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09030209 77 CITY OF CUPERTINO BUILDING DIVISION PERMIT + �1TR�► C3R I� RMATI�N ' BUILDING ADDRESS: PERMIT NO. 10625 N DE ANZA BLVD TBD - TO BE DETERMINED '-`rNER'S NAME: PERMIT ISSUE DATE 1 �� I�1l�YYJ' SAN P i-Y#.3CONTROL NO. ciONE: ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH INSTALL EVR PHASE II VEEDER Q Q Q Q u o o LICENSED CONTRACTOR'S DECLARATION ROOT IV APOR SYSTEM Job Description mI hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is y in full force and effect 2 ? License Class Lie.# C y Date ';f-— Contractor -4 611 ARCHITECTS DEC N X < I understand my plans shall be used as public records �yrJ 4 u- Licensed Professional N<� OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractors License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county 4 Pi which requires a permit to construct.alter,improve,demolish,or repair any structure y Zy prior to its issuance.alto requins the applicant for such permit to file a signed sutement < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation yF (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 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 ns Required Inspections and Professions Code:The Contractors 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 Contractors Li- cense Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a conuactor(s)licensed pursuant to the Contractors License Law. 0 1 am exempt under Sea B&P C for this mason •ner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificate of Consent to self-insure for Workers Compen- sation,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 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 (This section need Trot 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 mammgr so ash becomes bject to the Workers'Compensation Laws of California.Dar ^T Applicant NOTICE TO APPLI Al :If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you mast ,J O forthwith comply with such provisions or this permit shall be deemed revoked. Z . CONSTRUCTION LENDING AGENCY 1 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.) W A Lender's Name Lenders Address U 0 I certify that 1 have read this application and state that the above information is LL cored I agree to comply with all city and county ordinances and state laws relating to 0U building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. Ia. (We)agree to save,indemnify and keep harmless the City of Cupertino against r�r fn liabilities,judgments,costs and expenses which may in any way scenic against said City U Z in consequence of the granting of this permit. „y APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOUR 16QEGULATIONS. '-7_—0-Q 1 q Re-roofs 5 � 7 S azure of Applicant/Contractor Dare T Of R�Of 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 +de.Section 25532(a)? All roofs;chap be inspected prior to any roofing material being installed. [3 Yes eQNo If a roof i:i 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? 0 Yes 7 0 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 currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of occupancy. Signature of Applicant Date � x •[ r•�� -13-09All roof coverings to be Class" "or better Owner authonzcd agent Dare CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR SylviaM COPY # 1 Sec-, Twp: Rng: Sub: Blk: Lot: APN * @@ * smog : 32610028 . 00 DATE ISSUED. . . . . . . 07/13/2009 RECEIPT #. . . . . . . . ■ BS000008186 REFERENCE ID # . . 09030209 SITE ADDRESS . . . . . 10625 N DE ANZA BLVD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . 0 : CUPERTINO IMPACT A-REA . . . . . . OWNER . . . . . . . . . . . . ■ HABIB KHAYYAT ADDRESS . . . . . . . . . . .0 10625 N DE ANZA BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ANEIL CHAND CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : TELEPHONE . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BAPPLOTHE NO OF APPLIAN 1 . 00 61 .19 0 . 00 61. 19 0 . 00 1BCBSC VALUATION 10, 000 . 00 1 . 00 0 . 00 1. 00 0 . 00 IBSEISMICO VALUATION 10, 000. 00 2 . 10 0. 00 2. 10 0. 00 1PLMBLNCK HOUR 1 . 00 122 .38 122 .38 0. 00 0 . 00 1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00 1TRAVDOC FLAT RATE 1 . 00 40 . 79 0. 00 40 . 79 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 268 .25 122 -38 145 . 87 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 145 .87 visa --------------- TOTAL RECEIPTa 145 .87 CITY OF CLTPERTINO CITY OF CUPEf�TINO GENERAL BUILDING PERMIT APPLICATION FORM OqO:3 0 ZO APN # Date.- ? -------------- 2,-V 10 0 Z�-/()C,) III Building Actaress,-, LLA-PEV,4 0 M P!(g I P I Z Vs I 0 fo 2.5 W e; t%s ZA OP4. •�'�'`F Mailing A_Wf6ss (If-different from building address): _ — Owner's Name: A,AB`pJ Phone#: �c5� CS v7 7 2 HOA-. (Exterior work only) Yes ❑ No ❑ 0 19 'm .. from If Yes, proviae letter irom HOA Contractor., LoM��fAhtC� Phone-..Az)S 70(, q840Se'eVtC£ ?Wt4ACIE: Fust- 1_=tic- Fax: Contractor License#: S q.f cl 2w2., Cupertino Business License#: Contact'. Phone: oe�oe) A t4 J _ �p�._ l�g,�0 Fax: Residential ❑ Commercial Job Description: E-:qR hASE 711: VEEE��,Ejp �q,?o p Building Permit Info: Bldg El Elect El Plumb Er/ Mech El Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B [:] I1/111/V-A [:] H/111 B. IV-HT, V-B 3 Valuation: lot 000 00 Square Footage: Project Size: Express �---00`Standard ❑ Large ❑ Major D Green Buflaing-. Please complete relevant portion of the Green Buflding/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.build-itgreea,.org Revised 02/05/09 CITY OF CUPERTINO Cj -NO GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRFS or 1GENCOM I BB OILER I For the installation or relocation of ea M boiler/compressor to & including 3 horsepower, or ea absorption sys to & incl. 100,000 Btu/h (29.3kw) IBBOILER2 Installation/relocation of ea M boiler/compressor over 3 horsepower to &incl. 15 horsepower, or ea absorption sys over 100,000 Btu/h IBBOILER3 Installation relocation of ea M boiler/compressor over 15 horsepower to & incl 30 horsepower, or ea absorption sys over 500,000 Btu/h to &inci 1,000,000.000,000 Btu/h IBBOILER4 Installation relocation of ea M boiler/compressor over 30 hosepower to &incl. 50 horsepower, or for ea absorption sys over 1,000,000 Btu/h to &incl 1,750,000 Btu/h IBBOILER5 Installation relocation of ea boiler or M refrigeration compressor over 50 horsepower, or ea absorption sys over 1,750,000 Btu/h IBA.PPLOTH For ea appliance or piece of equip M regulated by this Code but not classed in other appliance categories, or for which no other fee is listed in this code. IELECINSP Other Electrical Inspections (per hour) E I MECHINSP Other Mechanical Inspections (per M hour) IPLMBINSP Other Plumbing & Gas Inspections P (per hour) IMEETINGIHR Application Meeting B 2 of 5