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CITY OF CUPERTINO
BUILDING DIVISION PERMIT CTNFORI [AT�®I�1t
BUILTS'i�I]D$FSVPERMIT NO.
O S S AVE CAMDEN FORD 07060174
OWNER'S NAME: PERMIT ISSUE DATE
CAMDEN FORD 07/25/2007
PHONE: SANITARY NO. CONTROL NO.
ABUILDING PERMIT INFO
RCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION IOU Description
W U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 70(1(1)of Division 3 of the Business and Professions Code,and my license is ADDING 2ND STORY DECK.
h in full force and effect
y? License Class Lie.rr
F-,wDate Conlraclor
W ARCHrIECfS DECLARATION
a< I understand my plans shall be used as public records
aU
min Licensed Professional
j OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
n 0 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
ti prior m its issuance,also requires the applicant for such permit to file a signed statement
Z
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
F m (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $22748
.2 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 ofNumber Occupancy Type
not more than five hundred dollars($500). 3 4 25 0 01 8
❑I,as owner of the property,or my employers with wages as their sole compensation,
will do Lhework.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply m Ulre
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.).
4L ors as owner of the property,am exclusively contracting with licensed contractto
o tract 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.
❑1 am exempt and ,B&P C for this reason
Owner Date
W—RKER'S COMPL2RSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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.
❑1 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 are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he 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,1 shall not
employ anyperson rn a}Y�anner so as to become sins to the Workers'Compensation
Laws of Califomia.,[iltc n
Applicant
NOTICE TO APPbONT.If,after ma ing this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codo,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
C
r r.
E-+ I hereby affirm that there is a construction lending agency for the performance of
Ri the work for which this permit is issued(Sec.3097,Civ.C.)
W n~ Lender's Name
aZ Lender's Address
U 1 certify that I have read this application and state that the above information is
(I. �--r correct.I agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
H (We)agree to save,indemnify and keep harmless the City of Cupertino against
t--t c/) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granti of this permit.
'-' APPLICANT UNDER DS AND WILL C P WITH ALL NON-POINT Issued by: Date
SOURCE REGULAT N . / J
Re-roofs
Signature of Applicant/Contractor -ale
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 yL1 No 25532(a)?
El Yes All roofs shall be inspected prior to any roofing material being installed.
,
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 1 No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code,Sections M05,25533 and 25534.I understand that if the building
docs not currently h tenant,that it is esponsibilily to notify the occupant of the
requirements wh' m t be met prior to'su cc of Certificate of Occupancy. Signature Of Applicant Date
G All roof coverings to be Class "B"or better
Owner or authorized agent Dale— _
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPS TING
APN# � �� Date:
i ,
Building Address: 1VIai1ang Address (if different from building address):
Owner's Name: Phone#:
C��., � L (:: des — �7� - 13 ( ci
Contractor: Ucense #:
Contact: Phone: Cupertino Business License#:
=�,3/�` Fax: 't�ag''87-3
Building Permit Info:
Bldg [9 Elect ❑ _ Plumb ❑ Mech ❑
Job Description:
Residential Q/ !�� _ _, Commercial ❑
Sq.Ft. Floor Area: - —_ Sq.Ft.:
?® y
Cost of Project: Occupancy Group:
—
Type of Constriction: Please check this box if the project is a
_ second-story addition: ❑
Project Size: Standard go*- Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler >500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.7_5 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
_BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR _ Constax-Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Flee Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of 3
Community Development
10300 Torre Avenue
✓- Cupertino CA 95014
Telephone(408) 777-3228
CITYOf~- Fax(408) 777-3333
CUPE�TINO
Building Department
JOB ADDRESS:/ C 145-5-
/ PERMIT#�D o
.�—J V f o S �I/-�K L.- .� i •lrf?w� C/
OWNER'S NAME: ., ,F o�S " PHONE # Off'- <37'-�—/3 r q
GENERAL CONTRACTOR: 611 IFAX#
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
RI 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,,.
Owner/Contractor Signature Date
I