09040132 CITY OF CUPERTINO 41S. � � �
BUILDING DIVISION PERMIT � R�
BUILDING ADDRESS: PERMIT NO.
20659 SHELLY DE R PERMIT ISSUE DATE
OWNER'S NAME: YOLANDF
13 A CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with SocGon 7000)of Division 3 of the Business and Professions Code,and my license is
`o y in full force and effect. ADD CAN f LIGHTS, I C, LESS THAN 20
v�Z License Class Lm•8
n F- Dam Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
X06 ri
O ti Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
❑O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct,alter,improve,demolish,or repair any structure
rl �' prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
Yh (commencing with Section 7000)of Division 3 of Business and Professions Code)or81000
y 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 APN Number Occupancy Type
not mom than rive hundred dollars(M). 35911024 . 00
❑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 Contractor's License Law does Trot apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements am 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.).
A
as owner o[the property,am exclusively contracting with licensed contractors to
ract the project(Sec.7044.Business and Professions Code:)The Contractors Li-
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 Contractofs
a2;KER
t .B&Pfor this aOw DaMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
L]I have and will maintain a Certificate of Consent to self-insum 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.
❑1 have and will maintain Worker's 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 am:
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)
1 certify that in the performance o the work fir which 's permit is issued.I shall not
employ any person in any man- e J< the Wor '-Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANYefflafir maki this ifcatc of Exemption,you should
become subject to the Worker's Compen 'on p 'ions of the Labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
z, CONSTRUCTION LENDING AGENCY
[�rA I hereby affirm that them is a construction lending agency for the performance of
(Y,> the work for which this permit is issued(Sec.3097,Civ.C.)
ti)A Lender's Name
Lender's Address
z
V C I certify that I have read this application and state that the above information is
(L E~ correct I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
0-.4
liabilities,judgments,costs and expenses which may in any way accrue against said City / 4
U,Z inconsequence of thc ranting of this permit. Date
►+ APPLICANT UND STANDS AND WILL COpK
WITH ALL NON-PO slued b :
SOURCE REGUL ONS. s
Re-roofs -
-
SignatureofAppli i/C ntractor Dale
HAZARDOUS M TERIAL DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haisrdous material
as defrncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? f All roof:-,shall be inspected prior to any roofing material being installed.
❑Yes
VV \\ If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
.ait hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? ?��l
❑Yes u
I have read the hazardous m rerials requirements under Chapter 6.95 of the Califor-
nia Hczith&Safety Code,Sections 25505,P533 and 25534.1 understand that if the building
doest curmnlly have a tenant that it' my responsibility to notify the occupant of the
.qui mets ichin met aCcrtificatcof cupa9ky Signatur.-of Applicant Date
All roof coverings to be Class or better
Owner or authorize agent Dam
tt ` CITY OF C-.UPERTINO
OF
CUPEkTINO GENERAI_j BUILDING
PERMIT APPLICATION FORM
APN # Date:
Building Address:
Mailing Address (if different from building address):
Owner's Name: �� h Ci Phone#: Z 7 /
HOA: (Exterior work only) Yes ❑ No
If yes, provide letter from HOA
Contractor: f�,/ /L 1 `� one:
/ 1 Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial ❑
Job Description:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
14-9
JZ 3
I-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT,V.B
Valuation: / oo Square Footage:
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
IFor help, contact Build it Green at www.builditgi•een.or
Revised 02/05/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEI�TiNO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 STUCOAP Stucco Applications (up to 400 sf) B
addition,.l stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/maE onry(includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbin a Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand A]one Mechanical Pln Ck(hrly) M
1 PLMBLNCK Stand Al one Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standarc. Plan Check (when no E/M/P) B
when not over counter) hourly-s:and alone
1 BCBSC Cal Bldl; Standards Commission Fee B ALL PERMIT
TYPES
/ 1 BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
/ 1 TRAVDOC Travel & Documentation B
I 1BUSLIC Business License B
5 of 5
` RESIDENT IAL PROJECT COVER SHEET
Assessor's Parcel Number:
Name of owner. Za-&/ Y
Project address. '{'y
2,7�
Contact person.
GL' Phz)ne.
Fav-
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
foot b 20 foot clears aces in;;ide the garage?�Y
Are there at least two 10 y P
Is privacy protection planting required for the project? Y
On what floor(s) is work being done? /
Brief description of work. 4r �o
Code editions:2008 CBC (Y -N)2008 CFC N)2008 CMC (Y-N)
2008 CPC (Y -N 3008 TVC
Effective 1/1/08 OG�OtiS
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Nus'
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\a A �i��$�� \ 4 0 of �oAy Y
e e INOti,\1
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Plan Review Process Work Book Page-8-Revised 1/l/0E