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CITY OF CUPERTINO
BUILDING DIVISION PERMIT co r �T® INFOR A.T.
BUILDING ADDRESS: TOENISKOETTER & BREEDING IJrRMITNc04040178
10455 BANDLEY DR
OWNER'S NAME: PERMIT ISSUE DATE
CHINESE CHURCH IN CHRIST 1960 THE ALAMEDA #20 06/15/2004
I PHONE: SANITARY NO. CONTROL NO.
(4 08) 246-3691
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
II o a 0
o p LICENSED CONTRACTOR'S DECLARATION
X V I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
U, with Section 7000)of Division 3 of the Business and Professions Code,and my license is
Z y in full force and cfject. (i(�y�1^ a , TI--CHURCH
j 2 License Class /- -Lic.N I
nt—iz Date Contractor
LU ARCHITECT-S DECLARATION
I understand my plans shall be used as public records
o u,
{ y Licensed Professional
h OWNER-BUILDER DECLARATION
I hereby allirm that I am exempt from the Contractor's License Law for the
0 O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
x-0which requires a permit to construct,alter,improve,demolish,or repair any structure $690000
FZ} prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9 Sq.Ft.Floor Area Valuation
is (commencing with Section 7000)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 of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($5170), C Occupancy Type
❑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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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. ,
❑I am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workcr'sCompen-
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 Worker's Compensation Insurance carrier and Policy number are:
�( Carrier. If-
s�'G 2-P4;&►'1'I 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 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 Ccnificate 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 O CONSTRUCTION LENDING AGENCY
E-+ I hereby affirm that there is a construction lending agency for the performance of
f 4> the work for which this permit is issued(Sec.3097,Civ.C.)
W 0 Lender's Name
]z Lender's Address
U Q 1 cenify that I have read this application and state that the above information is
U. correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r/7 liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit.
—+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU TIONS
� � Re-roofs
r Sign re Applicant/Comractor Date
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
Cole,Section 25532(a)?
r-1 Yes ❑Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
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
docs not currently have a tenant,that it is my responsibility to noury the occupant of the
requirements which must be met ' to issuance of a Certificate of Occupancy. Signature of Applicant Date
�ent Date All roof coverings to be Class "B"or better
Owner o authonzed agent - Datc
CITY OF CUPERTINO
CITY OF
CUPEf�I"INO PERMIT APPLICATION FORM
APN#.326 3 3 / u 2— Date: /1- zb
D d
Building Address: / J% &41yMailing Address (if different from building address):
Owner's Name: Phone#:` ,�O y ��
W a
Contractor: License#:
Contact: J� Phone: 9V%4'7//
Cupertino Business License#:
Fax:
Building Permit Info:
Bldg Elect Plumb ech
Job Description: J f
Residential ❑ ommercial
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: �� Occupancy Group: 14
Type of Construction: Plea a check this box sect is a
addition: ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permit sq. foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax–Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
1 of 3
wy Community Development
r 10300 Torre Avenue
Cupertino CA 95014
1J.
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
is Building Department
JOB ADDRESS: PERMIT #
oys(s 411 oyayD� 7�
OWNER'S NAME: PHONE # 2 yG
GENERAL CONTRACTOR: 6q&tj
n FAX#
I am not using any subcontractors:
CD1�(P
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting rf,[ 11,11Aer vZ�
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing C► � ljQ
Septic Tank
Sheet Metal
Sheet.Rock /��ous�;Go2
Tile
ay
O�vner/ Signature Date