09060090 CITY OF CUPERTINO
SUILDING DIVISION PERMIT C� R4QR � Y� �
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
O
SQ#FALiryU, CONTROL NO.
(510) 7-17-1234
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
u0p LICENSED CONTRACTOR'S DECLARATION Job Description
m 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
y in full Coree an%d r« C RMV & F"EPEC 4 WINDOWS,, NO CHANGE IN ROUGH
j ? License L Lie•Mof
F p Datc Contractort ' O P EN I NCS,
ARCHITECTS DECLARATION
ee I understand my plans shall be used as public records UVALUE= .2 9
?aU
Cy Licensed Professional
N OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
p OoG 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 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
%F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
su .. 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
net mere than five hundred dollars(M). 36937004 . 00
❑I,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 dors not apply m 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 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.).
❑1,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 contractar(s)licensed pursuant to the Contractor's
License Law.
❑I 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-
.tion,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 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 Compensa'M Insurance carrier and Policy number am:
Carrier +� % Policy No.; T�33
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
I certify that in the performance of the work for which this permit is issued,I 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
(~.i►�v I hereby affirm that there is a construction lending agency for the performance of
tY the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Lender's Name
z Lender's Address
V C) 1 certify that I have read this application and state that the above information is
V. torten.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorise representatives of this city to enter upon the
ove-
W abmentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City [< T
V Z in consequence of the granting of this permit. Date 6
0-4 APPLICANT DERSTANos AND W COMPLY WITH ALL NON-POINT Issued bre:
SOU LDER' -. y %S J
` � Re-roofs
Signature of Applicant/Contractor Dare T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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)? ,L., All roofs shall be inspected prior to any roofing in being installed.
❑Yesto
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
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
,trict?
❑Yes ,(o
1 have read the ha7ardouss 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 responsibty •n fy the occupant of the
reyuircmc h' ystbe et brtoissu fa e e riot Signature.of Applicant Date
�7 All roof coverings to be Class'JQ"or better
Own r or authorized agent Date'
c>
"1
CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #0(0
9 :5 -7 o o,'`/ O � Date:
Building Address: _ �
��) C/Tole,
Mailing Address (if different from building address):
Owner's Name: / ak t,1Phone#:-1 -9r,
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: Phone: 77-1-I z J4
Fax:
Contractor ' ense#: y�
Cupertino Business License#:
Contact: Phone:
Fax: 1,,f1,7-
Residential Commercial ❑
Job Description: <A•r!� ,
Building Permit Info:
Bldg,jk, Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B 52 k 3
Valuation: 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:
For help, contact Build it Green at www.budditgreen.or
Revised 02/05/09
i
G CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPE(�TINO
FEE S(:HEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 STUCOAP Stucco Applications (up to 400 sf) B
additionE.l stucco application
i 1 WINREP Replacement windows/sliding glass B
1 door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbin 1 Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1MECPLNCK Stand A]one Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand A]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-stand alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
I BSEISMICR Seismic Residential B
1 BSEISMICO Seismic Commercial B
ITRAVDOC Travel 6c Documentation B
1BUSLIC Business License B
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ARMSTRONG WINDOWS INSTALLATION & MEASUREMENT GUIDE ATTACHMENT A
(ESTIMATOR)
Customer a
Address
City
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Glass Types.
GC=Glue Chip NR=Narrow Reed 42=42 Clear BT=Bronze Tint E=Evergreen DGT Dark Gray Tint NA }
R=Rain DF=Delta Frost OBS=P516 STD GT=Gray Tint A=Azurlite SCB=Solar Cool Bronze
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HOMEOWNER'S STATEMENT: I AGREE THAT THE ABOVE IS CORRECT INCLUDING BUT NOT LIMITED TO STYLE, COLOR, FEATURES, SIZE,
TYPE, AS WELL AS LOCATION OF DOORS AND/OR WINDOWS. ALL MEASUREMENTS ARE ROUGH FOR PRICING PURPOSES, MEASUREMENTS
WILL BE FINALIZED BY INSTALLER AT THE TIME OF FINAL MEASUREMENT.
`OMEOWNEnS SIGNATURE )W—W`v . T����r.�,'IA DATE
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ARMSTRONG WINDOWS INSTALLATION & MEASUREMENT GUIDE ATTACH F�NT`AN
ESTIMATORf
Customer
Address -
Cit
Glass Types. s
GC=Glue Chip NR=Narrow Reed 42=42 Clear BT=Bronze Tint E=Evergreen DGT=Dark Gray Tint
R=Rain DF=Delta Frost OBS=P516 STD GT=Gray Tint A=Azurlite SCB=Solar Cool Bronze
FIN OPTIONS GRIDS HINGE
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12 x
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14' x
HOMEOWNER'S STATEMENT: I AGREE THAT THE ABOVE IS CORRECT INCLUDING BUT NOT LIMITED TO STYLE, COLOR, FEATURES, SIZE,
TYPE, AS WELL AS LOCATION OF DOORS AND/OR WINDOWS. ALL MEASUREMENTS ARE ROUGH FOR PRICING PURPOSES, MEASUREMENTS
WILL BE FINALIZED BY INSTALLER AT THE TIME OF FINAL MEASUREMENT.
`OMEOWNE^S SIGNATURE {wM` DATE��
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
',UPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT #�
OWNER'S NAME: PH NE #
GENERAL CONTRACTOR: F
any I
am not usingsubcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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