09050047BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHrrECT/ENGINEER:
a 0 0 LICENSED CONTRACTOR'S DECLARATION
VZ 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
sin full force and effect
2 License Class 3 2 A
LC' I O tic• N
Date Contractors n �✓ a-^� C'L L <
'< ARCHITECT'S DECLARATION
.� �—
I understand my plans shall be used as public records
DUI o.0
L o H Licensed Professional
y OWNER -BUILDER DECLARATION
1 hereby affirm that I 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
y^ V which requires a permit to construct, alter, improve, demolish, or repair any structure
In 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 to Contractor's License Law (Chapter 9
Yr (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not mom than five hundred dollars ($500).
❑ 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 dors not apply to an owner of
property who builds or improves themn, 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 u -
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 mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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. have and will maintain a Certificate of Consent to self -insure for Workees Compen-
ation, 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 am: ClIq 5;
Cartier P fL'e F5 ' 4 t 0 Policy Ne.: � lC —t11 O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section teed not be completed if the permit is for one hundred dollars (f 100)
or Iess.)
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
Lender's Address
I certify that I have read this application and state that the above information is
correct. 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
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
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL�NONP SOU RE ULATIONS.
5Sign icant/Con
HAZ OUS 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)?
❑ Yes POO
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
;trio?
❑yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my msponsibility to notify the occupant of the
requirements whicjl must be met prior to issuance of a Certificate of Occupan�_�
Owner or
FFIY•
• • • •
s •
Job Description
200 AMP METER UPGRADE.SFDWL
q. Ft. Floor Area
35603020.00
-1-6
Issued by:
Re -roofs
Number
Required Inspections
Valuation
Type of Rjof
All roofs :;hall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
All roof coverings to be Class " , or better
Date
PERMIT NO.
PERMIT ISSUE DATE
S A
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB
Job Description
200 AMP METER UPGRADE.SFDWL
q. Ft. Floor Area
35603020.00
-1-6
Issued by:
Re -roofs
Number
Required Inspections
Valuation
Type of Rjof
All roofs :;hall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
All roof coverings to be Class " , or better
Date
CITY Of
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
APN#35(p 0 a 0, �v
Date:
Building Address:
,
Mailing Address (if different from building address):
Owner's Name: 2 -e e
Phone #: ;2, 57 S — Z
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor:
Phone: ce- g S — £s S ?
7— eL LF 7- et C-
Fax:
Contractor License
Cupertino Business License #: 7
Contact:
Phone: Cr J5
6 -� F v �
Fax:
Residential Z Commercial El
Job Description:
2 6—
Building Permit Info:
Bldg ❑ Elect [3/,- Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ I All B, IV -HT, V- B❑
S F k
Valuation:
Square Footage:
tv 1200
170')� 5- •
IV
Project Size: Express R✓ 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.builditgi-een.or
Revised 02/05/09
t�� s
CITY OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1STUCOAP
Stucco Applications (up to 400 sf)
additional. stucco application
B
1 WINREP
Replacerr ent windows/sliding glass
door (ea 3 windows)
B
1 WINMEWSTR
New Window -structural shear
wall/masonry (includes plan ck fee)
B
1 EPERMITFEE
Electrical Permit Fee
E
1 MPERMITFEE
Mechanical Permit Fee
M
1 PPERMITFEE
Plumbin€, Permit Fee
P
1 ELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1 MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
1 PLMBLNCK
Stand Al,)ne Plumbing Pln Ck (hrly)
P
1 STPLNCK-(3 Hr Min
when not over counter)
Standard Plan Check (when no E/M/P)
hourly -stand alone
B
1 BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
/
1 BSEISMICR
Seismic Residential
B
1 BSEISMICO
Seismic ommercial
B
1 TRAVDOC
Travel &; Documentation
B
1 BUSLIC
Business; License
B
T
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:
C? 6, ALS 7rzC�L Gi
PERMIT #
090500y
OWNER'S NAME:
PHONE # SSS — Z 3 9
GENERAL CONTRACTOR: �r m �, �/ L -7 L - L c r
FAX #
I am not using any subcontractors: (Z,,) S// 1 /0
Pete
Date
T31hk a licable subcontractors and com the to owing information:
ease
c
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
0 Contractor Signature ate