09020010 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: 09020010
1160 S STELLING RD SHEPHERL SERVI
PERMIT ISSUE DATE
OWNER'S NAME: &
4AT�T T(lCF ('(1CA7+T DT(1TT7~zDC T12 0 BOX. S A CONTROL NO.
'ONE:
4085597160
BUILDING PERMIT INFO
ARCHITECl/ENGTNEER: BLDG ELECT PLUMB MECH
u p C LICENSED CONTRACTOR'S DECLARATION Job Description
v 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000 of Division 3 of the Business and Professions Code,andmy IlCensc is RMV & R�'LC RF TOP F URNC & DUCTS
n�y in full force andyftecL ��09,3
�.�z Lice CI (7��!3tS Lic-fl '4 M+ R.V(CI
3 E, Date_r Z O�1 Contractor (S
ARCHrrECPS DECLARATION
�C 1 understand my plans shall be used as public records
J�U
`u. LicensedPmfessional
rn OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p o following mason.(Section 7031.5,Business and Professions Code:Any city ar county
which requires a permit to construct,alter,improve,demolish,or repair any structure
n"y prior to its issuance,also requires the applicant for such permit to file a signed statement 3q•Ft.Floor Area Valuation
rz Gthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions Cade)or 550000
.. that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars(S500)• 36225029 . 00
0 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 dots 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 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. 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:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
-don,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
ave and will maintain Worker's Compensation insurance,as required by Section
yM of the Labor code,for the performance of the work for which this permit is issued.
My WorkeCompensation
Insurance carrier and Policy number are:
Carrier: - 11-- EYr 4/^'J Policy No.. r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
([his section need not be completed if the permit is for arts 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
`f., forthwith comply with such provisions or this permit shall be dcemed revoked.
Z 04 CONSTRUCTION LENDING AGENCY
(~-t I hereby affirm that there is a construction lending agency for the performance of
ai✓ the work for which this permit is issued(Sec.3097,Civ.C-) /
W Q Lender's Name /
r0.
7 z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
correcL I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby Authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
114 ('We)agree to save,indemnify and kap harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ��))
U Z in consequence of the o • permiL Date / ?
t-, APPLICA ND ST D D WILL COMPLY WITH ALL NON-POINT Issued b)
SO RCE O % Re-roofs '
Stfnatum f rcanuco tor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hrzardous material
as defined by the Cupertino Municipal 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.
0Yes 601. If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
.strict?
0 yes QfNu
I haw mad the hoz ous materials requirements undcrptcr 6.95 of the Califor-
nia Health&Safcty C 505.25533 and 75534.1 understand that if the building
docs ntc h a it is my responsibility to notify dre occupant of theDate
rmust t •ortoissuanceOraCertificateofOccuPartcy. Signature;of Applicant_?- All roof coverings to be Class'J or better
Owneed agent Date
u0/ �
CITY OF CUPERTINO
V 110 1,ANS
FUR'iACE/AC CD : �n BY
C' °F �ICATION FO
CUPERTINO PERMIT APPI
APN /_ Date:
to s 0a1 .
Building Address: +Y.
Owne 'sXNe-, Phone#:
Csus yC)9
Contractor: Phone#: Ljo g-s-s r--2-'6 a
S"Pf-fF,X �iz_U(c£ Fax#: C!o8,S3-r/-/08-7-
Contractor License#: Cupertino Business License#:
Contact: Phone#: Yog-313-33q6
Fax #:
Building Permit Info:
Elect Plumb ❑ Mech kA
Residential ❑ Commercial
JobDescription:-f P,A-c /2o6C
For Residential Installations:
Attic ❑ I" floor El
2°d floor 11
Adhere to minimum setback requirement ❑
For Commercial Installations:
Replacement same weight �Additional weight(structural calcs) EJ
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Construction (Usage Class):
d 0
Strapped On Platform H Bonded New Location Replacement
Project Size: Express ❑ Standard ❑ Large ❑ Major❑ _
Valuation: '5z Jkyu
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09
CITY OF C UPERTINO
FURNA,CE/AC
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
FURNACE FURN/AC
1MCRAA Commercial-RepsLir/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absoiption unit,or ea
heating,cooling,absorption or
evaporative cooliag system,incl
installation of controls regulated by this
code.
1MCREPALT Commercial for tie repair of alt/add to M
ea heating appliaiice,refrigeration
unit,cooling unit,VAV boxes,
absorption unit or ea heathing, cooling
absorption,or evaporative cooling sys,
incl install of controls regulated by
this code.
1MCSUSHTR Commercial Install/Relocate ea M
suspended heater,recessed wall htr, or
floor mounted unit heater.
1PGASCOM Commerical for ca gas piping System P
1-4 outlets
1BPGAS For each gas piping system of 5 or P
more per outlet.
1MCAPPVNT Commercial for 1he install/relocate/ or M
replacement of ea appliance vent
installed & not incl in an appliance
permit.
IBCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICO Commercial Seismic B
I MRRAA Residential Repair/Alteration/Add to M
ea heating appliance,refrigeration unit,
cooling unit,absorption unit,or ea
heating,cooling,absorption or —
evaporative cooling system,incl
installation of ccntrols regulated by
this code.
1MRSUSHTR Residential Install/Relocate ea M
suspended heate-,recessed wall htr, or
floor mounted unlit heater.
CITY OF CUPERTINO
FURNACE/AC
CITY OF
CUPEkTINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Grou
AIR FURN/AC
CONDITIONING
3 1BCAIRHAN Commercial A/C 1Jnits<= IOk CFM B
1 MCRAA Commercial Mech Repair/alt/add M
( 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
I TYPES
1BSEISMICO Seismic Commercial B
1 PGASCOM Commerical for ea gas piping System P
1-4 outlets
1 PGASRES Residential for ea;;as piping system P
of 1-4 Outlets
1BPGAS For each gas piping system of 5 or P
more per outlet. Comm/Resid
1 BREMAIRHAN Residential A/C units<= l Ok CFM B
1MRRAA Residential Mech Repair/alt/add M
1BCBSC Cal Bldg Standard;; Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1 EPERMITFEE Electric Permit E
1 MPERMITFEE Mechanical Permit M
1 PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel Documental ion B
1BUSLIC Business License B