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07010188 CITY OF CUPERTINO BUILDING DIVISION PERMIT �1N7C�A Tait NF AN .1 BUILDING ADDgES � ftno , • . PERMIT NO.CM 010'223 ,^�. /� hr PERMITLSSUEDATE as? OWNE�2'SNA � MC', 11 AIV 113C01 �� HONE: SANITARY 90. 1CONTROL NO. ?-63 _ 6 1 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 0 0 p LICENSED CONTRACTOR'S DECLARATION Job DOSCiIptlOn tit I hereby affirm that I am licensed under provisions of Chapter 9(commencing t Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is / y in full force and effect _ Q 3 .� eY,�..j huise f 1��rar License Class 9l con;tDatc /^A!—/D'1 ContractorIda i2sna-4— ARCHITECTS DECLA ATI N � L a< t understand my plans shall be used as public records �(,� 4. ,Lu 4 wo H Licensed Professional n OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county K which requires a permit to construct,alter,improve,demolish,or repair any structure Z y prior to its issuance,also requires the applicant for such permit to tilt a signed statement Valuation < that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area I Es m a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or y-R 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 OC Up ey Type not more than five hundred dollars($500). .� O ❑1,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 Required Inspections and Professions Code:The Contractor's 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.). ❑I,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 Contractors License Law. ❑1 am exempt under Sec. B&P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- 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 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 Work o pen ion Inst(t�nce carrier and Policy number are: Carrier+J AAAA Policy No.:2.2,1d?_ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for anc 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 manner so as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Qforthwith comply with such provisions or this permit shall be deemed revoked. Z" CONSTRUCTION LENDING AGENCY [-r tom. I hereby affirm that there is a construction lending agency for the performance of _ py > the work for which this permit is issued(See.3097,Civ.C.) QLender's Name ►7 z Lender's Address V O 1 certify that 1 have read this application and state that the above information is corset.1 agree to comply with all city and county ordinances and state laws relating to rJ U building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. W W (We)agree to save,indemnify and keep harmless the City of Cupertino against tF. rA liabilities,judgments,costs and expenses which may in any way accrue against said City / V Z in consequence of the gran' of this permit. Date 0 "+ APPLICANT UNDE DS AND WILL COMPLY WITH ALL NON-POINT Issued ty: SOU _ 1-31 -10Re-roof; Signat9c of Applicant/Contractor Dare Type of Roof HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino 7N. I Code.Chapter 9.12,and the Health and Safety Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will the applicant or future building occupant use equipment or devices which If a room is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes Nu 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 docs ftha.v�a tc r.that it is my responsibility to notify the occupant of the requidoes .-.. ti is y zee of a Certificate n of Occupancy_ Signatu;t of Applicant Date / -J/-07 All roof coverings to be Class"B"or better Owner r authorized Agent Date Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -UPEkTINO Buildf.ng Department JOB ADDRESS: PERMIT # --z 2 3 3 & ReM,(+ � . 0101 Wee OWNER'S NAME: G z i PHONE # 2 3 3 _2 S— GENERAL CONTRACTOR: iM cct ,c FAX # r !� I am not using any subcontractors: S ignature Date Please check applicable subcontractors and complete 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 / _._.,.. 6-117 -3 .7 Owner/Contractor Signature Date CITY OF CUPERTINO "', REPIPE/SERV �jJ: S/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN # Date. Building Address: Owner's Name: J Phone#: Z')--3 - ZSR Contrt"' orPhone: License #: r - " 763 YZ)l 3 Contact. Phone: Cupertino Business License#: �� 5��s �� 6e- - .6Q, "2-3 7 2 3 Building Permit Info: Bldg ElElect ElPlumb Job Description: I1 Residential 4Commercial ❑ Cost of Proj ec . Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg. Permit Fees BUILDING BPGAS Gas Piping System Fee PLUMBING PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE P epipe of Fixtures PLUMBING BPFIXTURE Pblg. Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BUSLIC Business License BUILDING