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CITY OF CUPERTINO
BUILDING DIVISION PERMIT�
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"'INFO ...TION..
BUILDING ADDRESS:
PERMIT NO.
10500 N DE ANZA BLVD F1,R I
DEVCON CONSTRUCTION
OWNER'S NAME:
PERMIT ISSUE DATE
0
PHO&PPLE
S A CON71101. NO.
(408)942-8200
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG SECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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
in full force and effwt.
DEMO RMVL CONCRT& SOIL FM FIVE (5) AREAS @GRND FLR
Lire rasa o
n Deco Contractor
OF (E) BLDG INTERIOR (7 0 8 5 SQ )
ARCHI7 ECI-S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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 rile a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of slit Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
143000
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant w a cavil penalty of
not more than five hundred dollars (MIXI).
31622017 . F LR 1
El1. as owner of the property. or my employers with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (sec. 71Y14, Business
m and Professions Code: The Conraers License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself car through his
own employes, provided that such improvements are not intended or offered for sae. 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
as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contactors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contacts for such projects with a contractors) licensed pursuant tothe Contractors
License Law.
exemptSecPC for this rcaso
L �a !
Owner I N` Date y�
4
,/
PYRICERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I hove and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nos section need not be complcted'tf the permit is forone hundred dollars ($100)
or lom)
I culifv that in the performance o�f tc work for which this permit is issued, 1 shall not
employ any person in any m y. so as to becgque subject to the Workers' Compensation
Laws of California. Data // 11
Applicant -
-
NOTICE TO APPLICANT. If, alter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Coda 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
,
Lenders Address
1 certify, that 1 have read this application and state that the above information is
correct. 1 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 inspecdom purposes.
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilides,f udgments, costs and expenses which may in any way accrue against said City
V��
in consequence of the ganti of this permit
APPLICAM UNDER NDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:('�� Date
SOURCE REG NS. j
Re-roofs
Type of Roof
Signature of A icani/Contractor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as deflned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
Code, Section z553z(a)T
❑Yes )(No
Allroofs shall be inspected prior to any roofing material being installed.
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 materials for inspection.
District?
4lu
❑ Yes
I have mad the hazardous materials require meats under Chapter6.95 of the Califor-
nia health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not cmrenty hav tenant, thu It is my responsibility to notify the occupant nr the
requirements whit fist be reel 'or to issuance or Ccruficam of Occupancy.
Signature of Applicant Date
All roof coverings to be Class 'A" or better
Owner [yam
or authorized agent
CITY OF
CUPEkTINO
CITY OF CUPERTINO
DEMO
PERMIT APPLICATION FORM
oq o (p o o (e�-j
APN# r _ � O ` n r
Date:
Building Address: 1000 N PE 4N?4 /.&o -�Za f Fy4?V
Mailing Address (if different from building address):
Owner's Name:
Phone:
*ZF
Yoh d6z-927 99
Contractor:
Cw S�,ev�i GAJ, /Ave
Phone: � 0 � _ � pa
Fax:
Contractor License #: 3 9 9 !l 3
Cupertino Business License #:
Contact: Z>A viD tv,4 E
Phone: 909
/�.v %
tr-'gL
B/ A41
Fax:
Residential ❑ Sq Footage Commercial Sq Footage
Job Description: RKateevA I�o vCv Soy ON
raeu- .
Valuati
A13. 000
Project Size: Express Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1DEMORES
Demo -Residential
B
1SFDWL-DEM
1DEMOPRES
Pool Demo Residential
B
1SFP00L-DEM
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICRE
Seismic Residential
B
fL
Revised 01/07/09
alo
CUPERTINO
CITY OF CUPERTINO
DEMO
PERMIT APPLICATION FORM
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
1DEMOCOM
Demo -Commercial
B
1COMML-DEM
1DEMOPCOM
Pool Demo Commercial
B
1CPOOL-DEM
1BCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT
TYPES
/
1BSEISMICOM
Seismic Commercial
B
1BUSLIC
Business License
B
Revised 01 /07/09