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07040107CITY OF CUPERTINO BUILDING DIVISION PERMIT ARCHITECT/ENGINEER: > p LICENSED CONTRACTOR'S DECLARATION u 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing > with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. O 3 Z License Class Lic. # f v ®j�'1 ®C. q Date ti�� , "r" . Contractor /LJ000 ARCHITECTS DECLARATION 4 ¢ I understand my plans shall be used as public records yU y Licensed Pmfessional OWNER -BUILDER DECLARATION _ I hereby affirm that I am exempt from the Contractors License Law for the :10 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 prior to its issuance, also requires the applicant for such permit to file a signed statement ¢ that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9 = o (commencing with Section 7000) of Division 3 of the Business and Professions Code) or i O2 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 not more than five hundred dollars ($500). ❑ I, 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 and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through 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 License 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 have and will maintain a Certificate of Consent to self -insure for Workers Compen- sation, 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 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 are: Cartier: b 1t ,"1 ✓ �� policy No.: f v t� ICC, -61. CERTIFICATE of EXE TION FROM OR COMPENS ON INSURANCE (This section need not be completed if the permit Is for one hundred dollars ($100) or less.) 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 Workers' Compensation Laws of California. Dale Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must O 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 > the work for which this permit is issued (See. 3097, Civ. C.) A Lenders Name Z Lender's Address ® I certify that 1 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 Vbuilding construction, and hereby authorize representatives of this city to enter upon the W 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 7 in corse tierce of the granting of his permit. APPLI A UNDERSTAND ND WILL COMPLY WITH ALL NON -POINT SOU GUL l /p -d 71.1.'n:ed c o ApplicanUContraclor Date HAZARDOUS MATERIALS DISCLOSURE ill the applicant or future building occupant store or handle hazardous material by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ YesJ No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? C] Yes No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health& Safety Code, Sections 25505,2553 and 25534. 1 understand that ifthe building does not curjpnl(� have a tenant, that it is nnesponsibility to notify the occupant of the requireme w h must br�gh�]p for to isshht��hce of a Certificate of Occupancy. Date PERMIT NO. CK9180M 6000 SF Job Description Sq. Ft, Floor Area Number Issued by: Re -roofs Type of Roof CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB - MECH Required Inspections Occupancy Type Date l _ i L>c., 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. Signature of Applicant Date . All roof coverings to be Class "B" or better CITY OF CUPEkINO CITY OF CUPERTINO PERMIT APPLICATION APN #Date: �r��,°� :�.�� ,r yrs ✓ �g� 0 ,� �° �..- c�� Building Address: Mailing Address (if different from building address): Ly MECHANICAL Owner's ame: Phone #: Contractor: ovc) c,s%u--o A) License #: % 9 /O r Contact: Phone: Cupertino Business License#: MAC 6 -1070 yI Building Permit Info: BBOILER5 Bldg Elect Er Plumb Mech CCS' Job Description: Residential ❑ N994i, 6wS , %;. " /. � �r�� "�" ��, 1�iC, Commercial 0� Sq.Ft. Floor Area: BCONSTAX Sq.Ft.: Cost of Projects BCONSTAXBQ Occupancy Group: B p� o`ZO COD BCONSTAXH Type of Construction: BCONSTAXR Please check this box if the project is a ❑ BUILDING BELEC1000 second -story addition: ELECTRICAL BELEC1001 Elec 600V > 1000A Project Size: Standard ❑ Large ❑ Major ❑ Elec Svcs 600V <= 200A Quantity Fee ID BAPPLOTHER Fee Description Other Appliances Fee Group MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler > IM to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <=1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY BENERGYADD Energy Energy Add Multi BUILDING BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 JOE ADDRESS: PERMIT /# OWNER'S NAME: `�2�1 PHONE # 4/08 - 73-cl:�c/ GENERAL CONTRACTOR: 1tJ4U 0 FAX # I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date C Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Ft(.0 2_ C p„ Linoleum / Wood Glass / Glazing G�S Heating 6`r Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper @ j Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock a 753-6 Tile C Owner/ Contractor Signature Date