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CITY OF CUPERTINO
BUILDING DIVISION PERNIIT �lAfl
BUILDING ADDRESS: PERMIT NO.
10501 STOKES
OWNER'S NAME: PERMIT ISSUE DATE
PHO SA CONTROL NO.
ARCHITECTIFNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REMODEL 200 S FT TO 2 D o 0 0
o o LICENSED CONTRACTOR'S DECLARATION BATH NON—STRUCTURAL
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
ywith Section 7000)of Division 3 of the Business and Professiuns Code,and my license is
3 y in full force and effect.
License Class Lic.# '
H a Date Contractor
to ARCHITECTS DECLARATION
.r I understand my plans shall be used as public records
Dyu
r;', Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
,c m which requires a permit to construct,alter,improve,demolish,or repair any structure
n Z prior to its issuance,also requires the applicant for such permit to file a signed statement
E=O that he is licensed pursuant to the provisions of the Contractor's License Taw(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
JI .. 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(5500). 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 notintended 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 through his
own employees,provided that such improvements are net 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.).
[11,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec 7041,Business and Professions Code:)The Contractor's Ld-
cense law does 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.
❑1 am tun Sec ,B&P C forth' mason
Owner Date 'J G
WORKS-1' CO PENSATIONDECLARATION
I hereby armunder pe t of perjury one of the following declare me
❑1 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 am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars(5100)
or less.)
I certifv that in the performance of the work for which this permit is issued,I shall not
employ anypers ' an anner so to bccom •ubject to the Workers'Compensation
Laws of California. tic �cl
Applicant
NOTICE TO APPLICANT:If,afIcNknakinpd6 Ccrti tcatc of Fxcmption,you should
become subject to the Worker's Corn^sadenitrovisions of the Labor Code,you must
.J O forthwith comply with such provisions oNhis permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
z
-t I hereby affirm that there is a construction lending agency for the perfommcc of
fYi the work for which this permit is issued(See.3097,Civ,C.)
QLender's Name
Q z Lender's Address
C�Q I certify that I have read this application and state that the above information is
(y correct.I agree to comply with all city and county ordinances and state laws relating to
Q U building construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in cc 4AU�DERST.'ANDS
of the granting of this permit.
"— APPL AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURUON .
b Re-roofs
Signature of ApplicanVCon ctor Date —
HA2:AR Us M AntLS DISCLOSURE Type of Roof
Will the applicant or foto wilding occupastore art handle hazardous ma 'al
as defined by the Cupertino Munict a1 Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)" 1 All roofs shall be inspected prior to any roofing material being installed.
❑Ycs A No
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 97 No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
ndath&safety Codc,Scctons 25505.75533 and 25534.I understand that if the building
dors h9t c nt ave a tenant,that it is my responsibility to nod fy the occupant of the
mquimm which sr'x met prior to issuance of a Ccnifhc to of Oc anry. Signature of Applicant Date
a
Owner or authorized agent All roof coverings to be Class r'�1"�}`r or better
tic� �
CITY OF CUPERTINO
ADDITION/REMODEL
CUPERTINO FEE SCHEDULE
oq b3��C�
APN # � Date: l,/f.gQ��-� �J 9vD� .
Building Address: Jal ior�� AV�IUL COF6_o ,),-ID C , 8501*
Mailing Address (if different from building address):
I5`l ► Pizbu (—c>, 204.3y
Owner's Name: Phone# :
1�fllZ?��'1 * -PO7KIL)A rt7�yf�Ss )N (,A4(b 7aa 210 76 )/
HOA: (Exterior work only) Yes E] No ray Ca. 3p� 00 D S�
If es, provide letter from HOA
Contractor: Phone#: .
Fax #:
Contractor License#:
Cupertino Business License#:
Contact: Phone#:
Fax #:
Building Permit Info:
Bldg. E Elect. Plumb. [] Mech. Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including addition)? —Goo
Remodel Includes Re-Roof. Yes ❑ No If yes list number of squares
Remodel Includes Structural: Yes ❑ No
Do you have the pre-application planning approval? Yes ❑ No ❑ �(
If es, lease provide a co of our planningapproval letter. Planners na e:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bathy Other
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ IUIIIN-A ❑ IUIII B, IV-HT, V-B �f
Valuation: 4 I��ZX�D Please check this box if the project is a
second-story addition ❑
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Please complete relevant portion of the Green Building
Checklist & attach it to the application or if applicable, Green Building Points Achieved:
include in plan set & the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 02/05/09
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: n PERMIT#
C)SO r S-rax"-e �-1yEriuG CuP ;.r/d N56i
OWNER'S NAME: Pfl%cje,,A z PHONE# 72o 2i d -7c ii
GENERAL CONTRACTOR: PR1Gi Z Nle ass FAX #
I am not using any subcontractors:
Signature Date
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
L,- Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
v Sheet Rock
Tile
Own ontractor Signature Date