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CITY OF CUPERTINO
PERAUT
BUILDING DIVISION
BU1 ��TEVENS CREEK BLVD
RELIABLE CONCEPTS CORP
PERMIT08010045
OWNER'S NAME:
PERMIT ISSUE DATE -
MATTESON REALTY
954 CHESTNUT ST
01/15/2008
PHONE:
SANITARY NO. CONTROL NO.
(408)271-6655
ARCHrTECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby aifirm that I am licensed under provisions or Chapter 9 (commencing
with Section 7030) of Uivislon 3 of the Business and Professions Code, and my l�ice�nse is
C OMM ' L T . I. RMV PRTN & DOOR CREATE O PN O F C 4 0 S Q
in full force and effect
License Class
Date +/%=-Contractor /Af
e��S L .
ARCHITECTS DE
1 understand my plans sball be used as public records
Licensed Professional
OWNER -BUILDER DSCIARAT70N
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, after. improve, demolish, or repair any anIctue
prim to its issuance, also requires the applicant for such permit to rile a signed sutcmern
is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he pursuant provisions
7000) Division 3 cite Business Code)
$ 5 0 0 0
(commencing with Section of of and Prolessions or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
316 210 8 9 °Dumber
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or
not more than five hundred dollars (550�
L as owner of the property, or my employers with wages as their sole compensation,
Required iced Inspections
will do the work, and the structure is not intended or offered forsale (Sec. WK4, Buairttsa
and Professions Code: The Contractors Liaowner rm Law does not apply to an ownof
Q p
property who builds or improves thereon, and who does such work himselfor through hit
own employees, provided that such improvements are not intended or offered for sal& ir.
however, the building or Improvement is sold within one year of completion. the owner -
builder will have the burden or 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
construct the project (Sec 7044, Business and Professions Code:) The CDntraaars LI-
ccnse 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 Con rector%
Liceax Law.
❑ I am exempt under Sec . B h P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one or the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure 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 Worker's Compensation lasurana, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
gare:
My Worker's Compensation insurance carrier and Policy number
Cartier.C.s•(e4CA AMIEe Policy No.:��rt-�o qC9 /
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(this section need not be completed it the permit is forone hundred dollars (S100)
or less)
i certify that in the performance of the work for which this permit is issued.) dull not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT. It. alter malting this Certificate of Exemption, you should
become subject to the Workers 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 performance or
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I 1 certify that 1 have read this application and state that the above information is
conca. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize mprescnutives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and kerp harmless the City of Cupertino against
j liabilities, Judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this perMIL
APPLICANT UND ANDS AND W OMPLY WITH ALL NON -POINT
Issued b. y:Date / •��
SOURCEREG O
Q� ���j �'�s
a -roofs � J
'Type of Roof
Signature ol'Applican ntriGor Data
HAZARDOUS MATERIALS DISCLOSURE
WAR the applicant or future building oaupartmore orhandle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 2553200? j,�
All roofs shall be inspected prior to any roofing material being installed.
,]Yes G^u
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future buildinLoccupant use equipment or &view which
emit hazardous air contaminants as by the Bay Area Air Quality Management
all new materials for inspection.
Disrict7
C] Yes o
1 have read the harardotss materials requirements under Chaptcr6.95 of the Califor-
nia Health & Sarcty Codc, Secdons 25505.25533 and 25534. I undasmW thm ifthe building
does no have a tcoan, that my ruxponsibility to notify the occupant of the
require is �} 1>rt prim m a,co or a to r ocNpanry. ��
'nature of Applicant Date
All roof coverings to be Class "B" or better
Owner or■ulhnr'vrdannnt Daln •
CITY OF CUPERTINO
001 00,+5
CUPEkT1NO
TENANT IMPROVEMENT
PERMIT APPLICATION FORM
APN # f r , ( q, F �
1 g o�
Building Address: Aqruc 1 N C_ ,
Mailing Address (if different from building address):
Owner's Name:
Phone #: - goZ_ l )06
C/
Contract :
Phone #:
Fax #:
Contractor License #:
Cupertino Business License #:
Contact:
Phone #:
Fax #: Z - $Z O
Alternate Contact:
Phone #:
Fax #:
Valuation (cost of project):
Job Description (be specific):
//�
r� q _Fox � � T �GYL �Daax, 7�0,m e fF164
Tenant Improvement Includes Re -Roof. Yes ❑ No If yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No
Type of Construction (Usage Class):
Occupancy Type:
1 FR, 11FRK] 11, 111, V-1HR ❑ 11, 111, 1V V-N
Project Size: Standard Large❑ Major ❑
Green Building: Attach LEED Checklist to plans and identify in sheet indes.
LEED Points Achieved:
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