09060092 CITY OF CUPERTINO � � > � ;
BUILDING DINUSION MI
PERT
PERMIT NO.
BUILDING ADDRESS:
20077 JOHN DR DELTA ELECTRIC pERMTTLSSUEDATE
OWNER'S NAME: '
S A CONTROL NO.
INE:
(408) 224-0176
BUILDING PERMIT INFO
ARCHrfECt7ENGINEER: BLDG ELECT PLUMB MECH
Z O p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm
V that I am licensed under provisions of Chapter 9(commencing
wilhSccdon70110)ofDivision3ofthcBusincssandProonsC ,a"dm� mylicense
SVC UPGFD, SUB PANEL & A/C CIRCT 200AMP
e y in full force and eff �'L
? License Class r, Contractor y
t-p Date
ARCHITECTS DECLARATION
nS� I understand my plans shall be used as public records
�yU
u.in Licensed Professional
"ISI
OWNER-BUILDER DECLARATION
"I 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p oS following reason.(Section 7031.5,Business and Professions Code.Any city or county
K$ which requires a permit to context.alter.improve,
demolish,t fi repair any structure Valuation
Al"W prior Io its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area
Z< that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 `q 2 590
YF=- (commencing with Section 7(100)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption Any violation oC Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number p y yp
not more than five hundred dollars((500} 3693305'- . 00
0 1.as owner of the property,or my employees with wages as their sole compensation,
will do the work and he suwture 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 sale.U.
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
concoct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Taw 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 I 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 Car Worker's Compen-
,ation,as 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 Worf�Compensation Insurance carrier and Polirynumber am: oOq 4��
Policy
CartierCERTIFICA OF FJLEMPT[ON 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 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
N077CE 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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
E~-e Cl)
— I hereby affirm that there is a construction lending agency for the performance of
1:4> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0.,Z Lender's Address
V 0 I certify that I 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
building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
�'CL (We)agree to save,indemnify and keep harmless the City o[Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in cons=!2
of this permit Date
►-e APPLS AND WI COMPLY WITH ALL NON-POINT Issued b)
SOUR
Re-roofs
Signaltor Data T e of Roof
OUS MA ALS DISCLOSURE YP
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.
C3 Yes IQ No 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
t hazardous air contaminants as defined by the Bay Area Air Quality Management all new r nate 'als for inspection
strict? I
❑Yes
1 have mad hazard—materials requirements under Chapter 6.95 of the Califor-
nia Health&Safc Secdow 25505,25533 and 25534.1 understand that if the building
does not curten y ve a tenant,that it's my responsibility to notify the occupant of the —7 icon Date
Occupancy-
requirements must be mel prior issuantce oC a Ccrtificatc of Occupancy. Signatur
All roof coverings to be Class or better
Date
Owner utho d agent
c-,
Min
tT CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # (,)Z Date: I S q
Building Address:
�.o o-7 -7 3--6 �A rJ D iZ
Mailing Address (if different from building address):
Owner's Name: ,P\--e.,>l ►AN D c v' Phone#: 612- --_ G-/
HOA: (Exterior work only) Yes ❑ No
If yes, provide letter from HOA
Contractor: Phone: 2 9,4 - 0 ( 7 Co
1—,)-e- L� E., LeC- Fax: 22`I— 30
Contractor License#: G.-- 10'j Z 9 g 7 2
Cupertino Business License#: Q 71
Contact: Phone:
Fax:
Residentiall2i Commercial ❑ ,-
1-5:�toN
Job Description: 5
2v'Vtc � �rV'V"dC
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
I-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B 1---
Valuation: Square Footage:
Z
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.builditj•een.or
Revised 02/05/09
_ I
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEi�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Des,-.ription Fee Permit Type
Group 1GENRES or
1 GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/mas:)nry(includes plan ck fee)
IEPERMITFEE Electrica. Permit Fee E
1 MPERMITFEE Mechani,;al Pen-nit Fee M
I PPERMITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand AlDne Electric Pln Ck (hourly) E
1MECPLNCK Stand AlDne Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand AlDne Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-sl and alone
! 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &:Documentation B
1BUSLIC Busines, License B
5 of 5
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
'%PEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: xAN,0 -e PHONE # Z2 t
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Si Date
Please check applicable subcontractors and com le e following information:
SUBCONTRACTOR BUSI14ESS NAME BUSINESS LICENSE #
Cabinets &Millwork -� _4-A 'C C- 7—
Cement
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
er/ on ctor Signature Date