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09040012°Wz UW U x '- W ;LLQ nqqy� YGC +lav _za zF'c CITY OF CUPERTINO BUILDING DIVISION PERMIT C� R¢iCTQR I �R�AT�01�. BUILDING ADDRESS: PERMIT NO. 19750 STEVENS CREEK BLVD TBD - TO BE OWNER'S NAME: -DF PERMIT L95UE DATE e e 9 PHONE: A CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that 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 infullforecandeffe GAS STUB RRELOCTN @MTR MANIFOLD . License CI s Lic. p Date Contractor "DESIGN PLUMBING PD FOR BSL 4/2/9 ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, 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 Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or $2900 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 36906008 . 0 2 ❑ 1, as owner of the property, or my employees 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 Contractor's License Law does not apply to an owner of q P property who builds or improves thereon, and who does such work himself or through his 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 completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to - construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- 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 Contractor's License Law. ❑ 1 am exempt under Sec. , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen- sation, as provided for by Section 3700 of the Labor Codc, 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 Workces Compensation Insurance carrier and Polity number are: P&;AL Carrier. I.JIPolicy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date — Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the perfurmance of the work for which this permit is issued (Sec. 3097, Civ. C.) ' Lender's Name , Lender's Address 1 certify that I have read this application and state that the above information is ' correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives 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 liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT APPLIC�GULA —Z Issued by: Date 7 SOURC Re -roofs Type of Roof 'Z" Signature ofApplican nlra or Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Codc, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑ Yesp(J Nu fu" If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building 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 1*o I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health &Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building does not currently ve a ten that i ' my responsibility to notiry the occupant of the requirements w ch must t ' to issu cc of a Certificate of Occupancy. Signature Of Applicant Date Ze All roof coverings to be Class". ' or better Owner Date or authorized agent 'flfl CITY Of CUPEV1INO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM k9q Oq ooi APN # q, C) v'• J� Fee ID Date: z --a� P Building Address: Permit Type 1926-0 S7EV&-71S Q Lv,O Owner's Name: Group Phone #: L !% 1PCSEWER 31-13-/0�� Contractor: 1CPSS Phone #: Alpo - 2,6,1 - `i i [Y Fax #: A/p8 - Z&q Contact: rPhone /c-; J sewer/sanitary sewer #: g Fax #: Contractor License #:��8 P Cupertino Business License #: Job Description: Commercial Gas Piping System Residential ❑ Commercial Valuation: Project Size: Express Standard ❑ Large ❑ Major Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Cal Bldg Standards Commission Green Building Points: ALL PERMIT Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1PGASCOM Commercial Gas Piping System P 1-4 Outlets _ / 1BCBSC Cal Bldg Standards Commission B ALL PERMIT / Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY Of CUPEkTINO CITY OF CUPERTINO REPIPE/SEWER/MALN SERVICE FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential building sewer/sanitary sewer P 1RPSS 1PRREPIPE Residential re -pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or "1RPWS 1 PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System 1-4 Outlets P 1BPGAS Gas Piping System 5+ Outlets P 1 PPERMITFEE Plumbing Permit Fee Issuance P n 1 PLMBLNCK Plumbing Plan Check P 1 PLMBINSP Other Plumbing/gas Insp. P p I 1TRAVDOC Travel & Documentation Fee B 1BUSLIC Business License B CITY Of CUPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: PERMIT # 7 �5�� Jtzl— 6�d OWNER'S NAME: PHONE # - Z(o - q[4 GENERAL CONTRACTOR: �� , FAX # I am not using any subcontractors: Signa e Date Please check applicable subcontractors and complete the following information: Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date