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09030070CITY OF CUPERTINU BUILDING DIVISION PERMIT BUILDING ADDRESS: 10275 STERN AVE OWNER'S NAME: uo0 =Z i AFD a-1j-', DLU LtyF a`A ny 00 Ets„G .7 0 Z � W ~ G. Q ►`� Z UO ILI F, OU Uz ')NE: ARCHITECLYENGINEER: LICENSED CONTRACTOR'S DECLARATION 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 Lic• # Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 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 rile a signed statement that he is licensed pursuant to the provisions of the Contractor'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 more than five hundred dollars (5500). 0 I, as owner of the property, or my employees with wages as their sok compensation, will do the work and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does 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 sate. 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.). 0 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code:) The Contractors 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 Contractors License taw. 0 [am exempt under S cJ B & P C for this Mason e C b Owner E LkV'u 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 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. 0 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 Workers Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($ 100) 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 !m7an so az to become subt to the Workers' Compensation Laws of California. Date Applicant NOTICE M APPLICAM: If, after making this Certificate of Exemption, you shoutid become subject to the Worker's 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 construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name L.cndees Address I certify that 1 have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction. and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to saw, indemnify and keep harmless the City of Cupertino against Liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS— w C (A / L C1 f 3 f' Signature oApplicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material az defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes cwe Will the applicant or future building occupant use equipment or devices which III. hazardous air contaminants as defined by the Bay Arca Air Quality Management Jislrict? E [-]Yes 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a tenant that it is my responsibility to notify the occupant of the rcquircmc which muses C pn uao� Catificatc cuF T-0 1//.t 3 Owner or authorized agent D—c APURVA Job Description INSTL CITY CLEAN—OUT& FIX COUPLER BET ABS & CLAY Ft. APN 37510045.00 V-16� V Issued b3 M Required Inspections Type of Roof i All roofs shall be inspected prior to any roofing material being installed. If a roof .s installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class'W' or better PERMIT NO. 09030070 PERMIT ISSUE DATE A CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB Job Description INSTL CITY CLEAN—OUT& FIX COUPLER BET ABS & CLAY Ft. APN 37510045.00 V-16� V Issued b3 M Required Inspections Type of Roof i All roofs shall be inspected prior to any roofing material being installed. If a roof .s installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class'W' or better T CITY OF CUPEkTINO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM -70 APN #t � 1 0 C7 i� � , 0 c) Date r j © f Building Address: 1021S— QTE�)2- t\J /( _\IE (fUPEKT)NO, Fee Group Owner's Name: U fZVAjk'T1 { TA Phone #: Contractor: Phone #: L Fax #: Contact: Phone #: �I,� �2 Commercial re -pipe per fixture P 1CPRP Fax #: Contractor License #: Cupertino Business License #: Job Description-1r�) <..Q — i -,x �f 0 1 e ID �1 Residential Commercial ❑ Valuation: Cal Bldg Stanc ards Commission Fee Project Size: Express Standard Large [] Major Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green BuildingPoints:` Quantity Fee ID Fee Descripl:ion Fee Group Permit Type 1PCSEWER Commercial bi.ilding sewer/sanitary sewer P 1CPSS 1BPREPIPE Commercial re -pipe per fixture P 1CPRP 1 PGASCOM Commercial G is Piping System 1-4 Outlets P _ 1 BCBSC Cal Bldg Stanc ards Commission Fee B ALL PERMIT TYPES 1 BSEISMICOM Seismic Commercial P Revised 01/07/09 MA CITY OF CUPERTINO = 1. REPIPE/SEWEIUMAIN SERVICE CUPEkTINO FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential P 1PRSEWER Residential build.ng sewer/sanitary sewer P 1RPSS 1PRREPIPE Residential re -pipe per fixture P 1RPRP 1BPWSVCS Water Service P 1CPWS or IRPWS 1PPRSEWG Private Sewage Disposal System P 1 PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping System 1-4 Outlets P 113PGAS Gas Piping Systen 5+ Outlets P 1PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Caeck P 1PLMBINSP Other Plumbing/, -;as Insp. P 1 TRAVDOC Travel & Docum ,-ntation Fee B 1BUSLIC Business License B 1. 2. OWNER -BUILDER VERIFICATION (Check one) I or my immediate family parent, spouse or child) will perform: A. 1'� the work authorized by this permit B. A portion of the we rk C. _ None of the work If B or C is checked, c :)mplete 2 or 3 below. A state licensed contractor will be hires. to do: A, All of the work B. — A portion of the work (complete section below) 3. _ I will utilize unlicensed person(s) other than my immediate fan-dly to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' cor-ipensati.on must be on file at the City of Cupertino Building Department office. PersorVFirm Address/City Phone NumberI Type of work to be —4�,-rno,4 ............................................................................................... I declare under penalty of perjury that the d3ove is true and correct. I have read and understand the Owner -Builder Information (reverse side). 013 Property Owner's Signature: Date: P rtY � V _� Permit # Job Address: Any changes to the information Provided_ on this form shall be submitted to the City of Cupertino Build Department.