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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21979 SAN FERNANDO AVE CONTRACTOR.i ou�� T7LD PERMIT NO: 10060102
OWNER'S NAME: CITY OF CUPERTINO INC CpH CAlZr-OAC DATE ISSUED:06/17/2010
OWNER'S PHONE: 4087773407 1 PHONE NO:
❑ ' LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.#
MECH r- RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: SUN SHAKE APRX 42'X50'SUPPORTED BY SIX COLUMNS
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
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:$29000
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
permit is issued. APN Number:35710008.00 - Occupancy Type:
APPLICANT CERTIFICATION
1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by- / Date
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Sections 25505,2 533,and 25534.
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 Worker's Owner or author' ed gent: /
Compensation laws of California. If,after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the 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 accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant and ands and will comply I understand my plans shall be used as public records.
with all non-p�oiinnt s�urce regulations pe the C mo Municipal Code,Section
9.18. ��v Licensed Professional
Signature Date �11�11e
t0I
ra
� ��°r�� CITY OF CUPERTINO
CITY Of
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN l C) O Date: a w
b � 9
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: Exterior work only) Yes ❑ No If es, provide letter from HOA
Owner's Name: Phone#:
C, Y� of CJ pR7l ja 77
Contractor: ,^ l Phone: 661-S�7- Woe-
/2
o z
C�v/2 fr J61 CRPeQ-r Fax: 669.29/
Contractor License#: e, 3 6 y
Cupertino Business License#: /v /-7
Contact: Phone: 7 7 7— 3/-29
'ro.-i (,,-)49 l f"P2s Fax: -177 — 3/37
Residential ❑ Commercial f
Job Description:
����� ya '� so ' . sJP��2tP� by
S ik Co I v/'7 Ns'
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV-HT, V-B [q�
Valuation: .2Square Footage: / v f
R� ear � 09
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.buildit reen.or
Revised 07/14/09
l- CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
11313OILERI 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)
11313OILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to &incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
11313OILER3 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
11313OILER4 Install ation/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
11313OILER5 Install ation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
113.APPLOTH 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.
1 ELECINSP Other Electrical Inspections (per hour) E
1 MECHINSP Other Mechanical Inspections (per M
hour)
1PLMBINSP Other Plumbing & Gas Inspections P
(per hour)
1 MEETINGI HR Application Meeting B
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