09040070 ed
CITE'OF CUPERTINO PERM
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BUILDING.DIVISION PFii�lr111 � `�"
PERMIT NO.
BUILDING ADDRESS: 040070
890 SEPTEMBER DR JOHNSTON ELECTRICAL
PERMIT ISSUE DATE
OWNER'S NAME: CONTRACTOR
A 9 9 CONTROL NO.
)NE:
(408) 26E)-0236 BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
Q p zo LICENSED CONTRACTOR'S DECLARATION Job Description
U C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
m with Section 7 )of Division 3 of the Business and Profession3 fCodc.and my license is ELCT SV(; UPGRD TO 2 0 0 AMP
e y in full fort an efftx G
s12? License CI Contractor
Date
ARCHITECTS DECLA AT10N
I understand my plans shall be used as public records
�yU
L O y Licensed Professional
y 3 OWNER-BUILDER DECLARATION
1 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 or county
Pi which requires a permit to construct.alter,improve.demolish,or repair any structure Valuation
In prior to its issuance,also requires the applicant for such permit to rile a signed statement S Ft.Floor Area
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
Yts- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 1700
y that he is exempt therefrom and the basis for the alleged exemption.Any violation Of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars(s5W)• 36214013 . 00
❑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 Conuactors License Law docs 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.).
[:11,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Cont actnes 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 mason
❑I am exempt under Sec.
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn-
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 Worke s Compensation Insurance carrier and Policy number am--
Carrier. Policy No.: )
CERTIFICATE OF EXEMPTION FROM ORKERS'
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 for which this permit is issued,I shall not
employ any person in any manner so as te 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 Workcr's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
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 A Lender's Name
z Lender's Address
V C) re
I certify that 1 have ad this application and state that the above information is
L1.H correct.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
above-mentioned property for inspection purposes.
W to save,indemnify and keep harmless the City of Cupertino against
IL. (We)agree
liabilities,judgments,costs and expenses which may in any way accrue against said City C j
U z in consequence the grams of this permit. Date 1/
�+ APPLICANT NDER AND WILL COMPLY WITH ALL O OINT Issued b:i:
SOUR O S. 01
Re-roof:
Sign APP ontract ate T Of Roof
MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni' I 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.
❑Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or fu ure building occupant use equipment or devices which
.nit hazardous air contaminFNo
defined by the Bay Area Air Quality Management all newmaterials naterials for inspection.
District?
❑Yes
I have read the hazardous materials requirements under Chapter 6.95 of thc Califor-
Mwncrora
ty Cade, 'ons 25505,25533 and 25534.1 undcrstart at if building
y ha that it is my responsibility,to 'i pent of the Date
h t prior to issuance of aCcrlifica ,cyp 7/ Signature of Applicant
L( All roof coverings to be Class" "or better
xcd agent
Date •
/G y 0070
-aL CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN#� �/ �� O � Date:
Building Address:
Mailing Address (if different from building address):
Owner's Name: M ki-UL)L Phone#:
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA
Contractor: Phone: 40g� . S--
�►-fC_--.-
Fax:
Contractor License#: 3 45a(o(� /
Cupertino Business License#:
Contact: Phone: J
Fax:
Residential Commercial ❑
Job Description: t Le e-�l CAS SU:3�✓` C4�3 11)9
Building Permit Info:
Bldg ❑ Elect Plumb ElMech ElType of Construction (Usage Cl ss): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B `Z
Valuation: Square Footage:
1
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.builditg •een.or
Revised 02/05/09
CITY OF I--'.UPERTINO
CITY
TING GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1 GENCOM
1 STUCOAP Stucco A-)plications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Wir dow-structural shear B
wall/masonry (includes plan ck fee)
1 EPERMITFEE Electrica: Permit Fee E
r
1 MPERMITFEE Mechani(;al Permit Fee M
1 PPERMITFEE Plumbing;Permit Fee P
IELCPLNCK Stand Aline Electric Pln Ck (hourly) E
1MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-s-und alone
1BCBSC Cal Bldg; Standards Commission Fee B ALL PERMIT
/ TYPES
1 BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
/ ITRAVDOC Travel ��Documentation B
1 BUSLIC Busines 3 License B
5 of
Community Development
10300 Torre Avenue
a3'As Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
:UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
1?0'�O o-7 O
OWNER'S NAME: N I SaL u2lule PHONE # -
GENERAL CONTRACTOR: r- FAX # - � -
I am not using any subcontractors:
a e Date
Please check applicable subcontractors and com-:)lete 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/Contractor Signature Date