09030066 CITY OF CUPERTINO PERMIT BUILDING.DIVISION, PERMIT 1 � L
PERMIT NO.
BUILDING ADDRESS:
10514 FELTON WAY ATN CONSTRUCTION INC 09030066
PERMIT ISSUE DATE
OWNER'S NAME:
0700 VT�;T A A O. CONTROL NO.
'ONE:
(408) 966-6541
BUILDING PERMIT INFO
ARCHrECT/ENGINEER: BLDG ELECT PLUMB MECH
u0p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
jusE
m with Section 7000)of Division 3 of the Business and Professions Code,and my license is TEMP POS JER POLE
y in full fore and effect "
v�Z License Class a Contractor
3 M Dale 71tN�}
ARCHITECTS DECLARATION. t
I understand my plans shall be used as public records
ha
�qU
i V.in Licensed Professional
OWNER-BUILDER DECLARATION
2 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
in O 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
o- ti prior to its issuance,also requites the applicant for such permit to rile a signed statement $q,Ft.Floor Area Valuation
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5000
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(S500). 35918035 . 00
0 I,as owner of the property,or my employees with wages az their sole compensation,
will do the work and the structure is notintended or offered for sale(Sec.7044,Business Required Inspections
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.).
0 I,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's L;-
cense Law donot apply to an owner of property who builds or improves thereon,and
rs
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
0 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:
have and will maintain a Certificate of Consent to self-insure for Workers Compen-
..hpn,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
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 ICSL)
I certify that in the performance of the w rk f which this permit is issued,I shall not
employ any person in any manner so az Workers Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,afte along this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
(..h►. 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.)
W Lenders Name
� Lenders Address
U C) I certify that I have read this application and state that the above information is
LL correct I agree to comply with all city and county ordinances and state laws relating to
V building construction,and hereby authorize representatives of this city to enter upon the
W ahove-mentioned property for inspection purposes.
1:6 (we)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the g 'ng of this permit Date
I" APPLICANT UN ER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued b.�:
SOURCE REGU TI S
3 Re-roof: -
Sig..of A pli UContractor Data T of Roof
MATERIALS DISCLOSURE Type
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
Cede,section 25532(a)? All roof:;shall be inspected prior to any roofing material being installed.
0Yas No
will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new-naterials for inspection.
strict?
0 Yes KN.
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safet C Sections 25505.25533 and 25534.1 understand that if the building
docs not current ha a tenant that it is my responsibility to notify the occupant of the Date
requirements w t prior to issuance of a Certificate of Occupancy. Signa of Applicant
All roof coverings to be Class'``or better
Owner or auth ed agent are
C9 o5 o
CITY OF 16UPERTINO
TEMP POWER
CUPERTINO PERMIT APPLICATION FORM
APN # Date: _3/ 1
�q 3 (..0. C> 0
Building Address: G t C
Owner's Name: �, .�15 1��1 IZ Phone #C,24oS) 1,6 -�5 3 g
Contractor: Phone #: (44 G g) c E 6�-z 1
� 1
ti �oUS I IwC._
Fax #:
Contact: Phone #: -
I ✓nh G}G�) X66 6 >�t
Contractor License #:
Cupertino Business License #:
Job Description: _
Residential Commercial
Valuation (cost of project): ,r C--> Type of Construction: N/A
Quantity Fee ID Fee Description Fee Group Permit Type
IERT>IK Res. Temp Power>1K E IREAP14
Amps
IERT<200 Res. Temp Power<200 E
I
Amps
1 ERT2001 K Res. Temp Pc wer 200-1 K E
Amps
IEPERMITFE Electric Permit Issuance E
1 ELCPLNCK Electric Plan ,'—heck E
1BCBSC Cal Bldg StarLdards B ALL PERMIT _
Commission:gee TYPES
1BSEISMICR Seismic Residential B
1 TRAVDOC Travel & Documentation B
/ Fee
Revised 01/07/09
Community Development
10300 Torre Avenue
aCupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
';UPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT # O 3
A Q'5 ) 4 Fc�jfi�n vjc� �
OWNER'S NAME: P CZA V-05 i`Ai iL— PHONE # A0'3. 3 t Z
GENERAL CONTRACTOR: ; 'H C c ti 5 T L-Ci IG►" FAX #
I am not using any subcontractors:
gnature Date
Please check applicable subcontractors and comn:)lete 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