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CITY OF CUPERTINO
BUILDING DIVISION pL1'RMIT * .'
BUIL DR PERMIT NO.
�bTTON PARK PL ENGINEERED SOIL REPAIRS, 08040003
OWNER'S NAME: INC PERMIT ISSUE DATE
FIGONE CHARLENE L AND FRANK J 1267 SPRINGBROOK RD 04/02/2008
PHONE: (925) 210-2150 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing P
;zw withscction7000)o iviaio ofthcBus;ncssandP tc io o and liccn-is INSTL ADJUSTBL SCREW JKS FOR FNDTN RE-LEVELING
h in full forte and e
License Lic.
Date Contractor
ARCHITECTS DFLLARA ON
< I understand my plans shall he used as pubic records
>yU
O y Licensed Professional
H J OWNER-BUILDER DECLARATION
j< I hereby affirm that 1 am exempt from the Contractor's License Law for the
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
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
• G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
e2 4 2 0 0 Valuation
F• (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
IRE that he it 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 Number QCCll
not more than rive hundred dollars(x500). 3 7 5 3 5 0 2 8 Occupancy P Y Type
❑1,as owner of the propety,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 docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or througb 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.).
❑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 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
Lice rise Law.
❑1 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 ha+ and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 or rhe 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 Worker'f�C'o�ens/ati�on insurance carrier and Policy number
Carrier. �+—�'-'( U_-� Policy No.: v
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(bis section need not be completed if the permit is for one hundred dollars(S 100)
or less.)
I 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'Compensadon
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 revoked.
z OCONSTRUCTION LENDING AGENCY
.�rA
[�►r 1 hereby affirm that there;s a construction lending agency for the performance of
�i H the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lender's Name ,
Z Lender's Address
U O 1 certify that I have read this application and state that the above information is
LL j. correct I agree to comply with all city and county ordinances and state laws relating to
C Com.) building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
C1w (We)agree to save,indemnify and keep harmless the City of Cupertino against
V) liabilities,judgments,costs and expenses which may in any way accrue againstsaid City
V Z in consequence of the granting of this permit. 7
r-r AP (CANT ERSTAN WILL COMPLY WI A f NON-POINT Issued by: Date ,-
UR GULATI
Re-roofs
urc o pli(;ant/ on actor Date
HAZARDOUS MAT94S DI cuRE Type of Roof
nt re
�.
Will the applicant or future building occupastoor handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
Yes All roofs shall be inspected prior to any roofing material being installed.
❑ XNo
Will the applicant or future building occupant use equipment w 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 )4No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafctyCod Sections 25505,25533 and 25534.1 understand that if the building
d t cbrcntl vc a tenant, r y responsibiliWyLonthe cupant of the
aireme ; trst piuancc of a Ca P - Signature of Applicant Date
wa ucr allthO fixe agcn Date- All roof coverings to be Class'rn"or better
(04 )
CITY OF CUPERTINO
acloF,
CUPEfkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# / O� (� Date: r/` 0-Ing
Buildi ddress: L��b �
Mailing Address (if different from building address):
Owner's Name: Phone#:
E 40 4CA -
Coenqi -w4d
ntracctor: ( Phone:
�\ � { ! - Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone: Z � Z 0 — 7L( �-o
Kd�
Fax:
Residential Commercial ❑
Job Description:
J
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1 FR, 11FR ❑ 11, 111, V-1HR ❑ 11, 111, 1V V-N
Valuation: 1 Square Footage:
Project Size: Standard Large ❑ Major ❑
CITY OF CUPERTINO
CITY OF
CUPEI�TINO GENERAL BUILDING
PERMIT APPLICATION ]FORM
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1 GENCOM
1BTEMPPER Temporary Building Permit(good for B
30 days)
1BBOILERI For the installation or relocation of ea M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
IBBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
IBBOILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to & incl. 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
1BBOILER4 Installation/relocation of ea M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
1BBOILER5 Installation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH For ea appliance or piece of equip M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
ti
IELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing& Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
CUPERTINO
Building Department
JOB ADDRES PERMIT #
� � P.,:(�(Z, P( - 'Fo If
OWNER'S
OWNER'S NAME: Yv- PHONE # p
GENERAL CONTRACTOR: e CFAX #
I am not using any subcontractors 412-loe?
Si atur ate
Please check applicable subcontractors and complete the following information:
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
4Tile
Ow r/Con ctor Signature Date