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CITY OF CUPERTINO
BUILDING DIVISION PERMITS
PERMIT NO.
BUILDING ADDRESS:
10131 P R r0 T
PERMrr ISSUE DATE
OWNER'S NAME:
SA CONTROL NO.
`N :
BUILDING PERMrr INFO
ARCHITECrfENGINEER: BLDG ELECT PLUMB MECH
STUCCO REPAIR 0
u me C LICENSED COWMACTOR'S DECLARATION Job Description
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Coe.and my license is
CA in full force and eft (� '/v)
License Contracto
;t: Date
ARCHI11 =TECTS DECLARWHO
0i ri used I understand my plans shall be ed ss public mco
1� t
L O y Licensed Professional v
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
no following mason.(Section 7031.5,Business and Professions Cock:Any city or county
which requires a permit to construct,alter.improve.demolish,or repair any structure
13-14
prior to its issuance,sow requires the applicant for such permit to file a signed statement 3q.Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
YF (commencing with Section 7000)of Division 3 of the Business and Professions Cook)or
y that he is exempt therefrom and the basis for the alleged exemption Any violation o[ ApN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500).
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 oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactoes License Law dors not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
town 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 turner of the property,am exclusively contracting with licensed contractors to
constntct the project(Sec.7044,Business and Professions Code:)The Contractor's U-
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 See. B tit P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate or Consent to self-insure for Workers Compen-
,don,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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My WorkeesiCompeription I tance carrier and Polity, W1 ( a
Cartier Polity No.: �(p
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(chis section need not be completed it the permit is for one hundred dollars(f 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 is 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 Workers Compensation provisions of the Labor Code,you must
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(..d►N. I hereby allirm that there is a construction lending agency for the performance of
94> the work for which this permit is issued(Sec.3097,Civ.C.)
W ALenders Name
aZ Lenders Address
U C) I certify that I have read this application and state that the above information is
IL— 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
W (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
V"�� in of th of this permit. Date
►-+ PLIC E ANDS AND COMPLY WITH AL716169
N-POINT Issued b): �-D
SOU S. O S
Re-roofs
Si of Applicant/Comractor Dare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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)? 1[ All roofs shall be inspected prior to any roofing material being installed.
0Yes / o
If a roof .s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new r laterials for inspection.
.strict?
Cl Yes 1".No
1 have read the hazartous maacrials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cate,Sections 25505.25533 and 25534.1 understand that if the building
Xqu' L-swhj
mntl t,that it ism ponsibilily m notify the occupant of the
be met prior to i of a caf"of Occup Signature:of Applicant Date
All roof coverings to be Class'. orbetter
horized agent Da
NC,
A(
CITY OF ir-'UPERTINO
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
J APN# Date:
c�
Building j�dress:
Mailing Address (if different from building address):
Owner's Name: r _ L Phone#:
1T.a,1 �l�
HOA{ (Exterior work only) Ye ❑ No ❑
If yes, provide letter.from HOA
Contractor: Phone: -
®�,Gt Fax: �� — c5 3(Q U L4
Contrac r License
Cupertino Business License#:
Contact: �'� -��.Uy\ Phone: ,(-/
Fax: - - -(
Residential ( Commercial ❑
Job Description: (,t O �1P,Aa--,-,�
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type: 9 --3
1-A, 1-B ❑ II/IIIN-A ❑ II/III B, IV-HT, V-B ]
Valuation: �f 7 75- Square Footage:
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.buildit reen.or
Revised 02/05/09
CITY OF CUPERTINO
CUPET1� 3 GENERAL BUILD1ING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
i 1STUCOAP Stucco Applications (up to 400 so B
additional stucco application
1 WINREP Replacem,-nt windows/sliding glass B
door ea windows
1 WINMEWSTR New Window-structural shear B
wall/masc n includes plan ck fee
1EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
IELCPLNCK Stand Alone Electric Pin Ck(hourly) E
1MECPLNCK Stand Alone Mechanical Pin Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pin Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard flan Check(when no E/M/P) B
when not over counter) hourl -stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
IBSEISMICO Seismic Commercial B
1TRAVDOC Travel &])ocumentation B
1BUSLIC Business License B
of 5
"M ,1 71 vw�',�v M, in,
y A Y
Cupertino .Village
Parish Place
10202
0201
ci
10194
N .Na .� W 0
N N o a 10193 ..... . __. ..
-1 N
_�, '► W w way , a 10192
10121 10123Swimming Pool IUI04
� b
o
10182
< 101 10133
1017
10141 _'' o 0 0 10173
141 a3 cv w 10172
` w
1 Q1-Io 10143 _ 10171
_j
P6rish PIace 10164
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May 15,2009
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City of Cupertino Building Department j
10300 Torre Avenue
Cupertino,CA 95014-3202
Re: Building Permits for the Cupertino Village Homeowners Association
i
10101 - 10251 Parish Place, Cupertino, CA j
Authorization for Draeger Construction,Inc. to obtain Permits on our behalf
To Whom It May Concern:
The Board of Directors of the Cupertino Viliag-I Homeowners Association hereby authorizes
Draeger Construction,Inc.,605 Commercial Street,San Jose, Ca 95112,to obtain permits for
miscellaneous remedial repairs to be performe&in the common areas of our complex as
F
referenced above. I
Should you have any questions,please do not r esitate to contact me.
t
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Ve truly yours, i
Diana Johnson
Association Manager ���en+
Cupertino Village HOA
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