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CITY OF CUPERTINO
BUILDING DIVISION PE=T
ss ,• .F; F� nos .,..3 k ave :: ::. � ,:
BUILDING ADDRESS:
PERMrr NO.
20800 HOMESTEAD RD TYPE 8A
WEST BUI
OWNER'S NAME:
PERMIT ISSUE DATE
PHONEA
O. CONTROL NO.
(510) 525-9378
ARCHITECT/ENGLNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am Licensed under previsions of Chapter 9 (commencing
with ScClion vision3ofdteBusinessandProfrsaioCode.andmy0cer
7�o nsela
in full and
DEFERRED SUBMITTAL OF M/E/P' S ORIG#0712,.0212-NO
License
�"`
Date Contractor
SANITARY REQUIREMENTS
ARCHi rECL'S DECLARATION
I understand my plana shall be used a public records
Licensed Professional
OWNER-BUILDERDECLARATiON
1 hereby affirm that i am exempt from the Contractors License Law for the
following mason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any stmcwm
prior to its issuance, also requires theapplicant for such permit o file a signed statement
that he is licensed pursuant w the provisions of the Contmcws License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 701)0) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged umption. Any violation of
$1000 —
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penally of
APN Number
Oceu
ane00). P y TYPe
not more than five hundred dollars (SS
32609056 TYPE 8 A
❑ L, as owner of the pmputy, or my employees with wages as their sole compensation,
.
Required iced Ins
es
will do the work and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions Code: Its ContractorI I= Law does not apply to an Owner of
q P ections
property who builds or improves thereon, and who doessuch work himself or tilrough his
own employers, provided that such improvements are not Intended or offered for ale. 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.).
L, as owner of the property. am exclusively contracting with licensed contractors to
tract the project (Sec. 7044. Business and Professions Code:) The Contractors U.
Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Consumes
License Lay.
❑ i ex to u B&PCf n
OwnerDate
S OMPENSATION DECLARATION
n
I hereby affi under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self-Iaum 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.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code• for the peftormance of the work for which this permit is issued
My Workers Compensation Insurancia carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA71ON INSURANCE
(This section Treed not be completed if the permit is for one hundred dollars (S 100)
or less.)
I certify that in the performance of the w9rk for which this permit is issued I shall not
employ any person in any rte mut subject the Wo xrs' pen 6011
Laws of CallfomiL Da
Applicant
NOTICE 7O APPU n Ce ate of pfion you should
become subject o the Workers Com nation provision of the Labor Code, you must
forthwith comply with such provision or this permit shall be deemed remked
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Namo
Lender's Address
I certify that 1 have mad this application and state that the shove information is
-
correct. 1 agree o comply with all city and county ordinances and state laws relating to
building construction, and hemby authorize representatives of this city to enter upon the
above-mendoned property for inspection purpneL
(Wer) agree to save indemnify and keep harmless the City of Cupertino against
liabilities, lodgments, costs and expenses which may In any way accrue against said city
in consequence of the granting of this permiL
APPLICANT UNDERSTAPS AND WILL COMPLY WITH LL NON -POINT
Issued by: Date /� Z �—
SOURCE ON
Re -roofs
Signawre n OUS MATERIALS Dts RE
Type of Roof
Will the applicant or future building occupant sore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12• and the Health and Safety
cede, sues 25532(a)7
[I YesAll
roofs shall be inspected prior to any roofing material being installed.
tNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicanterbuilding occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection. .
Disrim7
❑ Yes KO
'
KO
non
I have read the hard requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a trnAnt. that it Is my responsibility to otify the occupant of the
mqm ch or to issuance fa C - ter Occupancy.
Signature of Applicant Date
,V, .
All roof coverings to be Class'n/.�{.'' or better
owner g Date
aftn
CM of
CUPERTINO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
010
ZZ-,(aS s -P
APN #
,5� b f"C
Date:
s•ZZ•�e
Original Permit #:
Q-7 rLCrL! Z
Building Address:
20800 Row 5s e 4D R - `I�> V
Mailing Address (if different from building address):
Owner's Name:
Phone #:
W%
50.93l . 3Co 57
Contractor:
Phone: 11(08 , -7442.503c/'
W1%1-- -,u, L berus JZW •
Fax: qDS • -744P. 5(733
Contractor License #: ia25 7..,,q5
Cupertino Business License #: PIC)& j
Contact: L
1i'V (7
Phone: 610. 8/Z. s Z
�,)
Fax: 57/o • ,550 • X81
Building Permit Info:
Bldg ❑ Elect []'� Plumb ❑� Mech
Residential Commercial
Job Description- 3)efreRZb ,5u1341r�Z �DF MCPs
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 � a -? �
7,
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.buildit reen.or
CITY OF
CUPEI�I:INO
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
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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