08050223CITY OF CUPERTINO
BUILDING DIVISION PERA41T
BUILDING ADDRESS:
PERMrr NO.
20800 HOMESTEAD RD BLDG REC b9 WEST BUILDERS nRnsn99i
OWNER'S NAME PEID&T EMUE DATE
ARCHI E(-TIENGINEER:
O p LICENSED CONTRACTOR'S DECLARATION
i hereby affirm that I am licensed under provisions of Chapter 9 (commencing
i, with Sation 7000) of Division 3 of the Business and Professions Code, and my license is
y in full force and effect.
r r� Z License Class Lic. •
g
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
O � Licensed Professional
wOWNER-BUILDER DECLARATION
i i hereby atTtrm that I am exempt from the Contractors license law for the
a O following reason. (Section 70313, Business and Professions Code: Any city or county
S$ which requires a permit to conWuct, alta, improve. demolish, or repair any suucarm
r prior to its issuance, also requires the applicant for such permit to file a signed statemmi
i = p drat he is licensed pursuant to the provisions of the Conuacuses License Law (Chapter 9
s f : (commencing with Section 7000) of Division 3 of the _%usiness and Professions CodeLor
that be is eumpt therefrom and the basis for the alleged exemption Any vioW?& of
Section 70313 by arty applicant for a permit subjects the applicant to a civil penalty of
not more titan five hundred dollars (I500).
❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the worts, and the structure is not intended or offered for sale (Sec 7044, Business
and Professions Code. The Contractor's I imrse Law does not apply to an owner of
property who builds or improves thereon, and who does such wort himself or Idrough bis
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 compietion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
pq/L as stoner of the property. am exclusively contracting with licensed contractors to
coftunct the pmject (Sec. 7044. Business and Professions Code:) The Contractor's U -
cense Law docs 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 Contractors
C i . Law.
❑ i am exeyW-ulder Sq,, T g, ^ , B tit P C fyr ads rg--n
Owner // / u � 7 Date
i hereby affirm undo? penalty of perjury one of the following declarations
❑ i have and will maintain a Cmtifreate of Conant to self-insum for WorkeesCompen-
sadon, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which Ods 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 Workees Compensadun insurance carrier and Polity number ate:
Cartier Policy No.:
ciirr 7CATE OF 550rloN FROM WORKERS -
COMPENSATION INSURANCE
(mu section need rot be completed U the permit b for one hundred dollars (S I OO)
or lest)
I certify that in the performance the work for which this permit is issued. i shall not
employ any person in any mann o becemic'nbly to the Wo terra' mpemoul n
Laws of Calijperd , t
Appill
NOTICE TO : f, after making this Cerfificato orlhemprion, you should
become subject to the Wo 's Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
O
COMMUC77ON LENDING AGENCY
i hereby affirm that there is a construction lending agency for the performance of
fYi 7 the work for which this permit is issued (Sec. 3097, Civ. C.)
W 0
Lender,
s Name
z Lenders Address
V 0 i trrtify that I have read this application and state that the above information is
114 r"c conccL i agree to comply with all city and county ort6nancts and sate laws misting to
8 building construction, and hereby authorize reprtsentatim of this city to enter upon the
W above-mentioned property for Inspcc i purposes.
a (Wer) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, cost and expenses which may In any way accrue against said City
U ain consequence of the grantin f this pe7rmit.
APPLICANT UNDERST WILL COMPLY W ALL NON -POINT
SOU U ONS
Sign pp reran Date
US MATERIALS DI O
Will the applicant or future building occupant store or handle hmeardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes o
Will the applicant oxfu building occupant use equipment or devices which
omit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes o
I have mad the wnmierials mquimmcros under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
dors not currently have a w*t, tha it is my responsibility to notify the occupant of the
requirenr�paes-wlkich mhfst eV r to issuance of [ Certifhcite of Oseur ancy.
Owner or nvEo?b d<cn1 7— 1 1 1 Date
510) 525-93
Job Description
CONTROL NO.
PERMIT INFO
PLUMB MECH
DEFERRED SUBMITTAL OF M/E/P'S-ORIG#0712.0212-NO
SANITARY REQUIREMENTS
Sq. Ft. Floor Area Valuation
—._.-. -- --$-1000
APN Number Occupancy Type
32609056.RECS
Required Inspections
Issued by:
Re -roofs
'Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
. All roof coverings to be Class's" or better
CITY OF CUPERTINO
CUPEkTINO REVISION/DEFERRED
PERMIT APPLICATION FORM
o8o6 oa�3
3q(v�; s -F
APN # 2� � 0 q PD
•�
Date:
S• ZZ • 0 8
Original Permit #:
0-7 l"L021 Z
Building Address:
'OBOC) [�OVV4 6S1'E'%1'fl IZ 1�>
Mailing Address (if different from building address):
Owner's Name:
Phone #:
6-50-93/ .357
Contractor:
Phone: 40$ • 74(P . 5 p-r�
W I%1-
Fax: qDb • -7'147. 5CS-9
Contractor License #: 187'c 3q 5
Cupertino Business License #:
Contact: ` L (4N (/7
�
Phone: 510. 81Z • Z46-5-3
lw'
Fax: Slc� • ,550 • Z(o8
Building Permit Info:
Bldg ❑ Elect 0� Plumb Mech [[]�
Residential Commercial
Job Description- 3) ,
e� fre514i3►hr�;'L aF 07 �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 0 Large 0 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
S-I-11-1
CITY OF
CUPEkTINO
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
1 DEFINSP
Deferred Submittal not R-3
Inspection
B
1*
3 Y
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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