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07010113 CITY OF CUPERTINO BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: ' PERM UE DA OWNER'S NAME: 01/19/2007 HMS PROPERTY MGMT 10210 STERLING BLVD SANITARY NO. CONTROL NO. 'NE: (408) 557-8899 BUILDING PERMIT INFO rRCECT•/ENGINEER: BLDG ELECT PLUMB MECH p aLICENSED CONTRACTOR'S DECLARATION Job Description Vhereby affirm)hat I am licensed under provisions of Chapter 9(commencing c z w with Section 7000)of Division 3 of Ulc Business and ProfCssion�ad;and my license is 2 0 0 AMP L PGRADE y in full force and eff ,1 r I U vj z License Class Lam•g = p Datc Contractor 9 t— ARCHITECTS DECLARATION a I and rstand my plans shall be used as public records m� �yU u.y Licensed Professional o< OWNER-BUILDER DECLARATION a1 hereby affirm that I am exempt from the Contractors License Law for the In o following reason.(Section 7031.5,Business and Professions Code:Any city or county �%9 which requires a permit to construct alter,improve,dcmalLsh,or repair any structureValuation 4"H prior to its issuance,also requires the applicant for such permit to file a signed statement c' F[.Floor Area $2000 —?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 xI-- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or A that he is exempt therefrom and the basis for the alleged exemption.Any violation of Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 36907023 . �1' not more than five hundred dollars($500). 0 1,as owner of the property.or my employees with wages as their sole compensation, Required Inspections will do the work and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of 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 docs 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. B&P C for this reason 0 1 am exempt under Sec. Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 0 1 have and will maintain a Certificate of Consent to self-insure for worker's Compen- sation,asprovided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 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: Carrier. Policy No.: 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 thew k rs permit' not employ any person in any saner t to om tion Laws of Califomi Applicant NOTICE TO APP CAM:If,after making thd Ccifificatc of Exemption,you u become subject to the Worker's Compensation provisions of the Labor Code•yo must Z forthwith comply with such provisions or this permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY Fr rA I hereby affirm that there is a construction lending agency for the performance of Q! > the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name 4+ Lender's Address V 0 1 certify that I 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 C, building construction,and hereby authorise representatives of this city to enter upon the above-mentioned property for inspection purposes. >4 a (We)agree to save,indemnify and keep harmless the City of Cupertino against CA liabilities,judgments,casts and expo ' which may in any way accrue against said City V Z in consequence of Ute gran'ng of permit. Date (( r� APPLICANT UNDER DS D OMPLY WITH AL ON-, NT Issued b.f: SOURCEREGU Re-roofs— Signature of plicant/Contractor are Type Of ZOOf HAZARDOUS MA IALS ISCLOSURE yP 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 roof.,-,shall be inspected prior to any roofing material being installed. 0Yes If a roof is installed without first obtaining an inspection,I agree to remove Will the applicantor future building occupant use equipment or devices which all newmaterials for inspection. emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ' C]Yes o I have mad the hazardous aterials requirements under Chapter 6.95 of the Califor- nia Health&Safety Secd 05,25533 and25534.1undcrstan atif -,)ding docs not current a a n at it ism rcsponsihilily to notil' the occ ant the Date requirements tss ceota iIliiy cavo Signatuie of Applicant l/ All roof coverings to be Class"B"or better Ow o autho z gent nate Community Development fa 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 rUPEkTINO Buildi.n De artment JOB ADDRESS: , . PERMIT # OWNER'S NAME: � _. dal z bay-- �- 7�. PHONE # "�'"� GENERAL CONTRACTOR: r?rc FAX # I am not using any subcontractors: — S.gnatur ate Please check applicable subcontractors and corn plete the following information: 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/C actor Signature Date CITY OF CUPERTINO d�jD l O 113 a F' PERMIT APPLICATION FORM CUPEkTINO kPN# Date: Building Address: Mailing Address (if different from building address): 0(4 Owner's Name: Phone#:� O O License#: , / � 'f Contact: / 11 ,, Phone: a Cupertino Business License#: Fax: Building Permit Info: f Bldg ❑ Elec PI umb ❑ Mech ❑ Job Description: A ni Residential El XL ��?�� Commercial El Sq.Ft. Floor Area: Sq.Ft.: Cost of Project: Occupancy Group: Z �-� Type of Construction: Please check this box if the project is a �`p second-story addition: ❑ 2roject Size: Standard ❑ Large ❑ Maj)r ❑ Fee ID Fee Description Fee Group Quanti Other Appliances BAPPLOTHER pp MECHANICAL BBOILERI Boiler,<= 100,000 Btu MECHANICAL BBOILER2 Boiler-> 100K to 500K Btu MECHANICAL BBOILER3 Boil,;r> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Inii/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 Elea Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD anergy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING i of 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Th.-atrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Much Permit Issuance MECHANICAL PPERMITFEE -Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Plannin ,LR Comme/Multi-Fam PLANNING PLLONGRNGR Plannin ,,Long Range Residential PLANNING ZADDCHG Address Change BUILDING of 3