The URL can be used to link to this page

04010140CI'T'Y OF CUPEWrINO BUILDING DIVISION PERMIT CONTRAGTQR INFORMATION. a OR 3, r BUILDING ADDRESS: 21 000 2TR1_7RN2 CR.RRK P.1) PERMITN004010140 ER'SNAME: PERMITISSUEDATE PHONE: - SANITARY N0. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICCNSEDCONnRACfOR'S DECLARATION I hcrchy 1 limned Chapter 9 (commencing Job DescriptionP affirm thm am under provisions of with Scaion Division J of the 0uaincse and Pmfusinm Codc. and my license is rot affect, in full font and effect. FI��sr�D License Class ue.g TI--T MOBILE Dem Contractor ARCHITECTS DECLARATION ■11 1kI1 1 J Z�O4 MAR I understand my plana shall he u¢d a publie records BUILDING Liccnaed Profmsainnsl OWNER BUILDER DECLARATION hereby affirm that I am exempt from the Conuaelors License Law for the following are. (Secuun 7031.5, Business and Professions Code: Any city or county which requires a permit m construct, alter, improve, demolish, or repair any structureprior m its issuance, also mquiru the applicant for such permit to file a signed statemem that he is licensed pursmn0o the provisions of the Contractor's License Law (Chapter 9 Sq. FL Floor Area Valuation (commencing with Section 700B of Division J of be Businassand Professions Cm.) or that he is exempt Oamfrom and the basis for the alleged exemption. Any violation of Section 7031.5 by smy.ptlicant fora permit subjects the applicant an a civil penalty m( 3 tif$er00 Occupancy P Type nm mom roan five hundred dollars ($5M). Y ❑ 1, As owner of the property, m my employes wind wages As their sore compensation, will do the work. and the structure is not intended at offered for sale (Sec. 1044, Business and Pmfeviona Codc: The Conoadoes License Law docs mat apply m an owner of Required Inspections property who buildanrimproves thereon, and who doessuch work himself orthrough his own employees, provided Nal such impmvemenls arc not intended orofiered for sale. If, however. the building or improvement is sold within one you of completion. Ne owner. builder will have the burden of proving Nu he did not build or impraw for purpose of nalcJ. 1, a owner of Or, properly, am eaclusively contracting with licensed contractors to construct the project (See, 70,o4, Business and Professions Cade:) The Contractor's U. cense law does not apply to an owner of property who builds or improves lhemon,and, who contracts for such prpjceB with a contractor(s) licensed pursuant to the Contractors License Law. ❑lam exem/der B & P C for Nis ..on /Sao Oil' RKPR'g COMPENSATION DECf71tyTION O Iherebyalamunderpenaltyofperjuryoncaf lowing declarnicam: ❑ 1 have and will maintain a Cenifica. of Cordo m m aelf-inure for Workers Compere salion, As provided for by Section 7100 of the labor Code, for be performance of the work for which this permit is issued. El I have and will maintain Workers Compensation Ines.. as mquimd by Section 37M of the labor Code, for the performance of the work for which Nia permit it issued. My Worker's Compensation Insurance carrier and Policy number art: Carrier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE . Thissectimt treed not hecompletcd lithe permit is for one hundred Eullars ($10 )) mlcss.) - 1 certify, Nu in the performance of the work for which this permit is issued. 1 shall not employ any person in any manner so as at become subject o the Workeri Compensation Laws of California. Delo Applicant NOTICE TO APPLICANT. If. after making this Certificate of Exemption, you should become subject ro the Worker's CompcNation pmviaiom of the Late Coca you must forthwith comply with such provisions or this Permit shall he deemed revoked. CONSTRUCTION LENDING AGENCY 1 henry affirm that there its construction lending agency for the performance of the work for which Nia permit is issued (Scut. 7091, Civ. C.) Lenders Name . Lenders Address I certify that 1 have read this application and stem that the above information is com9m. I agree to comply with all city and county ordinances and sixth laws relating to building construction, And hereby Addition nermax nlallVCa of this city to enter upon the algvCme nudgedpmperst for purpwhich (We) agate ro... internal fy and kRp hanttleul the City of Cuporlina against exposes liabilities,c.fudgm may Leets and ex pensee Which may In any way aLCNC against said (.'lly 1' do Aconsequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SDU_W,E REGU/y`�ATIDNS . � Re-roofs Type of Roof sig tmeafApllC,noc uractro HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hasudous material as darned by the Cupertino Municipal Code, Chapter 9.11, and the Health and Safety c, Section 25532(M? 0Ym Ib Nu All roofs shall be inspected prior to any roofing material being installed. WiU 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 sardous air contaminants as defined by Oc Bay Area Air Quality Management all new materials for inspection. C _rt? ❑Yrs W. 1 have mall the havrdnua ma.rialsmyuiremcnts under Chapter 695 of One Califter. nit Health&Safety Codc.Scc..25505,7S5JJand255J4.lundcrsw A, lachuilmng Jou rrol cuncn0y Aave a tenant Nm it t my responsibility m noufy t occ pant of the myuii,�nmwhich most bu mct�-n isN,nec ofa certifies. of an �h- v/ Signature of Applicant Date f f/ All roof coverings to be Class "B" or better Oke,ar.tom iced agent Data 3ceZ °0O itu Qul _7rn � u. yQrn N -al OC lm� 314, _yam 2 C i - 0 Z C CITY OF CUPERTINO BUILDING DIVISION PERM CONT�n INFC�RMA. �N': BUILDING ADDRESS: 21000 2TEIT��N�; CREEK RID PERMITNO 04010140 OWNER'S NAME: PERMIT ISSUE DATE PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 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 folie arta effect. TI --T MOBILE License Chis Lic. N Date Contractor ARCHITECPS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I 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 Sq. Ft. Floor Area Valuation 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 Codc) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of 3 r-iyp,Tsy�,T ,F,,.,i�� O 0 3T3 4!' OrJlrJ r9' r Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars (S500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections will do the work, and the structure is not intended oroffered for sale (Sec. 7044, Business and Professions Code: The Contractor's 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 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 comractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exem or Sec. , B & P C for this reason dgper lltj �—-_.�--� Date 1.. Z` -0e. WORKER'S COMPENSATION DECLA'QON I hereby affirm under penalty of perjury one of the -f6llowing declarations: ❑ 1 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. ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Codc, for the performance of the work for which this permit is issued, My Worker's Compensation Insurance carrier and Policy number are: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (this section need not he 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, I shall not employ any person in any manner so as to become subject to the Workcrs' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Ccniicatc of Exemption, you should 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. I 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 (See. 3097, Civ. C.) Lender's Name - Lender's Address i 1 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 authorim representatives of this city to enter upon the ahove-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against j liabilities, judgments, costs and expenses which may in any way accrue against said City ' in consequence of the granting of This permit. - ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOUWF � REGULATIONS. ; �� l -ac !�. : ��` r Re -roofs Type of Roof Sig tureof Applicant/Co tractor Date HAZARDOUS MATERIALS DISCLOSURE 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, S 25532(a)? Yes �jJu ❑ Yes All roofs shall be inspected prior to any roofing material being installed. 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 emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection, DislrlcL7 ❑ Yes ANu I 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 docs not curently have a tenant that it is my responsibility to nosily th occupant of the regmimm�nwhich must be met prior ro issuance of a Certificate of Oce anc7✓�� _ Signature of Applicant Date V/ 2 /�. ( "B" All roof coverings to be Class or better ncr or aothorired agent Date CITY OF CUPERTINO CITY OF CUPERTINC PERMIT APPLICATION FORM � I i APN # Fee Description Fee Group Date: Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot Building Address: BBOILERI Boiler <= 100,000 Btu 11000 sficvcw5 C�'cLZ LU D 1 Lvrrc 2�6 C) Owner's Name: BBOILER3 Boiler > 500K to 1M Btu Phone #: BBOILER4 Boller> 1M to 1.75 M Btu MECHANICAL BBOILER5 Contractor: MECHANICAL BCONSTAX License #: ,K BCONSTAX Ind/Off/Comm/Quasi BUILDING Contact: Con. Tax for BQ Zone BUILDING Cupertino Business License#: Building Permit Info: BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC 1000 B Elect P b ❑ M e c--Jkl� kb escription: ELECTRICAL BELEC200 Residential ❑ ELECTRICAL Commercial ❑ Sq -Ft. Floor Area:$/Sq.Ft.: ?-2—S () . sl�— CS1 Energy Add Multi Cost of Project: u/, ` f Occupancy Group: Type of Construction: Comm. Housing Mit. Fee BUILDING Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 50CIK Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boller> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC 1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING I of 3 f ,) �-CITY OF CUPERTIN( CITY of PERMIT APPLICATION FORM CUPHIjINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMTviM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BOVERTINIE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,0.00 cfrn MECHANICAL BREMAIlZHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL 2of3 : , -ITY OF CUPERTINO CITY of PERMIT APPLICATION FORM CUPEUIINO Quantity Fee ID Fee Description Fee Group BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIN4 Swimming Pool BUILDI714G BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL_ BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING BMISCELL Building Misc Fees BUILDING 3 of 3