,:sd�
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
ResidentialCommercial ❑
Job Descrip ion: ��.�.i7t 14
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction (Usage Class): * Occupancy Type:
I-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B 0 3
Valuation (cost of project):
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
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.buildit reen.or
Revised 01/07/09
Valk,
�•' r e
l CITY OF CUPERTINO
CITY of REVISION/DEFERRED
CUPEf�T1N0
PERMIT APPLICATION FORM
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Group Permit Type
S Ft
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1REV'COMNEW Revision Commercial New B 1*
i
{ 1 REV'COMTI Revision Tenant Improvement B I* TI
1RE`JSFDWL Revision SFDWL B 1R3SFDW
J 1RE`JRESADD Revision Addition B 1R3SFDADD
1RE`JRESREM Revision Remodel B 1R3SFDREM
i
1DEFINSP Deferred Submittal not R-3 B IDS
Inspection
1DE:FPLNCK Deferred Submittal not R-3 Plan B IDS
Check
1DEFR3INSP Deferred Submittal Inspection B 1DSR3
1 DEFR3PLNCK Deferred Submittal R-3 Plan Chk B 1DSR3