09050093 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � � � '
PERMIT NO.
BUILDING ADDRESS:
10161 PA
PERMIT ISSUE DATE
OWNER'S NAME:
SA CONTROL NO.
-%N
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
STUCCC, REPAIR O O O D
�c c LICENSED CONTRACTOR'S DECLARATION Job Description
WC 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of '''on 3 of the Business and Professions Code,and icense is
e?y in full force and effect.
j ? License Class Lle•8
Date Contractor
R HITECTS DECLAR O
tt I understand my plans shall be used as public mcord�r Y�
;yU
Oin Licensed Professional
y 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
a O following reason.(Section 7031.5,Business and Professions Code:Any city or county
y a which requires a permit to construct.alter,improve,demolish,or repair any structure
prior to its issuance.also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
x t- (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($500).
0 1,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 Licertse 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 thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt uncle See. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aflicm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
,tion,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 Workefs 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 +per 'on Ins nce camer and Polity nu be a�re� 'r
Carrie Policy No.: Mr;, (J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This 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 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
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
[moi mom. 1 hereby affirm that there is a construction lending agency for the performance of
p+> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
]Z Lendees Address
V 0 1 certify that I have read this application and state that the above information is
L1.H correct.I agree to comply with all city and county ordinances and state laws relating to
5 U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes
GL (We)agree to save,indemnify and keep harmless the City of Cupertino against
h,to liabilities,judgments,toss and expenses which may in any way accrue against said City '
V Z in consequence of the ranting of this permit. Date
UN R ANDS AND IL ICOMPLY WITH ALL NON-PONT Issued b}:FW GUL S. 4 r. ,
�- CJ Re-roofs
Si are of-Applicant/Contractor Dam T Of Roof
HAZARDOUS 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 roofs shall be inspected prior to any roofing material being installed.
0 Yes o
Will the applicant or f?building occupant use equipment or devices which
If a roof .s installed without first obtaining an inspection,I agree to remove
I hazardous air contaminants as dcfhncd by the Bay Area Air Quality Management all new r)aterials for inspection.
.strict?
0 Yes x!u
I have read the hvardas materials requirements under Chapter 6.95 of the Califor-
nia Health&Safel ode.Sections 25505,25533 and 25534.1 understand that if the building
no y ha a tenant.that' y responsibility to notify the occupant of the
qct Ls i oat be met phi to i aanyyoI a arcate of Occup /( Signature of Applicant Date
`--G— Da .U All roof coverings to be Class'J4'`or better
mer or authorized agent
00� �
CITY OF C.UPERTINO
CUPS TINO GENERAI-j BUILDING
PERMIT APPLICATION FORM
J APN# i I G, • v Date: ` 1
(Pq q J
Building Address: ,,
Mailing Address (if different from building address):
Own !, Name: n 4 13-W �-,�i — Phone#: _
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter.from HOA
Contractor: Phone: Lj/(f�� —"
Ly
®fa w. Fax:
Contrac r License#: G '� U
Cupertino Business License#:
Contact: To L -��. UPhone:
Fax:
Residential IX Commercial ❑
Job Description: S�-�Ct p k�a--+�
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
-3
1-A, 1-B ❑ I1/III/V-A ❑ II/III B, IV-HT,V-B
SC44- RLV�� )�NQ�!-
Valuation: 4&q7 Square Footage:
Project Size: Express ❑ Standard ❑ Largiye ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicabl a,include in plan set&the sheet index.
Points Achieved:
For help,contact Build it Green at www.builditj!raen.or14
Revised 02/05/09
CITY OF CUPERTINO
CUPEk=SENO GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
i 1STUCOAP Stucco A)plications (up to 400 so B
additiona stucco application
1 WINREP Replacerr ent windows/sliding glass B
door ea 8 windows
1 WINMEWSTR New Window-structural shear B
wall/masonry( includes plan ck fee
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alone Electric Pin Ck(hourly) E
1MECPLNCK Stand Alone Mechanical Pin Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pin Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/1\4/P) B
when not over counter) hourl -stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
IBSEISMICO Seismic Commercial B
1TRAVDOC Travel&Documentation B
1BUSLIC Business License B
5 of 5
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10164
Parish Place
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May 15,2009 j
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City of Cupertino Building Department
10300 Torre Avenue
Cupertino,CA 95014-3202
Re: Building Permits for the Cupertino Village Homeowners Association
4
10101 - 10251 Parish Place,Cupertino,CA f
Authorization for Draeger Construction Inc.to obtain Permits on our behalf I
To Whom It May Concern:
The Board of Directors of the Cupertino Villag:Homeowners Association hereby authorizes f
Draeger Construction, Inc.,605 Commercial Street, San Jose,Ca 95112,to obtain permits for
miscellaneous remedial repairs to be perform&, in the common areas of our complex as
referenced above. `
Should you have any questions,please do not hesitate to contact me.
I
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Ve truly yours, ll
l4rycty
Diana Johnson
Association Manager (Al-e '� 47,c �'��
Cupertino Village HOA
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