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11120009 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22845 POPLAR GROVE'SQ CONTRACTOR:THRASHER TERMITE& PLRMIT NO: 11120009 PEST CONTROL OWNER'S NAME: FARI-F-Y ROBERT P 17427 FARLEY RD W DATE ISSUER: 12/012011 O\ 'S PHONE: LOS GATOS,CA 95030 I'DONE NO:(408)3544944 LICENSED CONTRACTOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT I— PLUMB r License Class Lic.N `I ~ � n -` MECH C—i RESIDENTIAL r COMMERCIAL r Contractor I',��-�'w'N'9 Dale "rt��) DESCRIPTION: REMODEL SHOWER STALLS WILL INCLUDE 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 REP UPLACUMUNTP (commencing with Section 7000)of Division 3 of the Business&Professions SURI'I,OOR PLYWOOD,NO PLUMBING OR ULEC'I'RICA1.. Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 1 have and will maintain a certificate of consent to self-insure for Worker's Compensation,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 provided for by Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$6885 permit is issued. APPLICANTCF.RTIFICATION APN Number:34233016.00 Occupancy'Type: I certify that 1 have read this application and state that the above information is 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 above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT' ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source ula'ons per the Cupertino Municipal Code,Section 9.18. lQ-— 1 —1 ( Issued by, DOIe:, Signawr Date OWNER-BUILDER DF.CLARA'1'10\ Rb:ROOFS: I hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Data Business&Professions Code) Signature of Applicant: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sce.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE,CLASS"A"Olt BE ITER I hereby offirm under penalty of perjury one of the following three declarations: HAZARDOUS MATFRIAI,S DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California liealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain 1 have and will maintain Worker's Compensation Insurance,as provided Ibr by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the perlbrmance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Roy Area Air Quality,%bmagement District I twill 1 certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,alter making this certificate 01'exemption,I 0/9`9 utharizeJ n nt• become subject to the Worker's Compensation provisions of the Labor Code,1 mus[ Bate: or LZ�•- I �� forthwith comply with such provisions or this permit shall be deemed revoked. �11 G CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is I hereby affirm than there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances laid stale laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,mid hereby authorize representatives Of this city to enter Lender's Name upon the above mentioned properly for inspection purposes.(We)agree to save nify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the ming of this permit.Additionally,the applicant understands and will comply ARCI I1'I'FC'1"S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO • 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34233016 . 00 DATE ISSUED. . . . . . . : 12/01/2011 RECEIPT 4 . . . . . . . . . : BS000015456 REFERENCE ID # . . . : 11120009 SITE ADDRESS . . . . . : 22845 POPLAR GROVE SQ SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER FARLEY ROBERT P ADDRESS . . . . . . . . . . : 6206 WATERS AVE 4403 CITY/STATE/ZIP . . . : SAVANNAH, GA 31406 RECEIVED FROM . . . . : JANET L THRASHER CONTRACTOR . . . . . . . : THRASHER, JANET L LIC # 17769 COMPANY . . . . . . . . . . : THRASHER TERMITE & PEST CONTRO ADDRESS . . . . . . . . . . : 17427 FARLEY RD W CITY/STATE/ZIP . . . : LOS GATOS, CA 95030 TELEPHONE . . . . . . . . : (408) 354-9944 • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL . ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 6, 885 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 6, 885 . 00 0 . 69 0 . 00 0 . 69 0 . 00 1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 00 0 . 00 1STINSP UNITS 3 . 00 390 . 00 0 . 00 390 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 506 . 69 0 . 00 506 . 69 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 506 . 69 MC --------------- TOTAL RECEIPT 506 . 69 • CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 is CUPER IS:1 (408)777-3228•FAX(408)777-3333 •buildinq(a_)cuoertin0 ora ❑NEW CONSTRUCTIONJjV❑ ADDITION �TIOEF N/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# / PROJECTADDRESS 2L'� 'PQL#A-. GA.odu SQ CALIDI5"j/.A0 APPN p2[L7 7 3 O/ OWNER NAME -J.`V ar 'PHONE � '1q5-W90 E-MAIL (`/ STREET ADDRESS [� CrrY, STATE,IIP Q ,K F CONTACT NAME oZ Q r PHONE E-MAI. STEM ADDRESS CfrY.STATE, ZIP FAX ❑OWNER ❑ OWNER-RUILDER ❑ OWNERAGENT ❑ CONTRACTOR 13CONTAACTORAGE1T ❑ AEcRrrECT ❑ENGINEER( ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICEN NeB't)b� LICENSE TYPE BUS.IICp COMPANY NAME�1`�]ni � _ q�� E-MAILfM �JJ FAX STREETADDRESS �'$TA'F.I.P.... Gf�' '15b3 o PHONE T X1'1 t-V� 3sy 44 ARCHIIECr/ENOINEER NAME LICENSE NUMBER BUS.LIC p COMPANY NAME E-MAIL FAX STREET ADDRESS CITY.STATE,ZIP PHONE 17 DESL'RTPTfON OF WORK rV' � iiYA�G �` S�}gyy�L_. `� rt61,Y5 $�Yt_ . EXIS'T'ING USE PROPOSED USE CONSTR.TYPE 11TORIFS USE TYPE OCC. SQ.FT. VALUATION(S) EXMG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODELAREA REMODELAREA REMODEL AREA PORCHAREA DECKAREA TOTAL DECKIPORCHARRA I GARAGE AREA: DETACH ATTACH N DWELLING UNTM; ISASECONNDUNIT OYES SECOND STORY YES BEING ADDED? [:IND ADDITION? []NO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF ISTHEBLDGAN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNINGAPPL# []NO PLANNING APPROVAL(BITER EICHLEA ROME? 13 NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act m the prpperty owner's behalf I have read thisU application and the information 1 have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t b ; 'ng con . I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant(AgenC Date: /2-- t -11 SUPPLEMENTAL INFORMATION REQUIRED PIANCHECKTYPE ROUTING SLEP New SFD or Multifamily dwellings: Apply for demolition permit for ovnaerti&coamza L'1 Btm,DUVG PLAN AEvaw existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ =BESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PvnucwORKs Tom if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEFT Copy of Planning Approval Letter or Meeting with Planning prior to Cl MAroB ❑ 9ANrrARY sEwP.B DISTB[cr b=ttal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B/dgApp 1011.doc revised 0621/11 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION • ILI ADDRESS: 22845 poplar grove square DATE: I REVIEWED BY: bob s. APN: BPk: "VALUATION: $6,885 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration I Repair PRIMARY SFD Or Dulex PENTAMATION p /J �� USE: PERMIT TYPE: �o WORK I remodel shower stalls will include replacement of subfloor plywood. SCOPE tf eh. 111,1"Ch", I- .Pla rtr Plan Check Elec Plan Ckzck Weak Pernt6 Fue. FlunI& Permit Fee: £lac. Permit Fee: l9 diher ,clr.Insp. Oiler P1141,11)bsP. 011w) Ever. hrsp. d-fech.Ins).Pee: Plumb. lnq;.Neec Elec.Inw. Fee: NOTE: This estlmale does not Include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District etc. . These fees are based on the prefinina In ormatlon available and are onir an estimate. Contact the Dept for addn'l Info. FEE ITEMS fFec Resolution 11-053 EH 7/L1j FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: (F) Reg. O OT 0.0 1 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: Hourly Only? Q Yes O No $0.00 Suppl. Insp. Fee:Q Reg. Q OT O,p hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consouction nn Administrative Fee: Q Work Without Permit? O Yes (j) No $0.00 (D Advanced Planning Fee: $0.00 Select a Non-Residential 0 Travel Documentation Fees: Building or Structure 0 Strong Motion Fee: IBSE/Shi1CR $0.69 F-3-07 hrs Inspections • Blde Stds Commission Feel IBCBSC $1.00 $390.00 IST/NSP I Inspection,Hourly SUBTOTALS: $1.69 $390.001 TOTAL FEE: 1 $391.69 Revised: 10/01/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 DU P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Z2 �5 ��— SQ PERMIT# OWNER'S NAME: pqr PHONE# GENERAL CONTRACTOR:' tC�s A4,--A C Otc'r BUSINESS LICENSE # ADDRESS: l-; 'I . •jMr bhp-SCe CITY/ZIPCODE *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCON CTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: �D Signature Date Please check applicable subcontractors and complete the following information: 6/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE# Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum / Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date