090101000 6-0 -?016 G
PERMIT #
PROJECT
ADDRESS 2
APPLICANT - Pn,,A
OWNER
DATE
WORKS
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APN# — 6CF-6 27 RES. (LUNG) (GARAGE)
COMM. SQ. FT. (NEW) T.I. SQ.FT. RES. REMODEL
CONTACT L PHONE# ��� ��� 6 b FAX �i'�� �.P'6'
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VALUATION (Cost of Project) /,-? v Dd
READ PAID
Cd' ONSTRUCTION TAX (Y) (N)
SCHOOL FEES (Y) (N)
HOUSING MITIG (Y) (I)
HEART OF THE CITY (Y) (N)
ISSUED BY
DATE TOTAL FEES / 5
PERMIT
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CITY OF CUPERTI
BUILDING DIVISION
UILDING ADDRESS:
OWNER'S NAME:
ARCHITECTIENGINEER:
LICENSED CONTRA(= IUR'5 DECLARATION
I 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
a full force and effect.
License Gass Lic. s
Date Contractor
ARCHITECTS DECLARATION
1 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 mpair 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 Conuactor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars (M).
❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the work and the suuctum is not intended or offered for sale (Sec. 7044. Business
and Professions Code: The Contractor's License Law does riot apply to an owner of
property who build& or improves thereon, and who does such work himself or thmugh 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
Z.).
L as owner of the property, am exclusively conuwdng with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors U-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractar(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt un , B & P C for ibis mason
Owner Date
WORKERS NSATION DECIARA71ON
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Conscnt to self-insum 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
❑ 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 carrier and Policy number are:
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be cernpleted if the permit is forone hundred dollars ($100)
or less)
I certify that in the performance of the work for which this permit is Issued. 1 shall not
employ any person in any manner so as to become subject to the Workers' Compernation
Laws of Califorpla.Date
Applicant
NOTICE TO APPLICANT. ] , a ter Wriois Cerificatc of Exemption, you should
become subject to the Workers ComprIMon provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I herby affirm that there is a construction lending agency for de performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lenders Name
Lenders Addmss
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 authorise 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
Iiabllilles, Judgmcmts, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULp731 J
Signature of Applican Contract/
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.17, and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
Will the applicant or future Iding occupant use equipment or devices which
emit hazardous air contaminants as fined by the Bay Area Air Quality Management
District?
C] Yes o
1 have mad the hazardous roster als requirements under Chapter 6,95 of the Califor•
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if die building
does not currently have a tenant. that it is my responsibility to nodfy the occupant of the
requirements wh b riot to issuance of a Certificate of j cupancy. n
Owner or authorized agent - Date
PERMIT NO.
FERMTT ISkM DATE
9
SQRr A
a 8
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
Job Description
REVISION: NEW FIRE PUMP ROOM
ORIGINAL# 08090166
Ft. Floor Area
Number
35908027.00
Issued by:
Re -roofs
Type of Roof
Required Inspections
Valuation
Occupancy
Date � - 1 l - d 7
4'-
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.
-P
Signature(LA
A licant Date
All roof coverings to be Classor better
r f
CITY OF CUPERTINO
REVISION/DEFERRED
PERNUT APPLICATION FORM,
P 16160"
APN # 359-08-927
Date 1 /22/09 .
Original Peratit #:
08090166-Byer Properties
Building Ads'
20830 Stevens Creek Blvd., Cupertino, CA 95014
Mailing Address (if different from buildiztg address):
Owner's Nance:
Phone #:
Staples Inc. -Byer Properties
415-626-2937
Contractor:
Phone: 925-606-3000
Shames Construction
Fax:
Contractor License #: B S3-t:5'►g
o Business License M
Contact;
Phone:
916-488-8500
RMB Architects -Larry Klug
Fax: 916-488-8566
Building Permit Info:
Bldg Elect Plumb EIL Mech
Residential Commercial
Job Description: R.
vas FIV F„zE
Is the project in the Wildlmd- Urban Interface Fire Area? Yes ❑ No
Type of Construgtion (Usage Class):
* Occupancy Type:
«M,
I -A, 1-B II/II:UV-A MM B IV -HT, V-B-
Valuation (cost of project
-7
f 06U
Project Size: Express Eff Standard Large LJ Major LJ
Green Building: Please complete relevant por tdou of the Green Buildinng/LEED Checklist & attach it
to the application or if applkable, mclnde in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green atmnrff.b_nH_d'd_wemore
Revised 01/07/09