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CIT'1 OF CUPERTINO CONTRACVR I1V
BUILDING DIVISION PERIW
BUILDING ADDRESS: TOENI KOETTER & BREEDING I (EERMIT N0.4 0 9 010 3
0455 BANDLEY DR
OWNER'S NAME: PERMIT ISSUE DATE
CHINESE CHURCH IN CHRIST 1960 THE ALAMEDA #20 10/18/2004
PHONE: SANITARY NO. CONTROL NO.
(408) 246-3691
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
X F I hereby affirm(hat 1 am licensed under Qvisions of Chapter 9(commencing Job Description
2 Z w withr3ecr n 7000)of Division 3 of the Busin and Professions Code,and my license is
infuaxrrecand effect. REVISION--ELIMI . 2 EXT. DRS . @ 112/113
Zy? LicenseClassLie.# NO NEW PERMIT ISSUED/ ORIG. #04040178
a y p Date Contractor
ARCHITECT'S DECLAR ION
°y5 ee< Tunderstand my plans shall he used as public •nrds
�,U
yO H Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
X m which requires a permit to construct,alter,improve,demolish,or repair any structure
m—rn 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(Chapter 9 Sq.Ft.Floor Area Valuatio 3 2
FT-o (commencing with Section 7000)M Division 3 of the Business and Professions Code)or
a m 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 APN Number Occupancy Type
not more than five hundred dollars($500). 32633102 . 00
❑ I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is notintended or offered for sale(Sec.71344,Business ns Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of q p
property who builds or improves thereon,and who does such work himsclfor through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
nI,as owner of the property,am exclusively contracting with licensed contractors to
stmet the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of properly who builds or improves thereon,and
who contracts for such projects with a contracior(s)licensed pursuant to the Contractor's
License Law.
F11 am exempt under See. ,B&P C for this reason
ONer - % ('� \ Date Q<
\ 7` OYW RKER'S COMPE SATION DECLARATION "
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc: -
Ca [: Policy No.:
CERTIFICATE OF EXEMPTION FRGM WORKERS'
COMPENSATION INSANCE
(This section need nothe completed if(he permit is for one hundred dollars($I(X))
or less.)
I certify that in the.performanee 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 Workcrs'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 Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
r
1 hereby affirm that there is a construction lending agency for the performance of
li the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
ZCL� Lender's Address
U O 1 certify that I have read this application and state that the above information is
" F"� correct.1 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
W ahovc-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against -�
fA 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: Dat
SOURCE REGULATIONS.�
' �� � ., �— ��f-�i��'d� Re-roofs �.
_,�i naty of A plicanUContractor Date ,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ur 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)?El 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 Arca Air Quality Management all new materials for inspection.
District?
❑Yes
1 have read the hazardous materials requi mments 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 nosily the occupant of the
requirements which mus�mct o )issuance of a certificate of Occupancy. Signature of Applicant Date
caner u orixcdagcnt F e All roof coverings to be Class "B" or better
� _� *CITY OF CUPERTINO*
C! of PERMIT APPLICATION FO
CUPERTINO 6q U q
APN# -3 Z/ Date: �
Building Address i,/Q �- � Mailing Address (if different from building address):
Owner's Name: Phone#:
Contractor: � � License#:
Cont , Phone: Cupertino Business License#:
I/r Fax: � 7J
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Me h ❑
Job Description: C/�//f -7X411) ! WS� ?
Residential El � ►MT , N G -mmerc1'al
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: check this box if the brojecit is a
r` sec n -stor addition: ❑
Project Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILER1 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
BELEC 1000 Elec 600V<= l OOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
4 -2�70
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