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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10486 STERLING BLVD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100078
OWNER'S NAME: CITY OF CUPERTINO DATE ISSUED: 11/16/2009
OWNER'S PHONE: 4087773200 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT T— PLUMB
License Class Lic.#
MECH F RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CONSTRUCTION OF A NEW NEIGHBORHOOD PARK WITH
(commencing with Section 7000)of Division 3 of the Business&Professions DRINKING FOUNTAIN LOCATED AT 10486 STERLING
Code and that my license is in full force and effect. BLVD-NEAR BARNHART CT.APPX.26,010 SQFT-
I hereby affirm under penalty of perjury one of the following two declarations:
I 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.
I 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 Sq.Ft Floor Area: Valuation:$500000
permit is issued.
APPLICANT CERTIFICATION APN Number:37523046.47PARK Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
Issued by:�%!% —�fJ Date:
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I 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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,l shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code._Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must O er or author d agent:.,'
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulation er the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature "� v - Date j� I� 1 Licensed Professional
of l
CITY OF CITY OF CUPERTINO
CUPEKrINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 75^ZJ O� Ph
� Date: . ( ,
Building�d4N, � s`et f�� Q/'
� � �,� - / (.�
Mail' g oAddressif��erent frm building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA
Owner's Name- Phone#:
r'lly 01- GOEM1130
Contractor: Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: VWV
Phone: ,616. 0050
&LkW Fax:
Residential ❑ Commercial ❑
Job Description: CG0 vS'mVc. '10V or Tpem
'��1U K11J h �UUrCfli�.
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Type of Construction (Usage Class): Occupancy Type: A
1-A, 1-B E] II/III/V-A ❑ I11/111 B, IV-HT, V-B M QC_
Valuation: Square Footage: h
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.buflditgreen.org
Revised 07/14/09
ti•
CITY OF CUPERTINO
CITY of GENERAL BUILDING APPLICATION
CUPEKrINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
t.s°� t•y ;i + �;?; 1GTsNG'O�'YI
11313OILERI ; ` a 3 DFor the installation or relocation of-ea'' " M ` ' `��� ''•
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,0 0 Btu/h Q .3k •)
1BBOILER2 y s InistatlatioriF/r'eloc •i6r 6Pe' • 1V�-�`•' '�'
boiler/compressor over 3 horsepower
to &incl 15 horsepower,.or ea
absorption sys over I OQ 000 Btu/h
11313OILER3 Installation/relocation of ea M r�
boiler/compressor overj�115 horsepower
to &incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to l
& incl 1,000,000 Btu/h
11313OILER4 Installation/relocation of ea M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea Y . ,, e,.t•
.;,
1,iVJ7.i:f absorption sys over 1,000,000 Btu/hifo";�.'r'¢
& incl 1,750,000 Btu/h
113130ILER5 Install ation/relocation of ea boiler or M
;�!-9':'«r �'."W'71 �. �'�i' ationS�co�i Pres r at�errS6s1"+ t�vf �1 Jy
horsepower, or ea abs' rptiensys over,- � 'L��
1,750,000 Btu/h • �;R, ;J�V V ;
113APPLOTH 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. f
1 ELECIN�,P r I Other Electrical Inspections (per hour) E
1 M1 . HI.NSP Other Mechanical Inspections (per , M-
11 ,, .� •'
hour) �a• t ,t ; f'
1PLMBINSP Other Plumbing& Gas Inspections ,
(per hour)
1MEETINGIHR Application Meeting B
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