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CITY OF CUPERTINO �, �g
BUILDING DIVISION PERMq g�1� -TIO ;ANFOU '
BUILDING ADDRESS:
PERMIT NO.
01 VOSS AVE CITY OF CITREIRT-11IG— Q7010040
OWNER'S NAME: PERMIT ISSUE DATE
CITY OF CUPERTINO 22601 VOSS AVE 01/08/2007
PHONE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECTfENGiNEER; BLDG ELECT PLUMB MECH
Z
E-10 0 0
O o LICENSED CONTRACTOR'S DECLARATION Job Description
t U`l— I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=Z, with Section70(NI)ofDivision3oftheBusincssandProfessionsCode.andmylicenseis INTERIOR REMODEL-SNACK SHACK-CITY JOB
=y in full force and effect.
License Class Lic.#
E- Dale Contractor
'C _3 ARCHITECT-S DECLARATION
ym U 1 understand my plans shall be used as public records
4
3
LO y Licensed Professional
�y�
OWNER-BUILDER DECLARATION
a 2 1 hereby affirm that I am exempt from the Contractor's License Law for the
n O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
,t m Fri which requires a permit to construct,alter,improve,demolish,or repair any structure
4-r prior to its issuance,also requires the applicant for such permit to file a signed statement $ Ft.Floor Area Valuation
E s< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9 q $1500
Y F$ (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 MIG 0 0 0 0 0 APIJNumber Occupancy Type
not more than five hundred dollars($500).
❑1,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 forsalc(Sec.7044.Business ns Required Inspections
and Professions Code:The Contractor's License Law dors not apply to an owner of 9 P
property who builds or imprn:es 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.).
0 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-
ccnse 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
1 hereby affirm under penalty of perjury one of the following declarations:
0 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.
M 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. 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.Dale—
Applicant
NOTICE TO APPLICANT:If,after making this CCrtifil'are 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
M
E--r 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.)
W Q Lender's Namc .
z Lender's Address
U Q 1 certify that 1 have read this application and state that the above information is
Gt+ H correct.I 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 about-mentioned property for inspection purposes-
(We)agree to save,indemnify and keep harmless the City of Cupertino against
tF',y l/j liabilities,judgments,costs and expenses which may in any way accrue against said City (12
U Z in consequence of the granting of this permit.
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re roofs
Signature of ApplicanUContractor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupamstore or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safcty
Code,Section 25532(a)?
C]Yes ❑No 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?
C3 Yes 171 No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safely Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met poor to issuance of a certificate of Occupancy. Signature of Applicant Date
Owner or authorized agent Da1C All roof coverings to be Class"B"or better
1101TY OF CUPERTINO
�noF PERMIT APPLICATION FORM Q/C60
CUPEK rINO ��
APN# �r' 3 Date:
Building Address: Mailing Address (if different from building address):
�a(ool ss
Avr 1,6AASACKooq
Owner's Name: 4 /Y ci/ -7-J I (D Pho y#: - 1739-O
993 7w
Contractor: License #:
tq UJNJ5/? w1,,
Contact: Phone: Y4W- ?_W.0WrJ Cupertino Business License#:
M/uA,04. _Z/oR..r Fax:
Building Permit Info: 1�ORJX Qj.,rMP04_ OoV),Y
Bldg Elect Plumb ❑ Mech ❑
Job Description: REIM000L Or- )QS7/ ' S" N AcjC 454AC N
Residential ❑ Commercial
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
iv000 rn"g otis d second-story addition: ❑
Project Size: Standard Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
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 BUILDI]vG
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of 3
� OITY OF CUPERTINOO
CITY of
PER1VgIT APPLICATION FORD
CUPER�HNO
Quantity Fee ID Fee Description Fee Grou
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC' Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM " -New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Ins ection Overtime " BUILDING
13PBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bld `Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING,
BPGAS -Gas Piping System Fee' PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
:BPLANCKADD Plan Check Add Multi ' 'BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING '
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water.Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMIVIISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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