08050214CITY OF CUPERTINO
BUILDING DIVISION PEMM
BUILDING ADDRESS:
20800 HI
OWNER'S NAME:
PHONE:
ARCHTLECrfENGINEER:
`O p LICENSED CONTRACTORS DECLARATION
id"id"R I hereby &Mrm that 1 am 1'rcceaacd under provisions of Chapter 9 (commencing
' �with Section 7000) of Division 3 of the Business and Professions Code, snd my license is
Ji in full force and cffwL
z License Class Lic. g
t Date Contractor
ARCHITECTS DECLARATION
o' I understand my plana shall be used as public records
>qU
toy Licensed Professional
t S OWNER -BUILDER DECLARATION
< i 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
: C1 o following reason. (Section 7031.5, Business and Professions Code: Any city of county
which requires a permit to constna:t, alter, improve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
C that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
$ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the bash for the alleged exemption. Any violation of
Section 7031.5 by srry appllant for a permit subjects the appBant to a civil penally of
not more than five hundred dollars (5500).
❑ L 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 docs not apply to an owner of
property who builds or improves thereon, and who does such work himself or tgrough his
own employees, provided that such improvements are not intended or offered for safe 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.).
as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense Law dors not apply to an owner of property who builds or improves thereon, and
who contras for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am—WI-agder SeeA B & P C fqr this re}sm
(510) 525-9
PERMIT NO.
PERMIT MUE DATE
129 8 O. CONTROL NO.
{
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
DEFERRED SUBMITTAL OF M/E/P'S ORIG#0712,0212-NO
SANITARY REQUIREMENTS
Sq. Ft.
Valuation
APN Number Occupancy Type
32609056.TYPE6
Required Inspections
Owner Date v
ATRATION
ENSION DECLA.
I hereby affirm u er penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of Consent to self -insure for Workers Compon-
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 Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF 5(EMFnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars ($ 100)
OrlcsL)
I certify that in the perforr once of the work r w ' h this permit is issued. I shall not
employ any person iffy!! y err so s be m ect to th W ricers p on
Laws of Califormla. Datil
Applicant13 it
NOTICE TO APPLI aficr m g this Certificate of emp6 , 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 he deemed revoked.
CONSTRUCTION LENDING AGENCY
t --t I hereby affirm that there is a construction lending agency for the performance of
Y4 > the work for which this permit is issued (Sec. 3097, Civ. C.)
0 Lenders Name
= Z L.cndces Addrrat
a O I certify that I have read this application and state that the above information is
J■ wont 1 agree to comply with all city and county ordinances and state laws relatibg to
F' building construction, and hereby authorize representatives of this city to enter upon the
Wabove-mentioned property for Inspection purposes.
y (We) agree to save, indemnify and keep harmless the City of Cupertino against
L� y liabilities. judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICA TAN& tNDYAN�LL COMPLY WITH ALLL NON -POINT Issued by:
❑R
HAZA1pDOUS MATERIALS DISCLOSURE
p[ia
Will the apnt at future building occupant store or handle hazardous material
as defined by the CupertinoXNo
'pal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
❑ Yes Will the applicant obuilding occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Managamcnt
Disuim7
❑Yes No
1 have toad the hazardmu 'als requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code. Sections 25505.25533 and 25534. I understand that If the building
docs not currendy have a tenant. nut it is my responsibilily to notify the occupant of the
mquim_pxl Wcjtmuibcrdle(Aor toissuance of a Crni www of OcsupwiZy.
Re -roofs
Type of Roof
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.
Signature of Applicant
Date
' I All roof coverings to be Class ';q" or better
Owns u ' ed ger Date '
ae-- CITY OF CUPERTINO
CITY OF
Cupkkylmo REVISION/DEFERRED
PERMIT APPLICATION FORM
Zaa & S qC
APN # -3� U 0 6 (PDate:
5
Original Permit #:
0-7 rLo21 Z
Building Address:
7,0$00 Rom t5s-r e*b
Mailing Address (if different from building address):
Owner's Name:
Phone #:
65O•931 .3(057
Contractor:
Phone: Z/0$ - -744?. J5 p3
WC -45-r 754(Ibe7f-S -T-i)C° •
Fax: qo&. 74P. 5033
Contractor License #: 'U' 3g 5
Cupertino Business License #: 74)901
Contact: L (
Phone: 6/0. 81Z. z653
Fax: 5/o • ,550 • Z-&81
Building Permit Info:
Bldg ❑ Elect Plumb 0� Mech
Residential F1 Commercial
Job Description- ,
�efre� 5ai3m -rr� v� wr�s
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction (Usage Class):
* Occupancy Type:
1-A, 1-B ❑ 11/111/V -A ❑ 11/111
Project Size: Standard Large Major E Valuation (cost of project):
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.builditgreen.org
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
FEE SCHEDULE
Quantity
Sq Ft
Fee ID
Fee Description
Fee Group
Permit Type
1REVCOMNEW
Revision Commercial New
B
1*
1REVCOMTI
Revision Tenant Improvement
B
1* TI
1REVSFDWL
Revision SFDWL
B
1R3SFDW
1REVRESADD
Revision Addition
B
1R3SFDADD
1 REVRESREM
Revision Remodel
B
1R3SFDREM
1DEFINSP
Deferred Submittal not R-3
Inspection
B
1*
1DEFPLNCK
Deferred Submittal not R-3 Plan
Check
B
1* OR
1* TI
1DEFR3PLNCK
Deferred submittal R-3 Plan Chk
B
1R3SFDW
1R3SFDADD
1R3SFDREM
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