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04080099zwz 400 U� �z n�� 7yU 3 U. t— yOy N �<i 0 Q lyemii y^rn �za QFC 0 Z z a �z UC wF Uz CITY OF CUPERTINO 'ISr r<;k BUILDING DIVISION PE+� BUILDING ADDRESS: TARN t S CONSTRUCTION PERMIT No04080099 OWNER'S NAME: PERMIT ISSUE DATE ALEXAMERIS PHONE: SANITARY O. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 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 in full force and effecL License Class- 30 DAYS TEMP PERMIT - (EXPIR. 09/12/04) Date contractor ORIG. #04050063 ARCHTiECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractors 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 that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 Sq. Ft. Floor Area Valuation $59 (commencing with Sectfon 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged cxemplion. Any violation of APN Number Occupancy Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (1500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, 31620052.00 will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business Required Inspections and Professions Code: The Contractor's License Law dors not apply to an owner of 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 cbastruct the project (Sec. 7044, Business and Professions Code:) The Contractors Li - corse Law docs 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 Contractors License Law. ❑ 1 am exempt u gr'Sbc. , B & P C or this -reason Owner Date �,. RK P� N DECLARATION I here ern u pequry one of the folaratiors: ❑ 1 have and ill maintain a certificate of Consent toself-insY r WorlkersCompcn- 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, is required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMP ION FROM WORKERS' COMPENSATION INSURANCE , Crnu section need not be completed if the permit is for one hundred dollars (1100) 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 is 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 Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a concoction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name Lenders Address I certify that I have read this application and state that the above information is coreCL I agree to comply with all city and county ordinances and state laws relating to building concoction, and hereby authorim representatives of this city to enter upon the about -mentioned property for inspection n purposes (We) agree to salindemnify and keep harmless the City of Cupertino against liabilities, judgments, toss and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDE ANDS ND WILL COMPLY WITH ALL NON -POI N'J' SOURCE REGULORIONS. %l D (l( Issued by: Date YJ Re -roofs Type of Roof HXLARDOUS MATERIALS DISCLOSURE . Dae gnats c of Zepcupertino Will thplicant or future building aecupant store or handle hazardous material as defined by Municipal Codc. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? Yes All roofs shall be inspected prior to any roofing material being installed. [3 sRNo If a roof is installed without first obtaining an inspection, I agree to remove W all thea licant or future buildin «ca ant trsc pp g p equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes -KN. 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505.255 3 and 25534. I understand that if the building does not curremly have air 'that it ' y responsibility no notify the ocoopant of the rcyuircmcns which til a prio ce of a Certificate ofOccupancyZ Signature of Applicant Date G All roof coverings to be Class "B" or better 0 cr ora orizsd ag l Date r V, 0" CUPEf�TINO *ITY OF CUPERTINO PERMIT APPLICATION F RM I APN #S - 2-0 - CGz Date: 1-0, 2 AvWsT- Building Address:,Mailing Address (if different from building dress): 1p3o IV. Wow Owner's Name: J� c- te-fd Phone #: 8 • �`�� • C Contractor: BBOILER2 License #: Contact: Phone: (o _go Cupertino Business License#: !OCG 0 [(Yl-9g�Fax: Boiler> 1M to 1.75 M Btu Building Permit Info: BBOILER5 Bldg ❑ A Elect ❑ Pl b ❑ Mech ❑ Job Description: lo BCONSTAX Residential ❑ BUILDING Commercial Sq.Ft. Floor Area: BUILDING $/Sq.Ft.: Cost of Project: BUILDING Occupancy Group: A Constax - Resi/Mobile O BELEC1000 Type of Construction: Please check this box if the project is a BELEC1001 V- S 2 (tii second -story addition: ❑ Pro'ect Size: Standarki Large ❑ //Major ❑ Elec Svcs 600V <= 200A Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax - Resi/Mobile BUILDING BELEC1000 Elec 600V <=1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 w CITY OF CUPEkTINO T •1 1• Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 a -- - - d I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information 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 Date