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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10185 N STELLING RD CONTRACTOR:CITY FACILITIES PERMIT NO:09110091
OWNER'S NAME: CITY OF CUPERTINO 10300 TORRE AVE DATE ISSUED:01/04/2010
OWNER'S PHONE: 4087773215 CUPERTINO,CA 95014 PHONE NO:(408)777-3228
❑ LICENSED CONTRACTOR'S DECLARATION r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# F 7
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE FOUNTAIN&APPURTENANCES&INSTALLING
PLAZA
(commencing with Section 7000)of Division 3 of the Business&Professions RENOVATIONS,CONCRETE FLATWORK,TRELLIS,LANDSCAPING.
Code and that my license is in full force and effect. NO FIELD WELDING,ALL WELDS TO BE SHOP WELDED.
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. Sq.Ft Floor Area: Valuation:$100
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:32654049.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I 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 DAYS FROM LAST 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
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
1 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
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&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. I 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
I 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 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,l 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. l 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 City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
09 It 0-0,9 �
CITY OF CUPERTINO
CUPEI�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# 3,2� _ O r v Date: ; rov,1�'
wcq
Building Address: N
J 0 "S5 AJ, s-ff1Rd- - rl
Mailing Address (if differentfr6m building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No,
HOA: Exterior work only) Yes ❑ No If es, rovide letter from HOA
O jer's Name- Phone#: 3 Z
0 0� (2'1"Oec 60 156og/
Contracto : 1NaAk� Phone: �^ ,�-1,7 _ �3
Fax: TzJ
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential ❑ Commercial Fq
Job Description:
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Building Permit Info: r
Bldg B Elect Plumb Mech 0
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ IUIIUV-A ❑ IUIII B, IV-HT, V-B
Valuation: . �r Square Footage:
Project Size: Express ❑ Standard [7 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 07/14/09
CITY-OF CUPERTINO r
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO 1 11
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 BBOILERI For the installation or relocation of'ea M
boiler/compressor to &including 3
horsepower, or ea absorption sys to &
1 incl 100,000 Btu/h (29.3kw)
1BBOILER2 i Installation/relocation of ea M
boiler/compressor over 3 horsepower
to &incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
1BBOILER3 Installation/relocation of ea M
I 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
1 BBOILER4 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 Install ation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1 BAPPLOTH 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.
I
1ELECINSP Other Electrical Inspections (per hour) E
1MECHINSP Other Mechanical Inspections (per M
hour)
1PLNfBINSP 1 Other Plumbing& Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B
i
2of5
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