09040075 CITY OF CUPERTINO
BUILgING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
18725 TILSON AVE BEN VALDEZ GENERAL 09040075
OWNER'S NAME: CONTRACTOR PERMIT ISSUE DATE
F.TmF.T\TF, 'Pay 3A01 "P. PAX.2149RE
NE: S A 9 CONTROL NO.
(650) 346-4719
ARCHI'i'ECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
u o p LICENSED CONTRACTOR'S DECLARATION
V I hereby affirm that I am licensed under provisions ofChapter 9(commencing Job Description
with Section 7000)oC Division 3 of the Business and Professions Code,and my license is
ny in full force and RPLC 4 2X2 SKYLIGHTS
Z License Class Lic,k
C-a Date — It 4 nlracto
HITECTS DECLAR
-) I understand my plans shall be used as public records
DyU
L C in Licensed Professional
n 0 3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
pO following reason.(Section 7031.5,Business and Professions Code:Any city or county
x,�,Pi which requires a permit to construct,alter,improve•demolish,or repair any structure
z prior u)its issuance,also requires the applicant for such permit to file a signed statement
s G that he is licensed pursuant to the provisions of the Contractor's Liccnse Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y f- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1800
y 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
not more than five hundred dollars($500). 3 7 518 0 C 1 . 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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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 sate.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
constntct 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
License Law.
❑I am exempt under Sec. B&P C for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
r037ave and will maintain a Certificate of Consent to self-insure for Worker's Compen-
as provided for by Section 3700 of the Labor Code•for the performance of the
for which this permit is issued.
ave and will maintain Workers Compensation Insurance,as required by Section
f the labor Code,for the performance of the work for which this permit is issued.
yorkers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Parent:hundred dollars($100)
Of 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 tocomes io _tETrisation
Laws oC Califo Date
Applicant
NOTICE TO PPL.ICA :If, ng of Exemption,you should
become subject to the Workers comlicris * provisions of the labor Code,you must
Oforthwith comply with such provisions is permit shall be deemed revoked.
z"" CONSTRU ON LENDING AGENCY
[~i I hereby affirm that there is a construction lending agency for the performance of
Ili> the work for which this permit is issued(Sec.3097,Civ.C.)
ALendces Name
z Lenders Address
V 0 1 certify that I have read this application and state that the above information is
LL'7" corset I agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes
(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
V z in consequence of the granting of this permit. `
APPLICANT UMIERSTANDS AND ILL C PLY WITH ALL NON-POINT Issued by: Date
SOURCE R ATTONS.
Re-roofs
Signat m a Applicant/Contractor Date
HAZARDOUS M ALS DISCLOSURE Type Of F OOf �.
Will the applicant or future rng occupant store or handle harardous material
as defined by the Cupertino Munici I 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.
❑Yes No
Will the applicant or future building occupant use equipment or devices which If a roof i s installed without first obtaining an inspection,I agree to remove
.:mit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new IT aterials for inspection.
District?
❑Yes X10
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
does not cy4fly have a tenant,th tt is my responsibility to notify the occupant or the
regain which matt be et or to c of a Certificate of Occupancy. Signature of Applicant Date
Owner or authorized agent Date
All roof coverings to be Class''"or better
IULf
CITY OF CUPERTINO
CUPf
CITY
GENERAI. BUILDING
PERMIT APPLICATION FORM
APN # ate:
375 � DoloOD �7/Build Address:—
Mailing Address (if different from building address):
Owner's Name: Nom_ Phone#: 9 � '_ � C/
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA'� Phone: �j S_Q -3 �,- y 7 )
Contractor:
Fax:
Contractor License#: y C-3 O-S -D
Cupertino Business License#:
Contact: Phone: S-0 •-3�{�- y l�
Fax:
Residential Commercial ❑
Job Description: vte IOLA.e< C4—�yt Z S �vJ Ua
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A7 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [� '
Valuation: Square Footage:
Project Size: ExpressE]_--.Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicab:e, include in plan set& the sheet index.
Points Achieved: _
For help, contact Build it Green at www.buildit$!i•een.or
Revised 02/05/09
n CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPERTINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
PARTITION WALLS
1 PARTICOMM Partition Interior Commercial B 1PARTICOMM
1PARTIR Partition InWrior Residential B 1PARTIR<=30
RETAINING
WALL(CONCRETE
OR MASONRY
1 RETSTN Standard (uI to 50 ft) B
1RETSP310 Special Design, 3-10' high (up to 50 `) B
1 RETSP 10 Special Desi gn, over 10' high (up to B
50')
1RETCRB< Gravity/Crili Wall, 0-10'high (up to B
50 ft)
1RETCRB> Gravity/Crib Wall over 10' high (up to B
50 ft)
SIDING
1 SIDEST/BK Siding, Store & Brick Veneer B
(interior/exterior)
1 SIDEOTHER Siding all o-her B
SKYLIGHTS
/ 1 SKYL<10 SF Skylight leEs than 10 sf B
1 1 SKYL>l 0SF Skylight gri;ater than 10 sf or B
structural
1STAIRS Stairs-first light/ea addt'l B
STORAGE RACKS -
1 SRACKS<=8 Storage Ra:ks 0-8' high (up to 100 sf) B
1 SRACKS>8 Storage Ra;ks over 8' high (up to 100 B
st)
4 :)f 5
' = CITY OF CUPERTINO
C U
CITY
OF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 STUCOAP Stucco A pplications (up to 400 sf) B
addition,.l stucco application
1 WINREP Replacer-lent windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechani:,al Permit Fee M
1 PPERMITFEE Plumbin;Permit Fee P
IELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK 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-s:and alone
1BCBSC Cal Bldg; Standards Commission Fee B ALL PERMIT
TYPES
/ IBSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1BUSLIC Busines;> License B
5 of 5
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
xCITY OF Fax(408)777-3333
XPEkTINO
Buildin De artment
JOB ADDRESS: T 1 ES 0r3 A e— PERMIT # ��C) v
OWNER'S NAME: e _IPHONE # O
GENERAL CONTRACTOR: �-� -3 -
I am not using any subcontractors: y�
Signa Date
Please check applicable subcontractors and com:)let following information:
SUBCONTRACTOR BUSINES 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