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07010103 CITY OF CUPERTINO ( rrr�•.. BUILDING DIVISION PERMIT "'�" � ZRMA:lIQ�: BUILDING ADDRESS: PERMIT NO. 20333 CLIFDEN WY CUPERTI PERMIT ISSUE DATE OWNER'S NAME: WILLIAM THROM 1300 DELL AVE, STE C 01/18/2007 JNE: SANITARY NO. CONTROL NO. (408) 253-0618. BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH p LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing z with Section 7000)of Division 3 of the Business and Professions Code,and my license is WATER MAIN CHANGE y in full force and eft—n / V �Z License Class ` Lic.# �+' �5 F,c Date I—. I V'� ConlraeWr if Iw ARCHITECTS DECLARATION z< I understand my plans shall be used as public records ul o in Licensed Professional �W OWNER-BUILDER DECLARATION 2 1 hereby affirm that 1 am exempt from the Contractor's License Law for the ECO following reason.(Section 7031.5,Business and Professions Code:Any city or county K 1.ff which requires a permit to construct,alter,improve,demolish,or repair any structure y Z} Prior to its issuance,also requires the applicant for such permit to file a signed statement $ Ft.Floor Area $1500 Valuation =e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q t—$ (commencing with Scction 7000)of Division 3 of the Business and Professions Codc)or y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3 6937004 .W Number Occupancy Type not more than rive hundred dollars(5500). ❑1,as owner of the property,or my employees with wages as their sole compensation, will do the work.and the structure is not intended or offered for sale(Sec.7044.Business Required Inspections and Professions Code:The Conuactoes License Law does not apply to an owner of property who builds or impmves 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.). ❑I•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 Worker's 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 Workces 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 arc: �/ Carrier. ��VL)tk_ Policy No.:7—C*,rl�-2 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ('[Lis section need not be completed if the permit is for one hundred dollars(S 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'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 Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY F.t .. I hereby affirm that there is a constructinn lending agency for the performance of p,h7 the work for which this permit is issued(Sec.3097.Civ.C.) WQ Lender's Name �z L.endees Address U O 1 certify that 1 have read this application and state that the above information is w►^" correct.I agree to comply with all city and county ordinances and state laws relating to Vbuilding construction,and hereby authorise representatives of this city to enter upon the W above-mentioned property for inspection purposes. i a (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 V z in consequence of the granting of this permit. / h APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b:/: Date Re-roofs c' Sign of Appii1tanV9.XRLrWtOr Date HAZARDOUS MATERIALS DISCLOSURE Type of.Zoof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? C]Yes BIC— All roof:.shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defpcd by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes u I have read the hazardous materials requirements under Chapter 6.95 of the Califor. nia Health&Safety Code,Sections 25505.25533 and 25534.1 understard that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the re ircmcnta must met prior to issuanc ate of occupancy. Date `--- ,� z7;7-` `'tQ9lj /- 17-07 Signator:of Applicant Owner ut oriz agent Date All roof coverings to be Class"B"or better Community Development k 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 �C1TYOf Fax(408)777-3333 17UPERTINO Buildin De artment JOB ADDRESS: PERMIT # OWNER'S NAME: ,�i l��Y►-. G. PHONE # y5 5 - 18 ��9 GENERAL CONTRACTOR: FAX # I am not using any subcontractors: l iFnature Date Please check applicable subcontractors and co m lete the following ' ormation: 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 CITY OF CUPERTINO cqo l o 1 � 3 REPIPE/SE E.FS/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# 3K Date: Building Address: Owner's Name: Phone#: G-1, C C ntractor: Phone: License#: Contact: Phone: Cupertino Business License#: 09 -3y i Building Permit Info: Bldg ❑ Elect ❑ Plumb ®'`- Job Descri ion: Residential Commercial ❑ Cost of Project: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING BPGAS (Jas Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Repi e of Fixtures PLUMBING BPFIXTURE 1'blg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING