08050220BUILDING DIVISION PERAUT
20800 HOMESTEAD
OWNER'S NAME:
ARCHITEGTIENGINEER:
1-.6 LICENSED CONTRACTOR'S DECLARATION
,41
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
H in full force and effect.
z License Class Lic. g
F Date Contractor
t� ARCHITECTS DECLARATION
i a I unde..t.rid my plans shall be used as public records
Io,G
U.
Licensed Professional
t y S OWNER -BUILDER DECLARATION
< g I hereby affirm that I am exempt from the Conuacoes Limnse Law for the
.09 following reason (Section 70313, Business and Professions Code: Any city or county
< $ % which requires a permit to construct, alas. improve, demolish. or repair any dr.cL„m
a prior to its issuance, also requires the applicant for such permit to rile a signed staicmcm
that he Is licensed pursuant to the provisions of the Contractor's LJc:nsc Law (Chapter 9
2 (commencing with Section 71700) of Division 3 of dee Business and Professions Code) or
u that he Is exempt therefrom and the basis for the alleged exemption Any violation of
Section 70313 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than rive 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 Cade: The Conuactores L.icertx Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or tlireogh his
own employees, provided that such improvements are not intended or offered for sale. IL
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
1, as owner of the property, am exclusively contracting with licensed contractors to
ccubtruct the pmject (Sec. 7044, Business and Professions Code:) The Coalraemrs LI -
cc= Law does not apply to an owner of property who builds or Improves thereon, and •
who contracts for such pnoJects with a contractors) licensed pursuant to that: ConU2=eS
LScense Law.
❑ I amyrom n and B& P Cror this n
Owner Due
iU' OMPENSATION DECLARATION
1 hereby affs ander penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worimes Compert-
sadon, as provided for by Section 3700 of the Labor Code, for the performance of the
wort 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 performance of the work for which this permit is issued
My Worker's Compensation Insurance artier and Policy number are:
Carrie Polity No-
CEILMCATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE .
Crhis rection need not be completed if the permit Is for one hundred dollars (S 100)
or Ics&)
I certify that in the perform of the cork for which this permit Is issued. I shall nes
employ any person in any ann a c je to the W errs C m(n:nsation
Laws of Calffomi& Date
AppGonl
NOTICE TO APPUCANT., otic ng this fiat: of Exemption, you should
become subject to the Worker's Co pensadon previsions of the Labor Code, you must
.J Z forthwith comply with such provisions or this pUTiL shall be deemed revoked.
zn O CONSTRUCTION LENDING AGENCY
I hemby aurum Qat there Is a construction lending agency for the performance of
i>~ the work for which this permit is issued (Sce. 3097, Civ. C.)
OWr 0 Lendds Name
.0 z Lender's Address
V Q I testify that 1 have read this application and sate Last the above information is
Gy , coned 1 agree to comply with all city and county ordinances and sate laws relating to
0 CV^ building construction, and hereby authorize representatives of this city to envy upon the
W above-mcndoned property for Inspection purpose&
(We) agree to save, indemnify and kwp harmless the City of Cupertino against
1(abiliQes,judgmentt, cora and expenses which may In any way accrue against said City
1, in consegtr:ruce of the gran' of this permiL.
APPW ER D WILL MPLY ITH All. NON -POINT
SO CE REG O
Signaiui+dfAWican4jLActor Date
HAFARDOUS MA DISCLOSURE
W(E the applicaill or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
[3 Yes /117 me
W(II the appikant or future building occupant use equipment or devices which
emit hazardous air contaminants tar defined by the Bay Area Air Quality Management
DisuicO
❑ Yes No
1 have read the aerials mquiremems; under Chapter 6.95 of the Califor-
nia Health tk Safety Code, Sections 25505.25533 and 25534.1 understand that if the drilling
does not currently have a u:*4�: is my rcapo4bOity to notify tLv co t of the
Date
510) 525-9378
FEIRM1T NO.
PERMIT ISSUE DATE
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
o a 0
Job Description
DEFERRED SUBMITTAL OF M/E/P ORIG#071202.12—NO
SANITARY REQUIREMENTS
Ft. Floor
APN N
32609056.RECN
Issued by:
Re -roofs
Type of Roof
Required Inspections
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's"' or better
CITY OF
CUPEkTiNO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
z2,P5 0,�� D
APN # —�n (J U q O 64, 40,
Date. s• ZZ • 0 g
Original Permit #:
Q-7 M 021 Z
Building Address:
20$00 RD✓L 6S-rE�I7,' 12J, C-, Ii
Mailing Address (if different from building address):
Owner's Name:
Phone #:
Lo
&5o.93/ .3&57
Contractor:
Phone: 40$ , -74A?. 5 C
W ti71-- 7?At,(L.1be7tS .T�VC •
Fax: qD8. 74�7. 50'33
Contractor License #: 187,5 3q 5
Cupertino Business License #:
Contact:` L VI) ��/Phone:
(7
C1a 81Z
Fax: 5710 • ,550 • X81
Building Permit Info:
Bldg ❑ Elect 0� Plumb 0� Mech
Residential Commercial
Job Description-
�)e60-'eRzb 51413k17t7Jq*L DF H'lC-Ps
Is the project in the Wildland- Urban Interface Fire Area? Yes ❑ No ❑
Type of Construction (Usage Class): * Occupancy Type:
1-A, 1-130 11 /111 /V-A ❑
Project Size: Standard 0 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.builditgreen.org
CITY OF
CUPEVI 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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