09050003 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT � I �
PERMIT NO.
BUILDING ADDRESS:
10056 ORANGE AVE MARCI PROPERTIES LLC 09050001
PERMIT ISSUE DATE
OWNER'S NAME:
MARCT ARfIDFRTTWQ T 0 SAgt� CONTROL NO.
.ANE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
TEMPORi�RY POWER POLE
Q p p LICENSED CONTRACTOR'S DECLARATION Job Description
VI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
<�y in full force and effect
v�Z License Class Lic.N
n E- Dam Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�yU
oy Licensed Professional
H OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K Ml which requires a permit to construct,alter,improve,demolish,or mpair any structure
rw prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
z< that he is licensed pursuant to the provisions of die Contractor's License Law(Chapter 9 3q.Ft.Floor Area
xH (commencing with Section 7000)of Division 3 of die Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars($50o).
0 I,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
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 sate.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
as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors La-
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.
0 lam e3�p ander Sea B&P C for this reason
Owner- AQ AA Date
OR Fits COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 i have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
satian,u provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 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 Workees 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 the work or which this permit is issued,I shall not
employ any person in any man to be o bject to the Workers'Compensation
Laws of Calif a
Applicant
NOTICE TOA EAft It.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Coda you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of -
fx.� the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
2 Lender's Address
V 0 I certify that 1 have read this application and state that the above information is
LL correct I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
rFy to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit Date � r
�+ APPLICANT UND STANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: G
SOURCE REGI) /
" G' 5'' 1-y 5 Re-roofs -
Signature of Applicant/Contractor D8e T of Loof
HAZARDOUS MATERIALS DISCLOSURE Type
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 roofs shall be inspected prior to any roofing material being installed.
0 Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof s installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes Nu
I 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
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requi ld It must et prior to issuance of a Certificate of Occupancy. S ignaturc of Applicant Date
1 _ of` All roof coverings to be Classor better
Owner o a6thorized agent Date-
Community Development
10300 Torre Avenue
{ Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
XPEkTINO
Building Department
JOB ADDRESS: PERMIT #
C{�Sov 6o
3
OWNER'S NAME:M t C - PHONE #_ 4- 77-? ~ 7'Z C)
GENERAL CONTRACTOR: ed- FAX # - - �-- 7 Z 1
I am not using any subcontractors: L,-,314 5 - l _ 013
Si;nature Date
Please check applicable subcontractors and complete the following information:
60 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
CITY OF CUPERTINO
TEMP' POWER
CUPEkTINO PERMIT APPLICATION FORM
ODDS`ObC)
APN # Date:
3 7 -7 0 5�-,00 S — v
Building Address:
DO�'-L D, Atj�
Owner's Name: Phone #:
Nr e L- c_ ZIA 7 7 7 z v
Contractor: Phone #:
,/V D Fax #:
Contact: Phone #:
Contractor License #:
Cupertino Business License#:
Job Description:
�Ot,-jc-ff-- JCC
C-.,�—
Residential Commercial
Valuation (cost of project): Type of Constructio . N/A
Quantity Fee ID Fee Descripti:)n Fee Group Permit Type
IERT>1K Res. Temp Power>1K E 1REAP14
Amps
1 ERT<200 Res. Temp Power<200 E
Amps
1 ERT2001 K Res. Temp Power 200-1 K E
Amps
f 1 EPERMITFE Electric Permit Issuance E
I ELCPLNCK Electric Plan check E
1BCBSC Cal Bldg Standards B ALL PERMIT _
Commission Fee TYPES
/ 1BSEISMICR Seismic ResiCential B
1TRAVDOC Travel & Documentation B
Fee
Revised 01/07/09