09050084 CITY OF CUPERTINO
BUILDING DIVISION PERMITTt?..I�( MATIQi '
BUILDING ADDRESS: PERMIT NO.
0905 0241
10101 PERMIT ISSUE DATE
OWNER'S NAME:
— SA CONTROL NO.
�N :
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
SIDING REPAIR D 0 O
y p C LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 70(IU)of Division 3 of the Business and Professions Code,an�my license is
w in full force and effectto I
/t(YY__ U
jgo q� License I le•L #A Date CHITECTS DECLA N S
tt -� I understand my plans shall be used as public records
5yd
Lu.y Licensed Professional
0 Gn OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
c O oO following reason.(Section 7031.5,Business and Professions Code:Any city or county
e$V which requires a permit to construct,alter,improve,demolish,or repair any structure
y�- prior to its issuance,also requires the applicant for such permit to Glc a signed statement
z< that he is licensed pursuant to the provisions of tits Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
YH (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 APN Number Occupancy Type
not more than five hundred dollars(S500).
0 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 does not apply to an owner of q P
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 does not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a contractor(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:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
_uon,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' ompe Con 1 urance Cartier and Policy number are: U
Career; Policy No.:
CERTIFICATE OF EXEMP71ON FROM ORKERS'
COMPENSATION INSURANCE
(This section reed not be completed if the permit is for one hundred dollars($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 Codc,you must
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm Utat them is a construction lending agency for the performance of
C�+ the work for which this permit is issued(Sec.3097,Civ.C.)
W A [.enters Name
Z L.cndees Address
U 0 1 certify that I have read this application and state that the above information is
(7." comet.I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorize representatives of this city to enter upon the
s
W above-mentioned property for inspection purpose
a (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 granting of this permit. Date
�-+ APPLIC NT UN STANDS AND L COMPLY WITH ALL ON-POINT Issued b}:
EGU NS. O U
Re-roofs
S' store of Applioanr/Contraclor Da ,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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.
0Yes o
Will the applicant or utum building occupant use equipment or devices which
If a roof .s installed without first obtaining an inspection,I agree to remove
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new r)aterials for inspection.
.urict?
0 Yes �dvu
1 have read the ba�ardows materials requirements under Chapter 6.95 of the Califor-
nia Health&SafctyCode,Sections 25505.25533 and 25534.1 understand that if the building
d no curen ve a tenant,that tt' y responsibility to notify the occupant o the
req cuts must be mel pri to i or ficae or 5 p Signature of Applicant Date
ov wnc authorized agent
Dae All roof coverings to be Class"JQ``or better
CITY OF CUPERTINO
CUP TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN Date: � ) v
Building Add ss: I
I �e-
Mailing Address (if different from building address)
Owner's Name: ' A ,Lk Phone#:
H (Exterior work only) Yes ❑ No
If yes, provide letter.from HOA
Contractor: Phone:
fQ"e Py— Ct)$t�CV-L-j-%-Lk& y. Fax: (2
Contract r License#: (P 1'7 WO
Cupertino Business License#: I
Contact: �'v hyo �.2Ywa r Phone:
15
Fax: 7 4t "S 3 7
Residential [ Commercial ❑
Job Description: S
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B M II/III/V-A ❑ II/III B, IV-HT,V-B S (pp,
Valuation: C Square ootage:
Project Size: Express ❑ Standard ❑ Large ❑ Ma-or ❑
Green Building: Please complete relevant portior, 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 •een.ora
Revised 02/05/09
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCIMEDULE
Quantity/Sf Fee ID Fee Des--ription Fee Permit Type
Group 1GENRES or
1GENCOM
PARTITION WALLS
1PARTICOMM Partition Interior Commercial B 1PARTICOMM
1PARTIR Partition [nterior Residential B 1PARTIR<=30
RETAINING
WALL(CONCRETE
OR MASONRY
1RETSTN Standard(up to 50 ft) B
IRETSP310 Special Design, 3-10' high (up to 50 `) B
1RETSP10 Special Design, over 10' high(up to B
50'
1RETCRB< Gravity/Crib Wall, 0-10'high (up to B
50 ft
1 RETCRB> Gravity/Crib Wall over 10' high(up to B
50 ft
SIDING
1 SIDESTBK Siding, S:one& Brick Veneer B
interior/caterior
r _ 1 SIDEOTHER Siding all other B
b SKYLIGHTS
1 SKYL<10 SF Skylight ess than 10 sf B
1 SKYL>10SF Skylight,treater than 10 sf or B
structural
1STAIRS Stairs-fiat flight/ea addt'l B
STORAGE RACKS
1SRACKS<=8 Storage Facks 0-8' high (up to 100 so B
1 SRACKS>8 Storage F acks over 8' high (up to 100 B
st
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Parish P1,ace
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