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09050127CITY OF CUPEKIT BUILDING DIVISION BUILDING ADDRESS: OWNER'S NAME: ARCHPrEcT/ENGINEER: PERMIT that I am licensed under provisions of Chaptcr 9 (commencing I hereby afl�i� with Section 7000) of Division 3 of the Business and ons y license is in full form and ef[ License Class Lic.tf Dam Contractor AR HITECL'S DECLAR 1 N I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following mason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct. alter. improve, demolish, or repair any structum prior to its issuance, also requires the applicant for such permit to rile a signed statement that 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 Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars ($500). ❑ I, as owner of the property, or my employers with wages as their sole compensation, will do the work. and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If. however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ 1, as owner of the property. am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li. cense Law does not apply to an owner of property who builds or improves thereon, and, who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec. B R P C for this mason 00 Z Cl. A ]z UO W. E. OU rF.t !n U Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self-lasore for Workers Compen- _ron, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Wos Co ens ssu nce carrier and Polity u Carrier. Policy No.: CERTIFICATE M EXEMPTION FROM W ERS' COMPENSATION INSURANCE (This section reed not he completed if the permit is for one hundred dollars ($ 100) or Icss) 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 Libor Code, you must forthwith comply with such provisions or this permit shall be deemed mvokcd. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name L.cndees Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorise representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City uence4f the granting of this permit. soot r s 109ERSI'ANDS AND WILL COMPLY WITH ALLi NAZI -POINT e -- ~ r` - HpZARpIv1ATERIALS DISCLOSURE ' 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). ❑ Yes Will the appli uture ng Occupant use equipment or devices which hazardous air contaminants as defined by the Bay Ama Air Quality Management Act? [3 Yes 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- SafctyCodc, Sections 25505 ,25533 and 25534.1 understand t�ng docs of sly have a tenant that it is my responsibility to no oa t of the m w mcnts a met or to iasnancc o[ a Cenif Owner dt authorized Date 594— POOL DEMO & FILL 3q. Ft. Floor APN N 36909012.00 Issued by Re -roofs Type of Roof Job Description Valuation Occupancy Type Required Inspections All roofs shall be inspected prior to any roofing material being installed. If a roof .s installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature: of Applicant All roof coverings to be Class'}.`` or better Date PERMrr NO. r nor. PERMIT ISSUE DATE S p CONTROL NO. BUILDING PERMIT INFO BLDG� ELECT� PLUMB� — Job Description Valuation Occupancy Type Required Inspections All roofs shall be inspected prior to any roofing material being installed. If a roof .s installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature: of Applicant All roof coverings to be Class'}.`` or better Date s CITY Of CUPEkTINO CITY OF CUPERTINO DEMO PERMIT APP]�ICATION FORM o q0: �--;) o t,) -i APN# Fee ID Date: L Building Address: I �0K� Permit Type Mailing Address (if different from building address): 1DEMORES Owner's �//� / Contractor: ,Phone: ro 1DEMOPRES q09--Vjr1q —�CL%Cf cf )t 1SFPOOL-DEM Fax: L40Y--) I — 1 Contractor License #: ��l 7 (TU'- 1 Cupertino Business License #: ALL PERMIT TYPES Contact: 4)-) Il'U 1 1BSEISMICRE Phone: KI Fax: k'7)� - Jft 9 Residentia Sq Footage Commercial ❑ Sq Footage Job Description: Too 0 L Valuation: �Q Project Size: Express ❑ Standard Large ❑ Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee D escription Fee Group Permit Type 1DEMORES Demo -Residential B 1SFDWL-DEM 1DEMOPRES Pool Demo Residential B 1SFPOOL-DEM / 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Buildin De artment JOB ADDRESS: 0 C4 PERMIT # /I OWNER'S NAME: Signature Date 4-1,o 4:f%11r%'TwTinor lnfnrmatinn' 1'led5C Llttn1t Q ta.cauic 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