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CITY OF CUPERTINO
BUILDING DIVISION PERMIT CTkt �TOR IOR7CIf31�1.
.., . .r.,;.., ., .....
BUILDIN9,. D,ORESS:, PERMIT NO.
R STELLING RD LANDMARK DEVELOPMENT 07120221
OWNER'S NAME: cc PERMIT ISSUE DATE
PAI,MAS STELLING LLC 1307 S MARY AVE STE 120 09/03/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: NEW TWO STORY TOWNHOUSE BLDG BUILDING PERO
ELECTPLUMB MECH
a 0 a a
o p LICENSED CONTRACTOR'S DECLARATION
v I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
,z w with Section 7000)of Divi'apn 3 of the Business and Professions Code,3qd my license is
<° in full force and effect
i r,�? ,$C
rr fLJ
License CI s Lic.ti
❑ Datc Contractor �-s ✓�
A CH17ECrS DECLARATION 'U zi>,D(•>_DAl(
.' YY
1 understand my plans shall be used as public records
tEU ,
CO< Licensed Professional
OWNER-BUILDER DECLARATION
a I hereby affirm that 1 am exempt from the Contractor's License Law for the
0 O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
e m Pi which requires a permit to construct,alter,improve,demolish,nr repair any structure
u"H prior to its issuance,also requires the applicant for such permit to file a signed statement
cthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft,Floor Area Valuation
I- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
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(S50(I). P Y YP
❑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 License 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 of
sale.).
❑1,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 contacts for such projects with a contracmr(s)licensed pursuant to the Contractor's
License Law.
El am exempt under Sec _ ,B&P C for this mason
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-insum 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 carrier and Policy number a,Im:�,/
Carrier. &;LJ"dtr�" �&A! Policy No.:OM 1S4D�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
or less.)
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 Workers'Compensation
Laws
of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
0
CONSTRUCTION LENDING AGENCY
I hereby-affirm that there is a construction lending agency for the performance of
C4 > the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Lender's Name
a Z Lender's Address
1,Q 1 certify that I have read this application and state that the above information is
ly correct-I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorise representatives of this city to enter upon the
>4RWi above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hamrless the City of Cupertino against
,may f/I liabilities,judgments,costs and expenses which�na ' ywayaccrueagainstsaidCity
U Z in con of th ting this it AP IC RSTA PLY WITH ALL NON-POINT Issued by: Date
UL'' Re-roofs
S,(gnature of ApplicanUCort ctor Date
HAZPLRDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as deftned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section No
25532(a)?
❑ All roofs shall be inspected prior to any roofing material being installed.
Yes
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
I have reav the hazardous materials requimmc is un cr Chapter 6.95 of the Ca)ifor-
niaHealth&Safety Code,Sec'ns255 53 5 Auoderstandduaifthe building
dors not nt a t respo ilfty to notify the occupant of the _
mqui ich mus issuanc a Certificate of Occupancy.
^8�� ®� Signature of Applicant Date
Date
All roof coverings to be Class in"or better
CITY OF CUPERTINO
NEW SINGLE/MULTI FAMILY DWELLING
CUPEI�TINO PERMIT APPLICATION FORM
7 2�/
APN# A,_ 07— J_7. Z, Date: — 1 - ' 6
Building Address: `
Mailing Address (if different from building address):
v7 5 L • � f- `(�- 5 .� I Zts ,; r.n ' v l_
Owner's Name: Phone#
Cont actor: Phone#: &,z -7-3-3 _ F-3
Fax #: `i1 7-3 S — "Z%9
Contractor License #: 9
Cupertino Business License#:
Contact: ff + 99 Phone#: 4�u `7 "� �� y S
f—b1 )kc 1 �' Fax #:' L l J3 -7315-- 92-
Ce
Alternate Contact: Phone#: C 3 6 `7 3=3 }(c
t7 Yr ;
Act c_wx -e— Fax #: /-/-06 7 3 S- 9 2_i j
Single-Story ❑ Two-Story Three-Story ❑ Basement ❑ Hillside. ❑
Multi-family Apartment ❑ Condo ❑ Townhouse
Sq.Ft. Living Area (Including Basement &Attached Garage: Sq. Ft. Garage ( etached Only):
Valuation:
Job Description: /,/e
Type of Construction (Usage Class): Occupancy Type:
1 FR, 11FR ❑ 11, 111,V-lHR ❑ 11, 111, lV V-N
Project Size: Standar Large Major❑
Green Building: Must attach completea Green Building Checklist to the plans
Green Building Points Achieved:
For help, contact Build it Green at www.huilditareen.org