09040082 CITY OF CUPERTINO � � � � *
BUILD DIVISInN PENT
PERMIT NO.
BUILDING ADDRESS:
6069 SHADYGROVE DR SMITH E�ECTRIC PERMIT ISSUE DATE
OWNER'S NAME:
nrrn7 F R CmT+ujD-1�E'I"�'3� 7 A 9 CONTROL NO.
,NE: 1)1)n
(408) 91 -7619
BUILDING PERMIT(NFO
ARCHITEGT/ENGINEER: BLDG EO PLUM MEECC,H
a p C LICENSED CONTRACPDR'S DECLARATION Job Description
v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Cry,and my license is PNL U PG RD TO 2 0 0 AMP r SAME LOC
by in full force and effect J l9.Jl
� z LicenscClaa: 1` L'o **SMITH ELCTRIC RENWD BUS LIC 4/16/9
3 t-o Date – Contractor
eg ARCHITECTS DECLA ATION
4 d< I understand my plans shall be used as public records
�,U
L rn Licensed professional
U.
OWNER-BUILDER DECLARATION
I hereby alTirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m which requires a permit to construct,alter,improve,demolish,or repair any structure
y~rn prior w its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
Y F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or82500
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($500). 3 7 5 4 0 0 C 6 . 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 docs 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
ostruct 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 contractor(s)licensed pursuant to the Contractor's
rise Law.
I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
hero and will maintain a Certificate of Consent to self-insure for Workees 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 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 are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not be completed if the permit is for 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 is to ecome subject to the Workers'Compensation
Laws of Cali mipDate— _rd–
Applicant y` rT 01 _z
NOTICE TO A PLICANT: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.
Z'.-i CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
(3, the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendces Name
z Lcndees Address
[certify that I have read this application and state that the above information is
LUL corrccL I agree to comply with all city and county ordinances and state laws mlating to
0 C> building construction.and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
„H„to liabiliti 'udgmcnts,costs and expenses which may in any way accrue against said City l� /
V z rj�CGULA
the granting o rmit Date ( `v
�--h �NS.
C PLY WITH ALL NON-POINT Issued b y:
Re-roof:
IlIlmAdre of App' [/Contractor Dam 'j Of Roof
DOUS 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)? All roof;shall be inspected prior to any roofing material being installed.
Cl Yes gNo
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 naterials for inspection.
District?
Yes au
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
does n curendy have a tenant,th ' is my respo ibility to notify the occupant of the
requ' m n hick mug be et or issuance of ni ate of Occupancy. $ignatuI a Of Applicant Date
All roof coverings to be Class'JW'or better \
1.0_ authoriz a cnt Date
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
r,
PERMIT APPLICATION FORM
APN # 7.5-flU Date: 4 lG/ Ito
Building Address: ® O S Ve blv
Mailing Address (if different from building addr
Owner's Name: P y�� _ Sy Q
HOA: (Exterior work only) Yes ❑ No
If yes, provide letter from HOA
Contractor: >�°(�,�\ L 'v Phone:ell
Fax:
Contractor License S 310
Cupertino Business License#: a T 13 a
Contact: 1,t, )e, S (VLLW Phone 6i o - 2 (
J
Fax:
Residential Commercial El
Job Description:
paj,vd L-ce
Building Permit Info:
Bldg ❑ Elect LTJ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Valuation: � Square Footage:
Project Size: Express ' tandard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portior, of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
IPoints Achieved:
For help, contact Build it Green at www.builditgi-een.or
Revised 02/05/09
CITY OF C.UPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEkTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Des,:ription Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
IEPERMITFEE Electrica, Permit Fee E
1 MPERMITFEE Mechani-,al Permit Fee M
I PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone 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 Bldg Standards Commission Fee B ALL PERMIT
TYPES
I BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1BUSLIC Busines3 License B
5 of 5
Community Development
10300 Torre Avenue
s4t!an
Cupertino CA 95014
Telephone(408)777-3228
OFFax(408)777-3333
„U PEkTINO
BuildingDe artment
JOB ADDRESS: PERMIT #
OWNER'S NAME: RJ14 PHONE # 4 0� ,?S-4- -9 S(4 C�
GENERAL CONTRACTOR: E! LC_ (aLFAX #
11 q- (6 ,
I am not using any subcontractors: f/,,,I
i;nature Date
Please check applicable subcontractors and c m 3lete 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
T'
�� r6 -o9
er/Contractor Signature Date