09030028J 0( z 1...------;-;;:;;;:;;;~;;;:;;:;:;:;;AMYi<;;<;N;r""-OATiiw_---_t-------------------J--=1=L _
"0 I LICENSED CONTRAcroR'S DECLARATION ~~ B I bcn:by aIlinn thai I am licensed under provisions of Chapler 9 (commencing Job Description
z with Section 7000) of Division 3 of the Business and Professiuns Code, and my license is ~f~e; infullfolCCande~ ~.(;1/1 J TEM~ PERMIT GOOD THRU .4/9/9; (ORIG#0902Q016)TI
• '" Lleen." 9'\SS t:L We. It-> ~ , • \Q ..;;>
~-_I-fil Dale...,/tftp3 ConltaC;orrVd"!\ ("JI~\X'I(tr\,.n 1ST&2ND FLR EXTG OFC I LAB BLDG
-... ARCHiTEcrS DECLARATION ~~~ lunde.....dmyplansshallbeuscd .. puhlic~eanls IMPRVMNTS I MODS I WALLS I CEILINGS I
~ ~ ~ ~L"'ic-cnsc-d"'P=-ro-~:-e-ss"'io-na""I"""'------------------
~.. ... OWNER-BUIl.DER DECLARATION
~ ::: ::E I he~by .lTInn th'l I am c..mpt from the COnlraClor's Lieen50 Law for the
_ Q 0 following n:ason. (Section 703 \.S, Business and Profc.uiuns Code: Any city or eounly
~~~ which requires a pcnnil to conslnict. alter. hnpmvc, dcmoliM. or repair any structure
,,-en prior lD its issuance. also n:quircs lIIe applicanl for such pennilto file a signed sLalCment f---------;:;--;::;:--;::;;,--;----------,----------__:,.."..-:--,------<f_----~~ ~ thai he is liccn5Cd pursuanlto the provisions of the CoalraClDr's License Law (Chapler 9 Sq, Fe Floor Area Valuation" I-~ (commencing with Section 7000) af Divisioa 3 nf the Business aad Professions C~) or
f ~ -thaI he is csempt thcmfrom and lIIe basis for the alleged exemption. Any violation of L ~;y:~:-;-;:____;,.--~------__lr_----'~4L1:!O..lO~O~0~0~O~--__:=_-_1f------
Seetioa 7031.5 by any applicanl for a pennil subjecl> the applieanllo a civil penalty of , APN Number Occupancy Type
nol more than live hundn:d dollars (SSOO). 316 a9 a37 .APL
D I, as owner of the property, or my employees with wages as their sole compensallon. L """":::-_-:-_:-:"-__-:---j _
CITY OF CUPERTINO
BUILDING DIVISION
BUILDING ADDRESS:
18880 HOMESTEA
OWNER'S NAME:
R
PERMIT
DE CON
CONTROL NO.
(408)942-8200
ARCHITECTIENGINEER: BUIl.DING PERMIT INFO
BLDG ELECT PLUMB MECH
1--,='==1'--_1=1==!I_---!I=dl
will do the wort. aad the slnlClun: i. nOI in ..nded or offeml for sale (Sec. 7044. Busiaess I
and Professions Code: The ConllaCtor'S License Law docs nol apply to aa owner of Required Inspections
property who builds or impro... lhcreon, and who docssueh work himself or through his
own employees, provided that such improvemenl> an: not ialended or offered for sale. If,
however. the buiJding or improvement is sold within one year DC completion. the owncr~
builder will have the burden of proving thai he did nol build or improve for purpose of
sale.).
D I, as owner of the propeny. am csclusively conlraCting wilb licensed CQalraelors lD
conslnlclthe projecl (Sec. 7044, Business and Professions Code:) The ConlraC1Or's li
cense Law does n01 apply to an owner of property wbo builds or impro'YeS thcn:on, and.
who conuaclS (or such projeclS with a conlt'lCtor(s) licensed pursuant to the Contraclor's
License Law.
D 1am csempt uader Sec. • B &; PC for this "",on
Owner DalC
WORKER'S COMPENSATION DECLARATlON-:----
I hereby affinn under peaally of peojury one of the following deelanltions:
D I h.", .nd will mainllin a Conifica.. ofCoa5Oaiio self-insure for Worlccr's Compen
sation, IS provided for by Sectioa 3700 of the Labor Code. for the perfonnance of the
work for which this pennil is issued.
I have and will mainlain Worlccr's Compensation Insuraace, as n:quired by Section
of the Labor Code. for the perfonnancc of the woric for which this pennil is issued.
My WorY;'s Compensation Insunnce cal.!ic:r ~d Policy number are:
Carrier:L1JCj ([, A"I\€fI(q,;J''1r"5licy No.: (--,b--63Ysv], '6~
CERT1ACA1C OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nced nOI be complcled if the pennil is far One huadred dollars (S 100)
nr less.)
I certify that in the pcrfonnanee of the wori< for which this pennil is wued. ( shall nOI
employ any person in any manner so I.!Ji 10 become subjccllO the Workcn' CompensationLaws of California. Dale _
Apptieanl _
NOTICE TO APPUCANT: If, afler malciag this Cenific.1e of Eaemption. you should
become subjecllD the Worker's Compensation provisioas of the Labor Code. you musl
fonhwith comply with such provi.sions or this p:~il shalll:x:: deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affinn Lhal Lhcre iSI conslrUction lending agency for lhc perfonnanc: u(
the work for which !his pennil is issued (Sec. 3097. Civ. C.)
t;~:~:~:.:..-------~-------------
I certify thaI I have ~ad this applicatioa and ala" thai the above infonnallun is
COrn:cL I agree 10 comply with all cily and counly ordiaances and sLa.. laws relating to
building conslrUCtion, and hereby iluthOri7.e represenLativcs of this city La enter upon lhc
ahove-mentioned propeny for inspection purposes.
(We) ag~e 10 save. indemnify and keep hannless the CilY of Cupertino againsl
liabilities,judgmcnts.costs and expenses which may in any way accrue against said City
ia consequence of the granting of this penniL
S EREG L
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
Date
Re·roofs
Signature of ApplicanVConlraClor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicanl or fUlure buildinG occupanillore or handle hazardous malCrial
as defiaed by the Cupertino Municipal Code. Chapler 9.12, and the Health and Safely
Code, Secllon 2.'iS32(a)1 All roofs shall be inspected prior to any roofing material being installed. DYes ;MNO
If a roof is installed without first obtaining an inspection, I agree to remov¢ Will the applicant or future building occupant usc equipment or devices which
emil hazanious air con"-minanlS as defined by the Bay Area Air Quality Manag~menl all new materials for inspec60n.
DiSlriCl?
DYes ~o
I have n:ad the lLa7.ardous ma<erials n:quin:ments under Chapler 6.95 of the Califor
nia Health &; SafclY Code, Sections 2SS0S, 2.'iS33 and 2.'iS34.1 uodcrsLaod thaLifthe building
da:.s not currcnLJy tulvc IlCnant. that il is my responsibility to notify lhc occ:upanl ofLhc
rc i cnts whi prior to issuance of a Ccniflf=alC of Occupancy. Signature of Applicant Date
All roof coverings to be Class "It or better Dale .
. 2.. V1
'-J
CUPEIUINO
CITY OF CUPERTINO
TEMPORARY PERMIT
PERMIT APPLICATION FORM
APN# Date:~/s-/c>Ci
i
iOriginal Pennit # (" G I Co.. I') -/()2--Cm . I
Building Address: I
C~ p:..ri-\ n ~I Il%'(S-o tb1V'C.--S.-teO-G ~d. i
I
Owner's Name: Phone #: CU~("t-I_VK" (}t\lCe R,,-thes:::. LlC 9D lY~)<)b7-?900
fv\l:::V\ IDf0 () 1+, ~ V"''\c-v \u:;.'"("vv\.ev \;+
Contractor:~ ,J Phone #:(<-t<.%) C,4 2-&?c-a
~.L'LO/\ COV\~\lr\.) c..+l L){"\
Fax #:( 4c1s) ;:Lc, 2-d.~ 'iL.
Contact:
Phone #: I
(406)~Cll ~9 6~ 20\\t<S -\-\v\.C: ~!\/\ \
<
V,-e (-t
Contractor License #: 31c1J~?
Cupertino Business License #:
JobD~escr~?tio~: TX -~,.r JS-r'4~~~-~! +Ic{) \ <~CX6+'YK') o'-~-'ha:IJ{"b bvil(\
'v q ff u{"'Y'. te~ p' _ -(c. -'IS I "(;,-t" c:1 I V\ -k \Ie '. ;\o-1C'<J t£'~1 (en. \J '0.~ i.JI W (,;" \ Is ( ce \I\V/t.-) (".::..1c'l
deA u\, (1'v'lC ,~/\LVJ +\VII:::,k~.Al~c I Ii,C k.»(k'~<") 1~(-~\¥-I(·(/J.-\1Lj/"5+''':;'C::J<I<_+\~ {fx-\:L"
r rt;t,(.'\'-.><' \1 (r'd Kh'\.C -a. ("t"f, tvncr -'VI, , i
" J _) t.
Valuation (cost of project): Type of Construction: ,TL i
IProject Size: Over the Counter i
!
Quantity FeeID Fee Description Fee Group Permit Type
;
)
1TEMPPMT
(Flat Fee)
Temporary Pennit Good
for 30 days -Commercial
only.
B ITEMPPMT
ALL PERMIT I
ITYPES !) 1BCBSC Cal Bldg Standards
Commission Fee
B
01/07/09