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09040052QaC m U Z ��tCr i u, e- �O� g2�h ; rc yam: E=C y CITY OF CUPERTINO PERMIT..�`T�' BUILDING DIVISION BUILDING ADDRESS: PERMIT NO. 21599 EDWARD WAY MP3 MASONRY OWNER'S NAME: TFHRA TTAN PERMIT ISSUE DATE `NE: S A CONTROL NO. (831)6-:7-6663 ARCHITECT/ENGINEER: A BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I 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 efT '� REPAIR EXTNG MASONRY CHI= FM FOUNDATION License Cl L•ec• S 6 5�j s Dam contractor ,4 SGAry ARCHITECTS DECLARA ON 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's 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 Sq. Ft. Floor Area Valuation prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's Liens Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or 5 3 0 0 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 ($5W). 35619008 .00 0 I, as owner of the property, or my employers with wages as their sole compensation, ns Required Inspections q P will do the work and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply o 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 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 docs not apply to an owner of property who builds or improves thereon, and , who contracts for such projects with a contracmr(s) licensed pursuant to the Contractor's 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: I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- .,ation, 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 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 Polity number are: �7 Polity Ng,t�� / t Carrier.-� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is far 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 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 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.) ~ Lender's Name L.endees Address I certify that I have read this application and state that the above information is cormCL I 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 U above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against ell liabilities, judgments, costs and expenses which may in any way accrue against said City 7 in consequence of the grantin is permit. /1 APPLI UNDERST DSN WILL COMPLY WITH N N -POINT Issued b'r: Date SOU RE O %L Da Re -roofs T of ] 2oof Type Si tree of ApplicanVCon r 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, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. 0Yer / 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 +t hazardous air contaminants as defined by the Bay Area Air Quality Management all new r materials for inspection. strict? 0 Yes (�l' 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 docs not currently have a tenant. that it is my responsibility to notify the occupant of the requirem r to issuance of a Ccr if or 9rcuparicy, Signature • of Applicant Date All roof coverings to be Class 'j`r or better ` Owner or authorized agent Date CITY OF CUPEkTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM --�5 (0 / qo v '", v v APN # Date: Building Address: fs99 E.v 4� � Mailing Address (if different from building address): Owner's Name: � Phos-n7e #: HOA: (Exterior work only) Yes ❑ No [ — / / "71P'07,) - If yes, provide letter from HOA Contractor: Phone: d;,,.3 Fax: Contractor License #: Cupertino Business License #: Contact: Phone: Fax: Residential Commercial El Job Description: Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: C2 -3 1-A, 1-B [-] II/III/V-A ❑ II/III B, IV -HT, V- B [- 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.builditgreen.or Revised 02/05/09 _1�1 a40-1 CITY OF CUPEf�TINO CITY OF CUPERTINO GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM ACOUSTICAL REVIEW IACOUSFDW SFDWL/Duplex New B IACOUSRESAD SFDWL/Duplex-Addition/Alteration B 1 ACOUSCOM Multi-Family/Commercial B CHIMNEY'S 1 CHIMNEY Chimney B 1 CHIMNEYR Chimney Repair B FENCES 1 FENCE>6FT Non -masonry, over 6 ft in height B 1 FENCEMAS>6 Masonry, over 6 ft in height B FIREPLACES 1 FIREPLMAS Fireplace Masonry B 1 FIREPLFAB Fireplace Pre-Fabricated/Metal B 1 FLAGPOL>20 Flag pole (over 20 ft in height) B 1 MODUSTRU Modular Structures B FOUNDATIONS 1 FOUNDREP Foundati m Repair B 1 PILECAST Pile Foundation Cast in place concrete B 1 PILEDRIV Pile Foundation Driven (steel, pre- stressed concrete) B 3 of 5 CITY OF CUPEkTINO CITY OF CUPERTINO GENERAL BUILDING APPLICATION FEE S(:HEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) additionzl stucco application B 1 WINREP Replacement windows/sliding glass door (ea 8 windows) B 1 WINMEWSTR New Window -structural shear wall/masonry (includes plan ck fee) B IEPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechani -al Permit Fee M I PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P I STPLNCK-(3 Hr Min when not over counter) Standard Plan Check (when no E/M/P) hourly -s1 and alone B 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Seismic Residential B 1BSEISMICO Seismic '.ommercial B 1 TRAVDOC Travel &. Documentation B 1 BUSLIC Busines., License B 5 of 5 ..� _ CITY OF `UPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: PERMIT # SUBCONTRACTOR BUSINESS NAME OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX # I am not using any subcontractors: j / d� ignature Date Please check applicable subcontractors and complete the following information: i Owner/ 06ntra ctor Signature Date 60 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 i Owner/ 06ntra ctor Signature Date