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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10486 STERLING BLVD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10040005
OWNER'S NAME: CITY OF CUPERTINO INC DATE ISSUED:05/03/2010
OWNER'S PHONE: 4087773354 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F! ELECT I— PLUMB F
License Class Lic.#
MECH F RESIDENTIAL F, COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE EXISTING WOOD PROPERTY
(commencing with Section 7000)of Division 3 of the Business&Professions LINE
Code and that my license is in full force and effect. FENCE BETWEEN 10486&10476 STERLING BLVD;ELITE
LANDSCAPING PD FOR BUS LIC
I hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$100
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:37523046.00 Occupancy Type:
correct.I 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 inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: --- Date: -��-5
t
OWNER-BUILDER DECLARATION
�Ihcrcby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
r oar' d agent:
forthwith comply with such provisions or this permit shall be deemed revoked. O jy�w
LJ4er utho
r►.c,..� 0Date: s /D
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all n pint source reg a ons per the Cupertino Municipal Code,Section
9.18. ARCHITECT'S DECLARATION
� 1 understand my plans shall be used as public records.
Signatu Date D
Licensed Professional
CITY OF CUPERTINO
CITY OF
CUPEKrINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN #� 7 / I ' I 00 Date: ,1
Buil ing Addr ss:
��� .
a� & S
Mailing Address (if different fromAdilding address):
op p rye, A-ve . C u per ,na
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: Phone#: .1 7 _ 2
u �r -i0o � L D9 - J
Contractor. w- ,I- Phone: 22
LAn h Fax: ®
Contractor License#: C� '
Cupertino Business License#:
ConPhone: �
ff,faq
� D 05 Fax:
Residential Commercial ❑
Job Description: a G n wood
r� 0) o� -(' p G e b �fu�ee-� f
Building Permit Info:
Bldg [Z/ Elect ❑ Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B
Valuation: v Square Footage:
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/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.builditgreen.org
Revised 07/14/09
CITY OF CUPERTINO
CITY of GENERAL BUILDING APPLICATION
CUPEKrINO
FEESCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1BBOILERI 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)
1BBOILER2 Installation/relocation of ea M
boiler/compressor over 3 horsepower
to &incl 15 horsepower, or ea
absorption sys over 100,000 Btu/h
113130ILER3 Installation/relocation of ea M
boiler/compressor over 15 horsepower
to &incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
&incl 1,000,000 Btu/h
1BBOILER4 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
11313OILER5 Install ation/relocation of ea boiler or M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH 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.
1 ELECINSP Other Electrical Inspections (per hour) E
1MEC'HINSP Other Mechanical Inspections (per M
hour)
1PLIv[BINSP Other Plumbing & Gas Inspections P
(per hour)
1MEETINGIHR Application Meeting B
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