08050215D C
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
R �f � DRP►'I' I
BUILDING ADDRESS:
PERMIT NO.
20800 HOMESTEAD
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
1698 412H ST. STE He
888 CONTROL NO.
510 525-937
ARCHI'[ECr/F1JGiNEER:
BUILDING PERMrrINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I Mreby affirm dot 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.
DEFERRED SUBMITTAL OF M/E/P' S ORIG#0712:0212—NO
ass&
Date Contractor
SANITARY REQUIREMENTS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licuued Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 70315, Business and Professions Code: Any city or county
which requires a permit to construct. alter. improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing _wlth Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt tberdmin and the basis for the alleged exemption Any vfoiadon of
_ —
-8-1000-
APN Number
Occupancy Type
P Y YP
Section 70315 by any appBum for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars (S5W).
3 2 6 0 9 0 5 6 TY PE 7
❑ L as owner Of the property, or my employers with wages as their sole compensation,
.
Required Inspections
will do the work and the structure is not intended Or Offered for sale (Sec. 7044, Business
and Professions Code The Contractors License Law does not apply to an owner of
P
property who build& or improves thereon, and who does such work himself or through his
own employees, provided that such improvements ere not intended oroffered forsala U.
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 Contractors U.
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 Conuracor's
License Law.
❑ I am txem Se , B & P C r this
Owner Date 1
DECLARATION
y afifirm on �:MPENSATTON
1 y alfum un penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-Insum 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performarnce of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(IMLs section need not be completed if the permit is for one hundred dollars (S IOU)
or leu)
1 certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any roam cr become subject to the Wo ens' Cmensatiom
Laws of Califrm'5
Applicant
NOTICE TO AP making this Cettilicate of Eximpdod fou should
become subject to the Worker mpena tion provisions of the Labor Code, you must
forthwith comply with such provisions or this peuznft shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the worts for which this permit is issued (Sec. 3097, Cir. C)
Lenders Name
Lenders Address
I certify that I have read this application and slue that the above information is
.
cormcL 1 agree o comply with all city and county ordinances and sure laws relating to
building construction, and hereby suthorire mpncaentaivcs 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
liabil(Iles, judgments, costs and expenses which may in any way &sere against said City
S
in consequence of then2liling of this permit
APPLI UNDER A S AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date . 2
�
S CE ATl .
Re -roofs
Type of Roof
h 11 Ltl UR
signA Ual S MATERIALS DISCLQS14RE Dao
Will dto applibint or future building occupant store or handle hazardous m ilyd,l
as defined by the Cupertino Municipal Code. Chapter 9.11, and the Health and Safety
Code, Section 25532(a)7
❑ Yes
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
Will the applicant oTubtfilding occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes akNo
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Coda. Sections 25505.25533 and 15534. I undersand that if the building
does not currently have a t that it is my responsibility to notify tine occupant of the
rrquircmT'0'%FR7 m tssuantce of ccnifitatc r
Signature of Applicant Date
11
All roof coverings to be Class's" or better
Owner or an r Dam
CITY of
CUPEVI INO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORINT
(57-2 $-P
APN #
�CQo q(� �' �7
Date:
s•z2•o13
Original Permit #:
p"112o21 Z
Building Address:
7,0$00 Rom t5srEl,4DI7, `�
Mailing Address (if different from building address):
Owner's Name:
Phone #:
�Lo
(� 5 v • g3I .3(� 57
Contractor:
Phone: Z/0$ . -744?. A30SV'
W 51- -$1�1,ILI�C�� TAW •
Fax: qc)b. 7`1��P• 50'33
Contractor License #: 1B7,5 3q 5
Cupertino Business License #: 7,q6)(P
Contact -Phone:
(
6/0. 81Z. Z46-5-3
7
Fax: s/o . ,550. X81
Building Permit Info:
Bldg ❑ Elect 0� Plumb Mech [�
Residential Commercial
Job Description- 3>eWeM5141341 17t-J9Z OF M 6P,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 ❑ 11111 91
Project Size: Standard Large Major 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.buildit2reen.or�
ITY OF
CUPEI,TINO
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''
1 REVRESADD
Revision Addition
B
1R3SFDADD
1REVRESREM
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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