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CITY OF CUPERTINO
BUILDING DIVISION PERMIT �d1RA 'F(3II`INEfIA`FI�N*
BUILDING ADDRESS: PERMIT NO.
21979 SAN FE YR CONSTRUCTTON
OWNER'S NAME: PERMIT ISSUE DATE
PHONE- S A CONTROL NO.
L'7t D TR
408) 316-1261
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
400 LICENSED CONTRACTOR'S DECLARATION
art 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
t'y in full force and effect. DEMO FOR CONCESSION STAND WORK @BLACKBERRY FARM
j 2 2 License Class Lie.N
F❑ Dale Contractor
t' ARCHITECTS DECLARATION
I understand my plans shall be used as public records
)yU
14, Licensed Professional
1 0.4 OWNER-BUILDER DECLARATION
C I hereby affirm that 1 am exempt from the Contractor's License Law for the
❑opr following reason.(Section 7031.5,Business and Professions Code:Any city or county
<m li which requires a permit to cnnsuuct,alter,improve,demolish,or repair any structure
—rn prior to its issuance,also requires the applicant for such permit to role a signed statement
-z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
K ts- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
u W$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of8100
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(5500). P Y yp
❑1,as owner of the property,or my employees with wages as their sole compensation, 35710005 . 00
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 impmvemenl 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.).
G&r—as owner of the property,am exclusively contracting with licensed convenors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors la-
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 Contractors
License Law.
❑I am exempt under See. B&P C for this reason
OwneF�- Dale '� f
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dedaralioas:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Phis section need not be completed if the permit is forone hundred dollars($100)
or less)
1 certify that in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner so as to become subject to the Workers'Ca lien
Laws of California Datc
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 mast
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
-r�+ 1 hereby affirm that there is a construction lending agency for the performance of
pf > the work for which this permit is issued(Sec.3097,Civ.C.)
Wf� Q Lenders Name
]z Lenders Address
U Q 1 certify that I have read this application and state that the above information is -
Ly— 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
shove-mentioned property for inspection purposes.
OW (We)agree to save,indemnify and keep harmless the City of Cupertino against
oo rA liabilities,judgments,costs and expenses which may in any way accrue against said City
V rZ in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. � �f
Re-roofs
Signature of ApplicanvConuactor Date -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stow or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cadc,Section z5532(a)?
C3 Ya --ORO 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 Nu
1 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
does not currently have a tenant.that it is my responsibility to noufy the occupant of the
mqui cots which must be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
Owner or authorized agent Date' g
All roof coverings to be Class `r or better
�
CITY OF CUPERTINO
. . DEMO
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 ! 11
0 b OJ , k::) Date /a
Building
Building Address: - l
2-I n Ftway� �� �� � :
Mailing Address (if different from building address):
o �Do -Forre- A s e_
Owner's Name: Phone:
Ci u. r+i qo zA- )S- '7`7-7 - 3 Z I
Contracto : � � Phone : (P -/ZCo (
10-1q S ryV1ne ffe. �, re— SOI Fax:
Contractor License #: Sej G
Cupertino Business License #:
Contact: � L Phone:`loi- 0 2-r.:,
Fax:
Residential ❑ Sq Footage Commercial Sq Footage
Job Description:
r �Z�Y1�C�SSi �7Z;�n lir <<—
Valuation: o�
Project Size: Express Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFPOOL-DEM
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Residential B
Revised 01/07/09
,. CITY OF CUPERTINO
DEMO
CUPEkTINO ]PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMOCOM Demo-Commercial B 1COMML-DEM
1DEMOPCOM Pool Demo Commercial B 1CPOOL-DEM
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
1BSEISMICOM Seismic Commercial B
1BUSLIC Business License B
Revised 01/07/09