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12030036 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11143 WILKINSON AVE CON IRACI'OR:WE]JOHN S AND WEN- PERMIT NO: 12030036 LING OWNER'S NAME: WEI JOHN S AND WEN-LING 11143 WILKINSON AVE DATE ISSUED:03/082012 OWNER'S PHONE: 4082578948 CUPERTINO,CA 950144734 PIIONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION AOR DESCRIPTION: RESIDI,NFIAL COMMERCIAL License Class Lie.9 REPAIR THE STUCCO AT THE EXISTING CHIMNEY. REMOVE Contractor Date AND REPLACE EXISTING 322SQFT TRELLIS- Lhereby affirm that I am licensed under the provisions of Chapter 8/30- REMOVE EXISTING CHIMNEY AND FIREPLACE AND (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following Ivo declarations: 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 performance of the work for which this permit is issued. Sq.FI Floor Area: Valuation:$3000 1 have mid 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 APN Number:35617042.00 Occupaney'rype: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances mid state Imus relating WITHIN t80 DAYS OF PERMIT ISSUANCE OR to building consruction,and hereby aphorize representatives of this city to emer upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, ? costs,and expenses which may accnm against said City in consequence of the Date: (/ 'JO�� r granting of this permit. Additionally,the applicant understands and will comply Issued by: v ' L—, with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RF:ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that 1 am exempt from the Contractor's License haw fur one of the following Iva reasons: ALI,ROOF COVF,RINGS TO BE CLASS"A"OR BE'1-rER 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&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to IIAZARDOUS JIATERIAIS DISCLOSURE construct the project(Sce.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury nne of the following three maintain compliance with the Cupertino pl unicipal Code.Chapter 9.12 and the declarations: Ilealth&Safety Code,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections'_ 505,25533, nJ 25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized Date: 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 Worker's Compensation laws of California. If,after making this cer i0cae of exemption,1 C0NS'rRUcr1ON LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANTCERTI FICATION Lender's Address I certify that I have read this application and state that the above information is correct.1 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 ARCII ITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against I iabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. grinding of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date �� Z CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION nmx 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 LO GUPERTINO (408) 777-3228• FAX (408) 777-3333• buildine(a)cuoertino.oro �J ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT N �O U3/JG3� PROJECT ADDRESS/ -� % A �� j APNN t OWNERNAME I ,1 I n i PHON� _ 44 (i E-MAIL07 Q S ET A D S V V JC CITY STATE, i v ZIP u .P CTI CONTACT NAA1E PHON E-AJAIL STREETADDRESS CITY•STATE, ZIP FAX OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONIRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPERS ❑ TENANT CONTRACTOR NAME .d W�kA LICENSE NUMBER LICENSE TYPE BUS.LIC a Vz COMPANYNAME E-MAIL FAX z STREET ADDRESS U CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC A COMPANY NAME E-MAIL FAX STREETADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK 1/l /�/' �, / 7/C li iJ J/✓E g 7G IAI EXISTING USE PROPOSEI?,IJSE CONSTR.TYPE 4STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EAISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA RFI.IODEL AREA REAIODELAREA PORCHAREA DECKAREA TOTALDECWORCH AREA GARAGEMEA: DETACH E]ATTACH NDWELLING UNITS: IS A SECOND UNIT ❑YES SECONDSrORY DYES I BEINGADDED! []NO ADDITION' ANO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF ISTIIEBLDGAN ❑ITS 'RECEIVED BY .; +C"�'r"'w.? TOTAL TI0' PLANNINGAPPLN LINO PLANNING APPROVAL LETTER EICHLERIIO+IE' NO ,i j ;'_^!-, ' By my signature below,I certiN,to each of the following: 1 am the property,owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws rel?\tingtobuilding c 'nSWct`i. nn. In representatives of Cupertino to enter.the(above-identified property for inspection purposes. Signature of Appl.......gna: Date: SUPPLEn1ENTAL�INF0111%1ATI0N REQUIRED .^'�:'x it K Y P"�` _New SFD or Multifamily dwellings: Apply for demolition permit for � Y -\r- ua r -2- Iy"O\'ER-ril4COU\TFH I t y "'RUILDI\C i LA.\RF\IFwy^.4a existing building(s). Demolition permit is required prior to issuance of building I/ I s ��aarP permit for new building. OI T V Riss 'kms"- l � ❑�i LA\\r\CPu\RF\11:N c , "g.'sn ;—I t�+ 4> A4 _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure © sTA\mnuDf. � ,y Ells/uuuc\\oahs)< `. s: form if any Ilazardous Materials are being used as part of this project \❑II \RCG"3 Yrly < a" Q!FIRE _Copy of Planning Approval Letter or Meeting With Planning prior to r❑a\fAJOR�r \ E."' ❑ submittal of Building Permit application. I ss- ,e w'�" N` - � . SA\IIARISENER DISTRICT L© F\\IRONYfE\TALHF.AI.THii,_1 0 B(dgApp_1O1l.doc revised 06121/11 `l 7 w ti -c d O O O O < a A ❑ O n• N � � (n X n. Oi Cn XX n o m 0 • CD "4 rn T. n i W CD CD 0 0 ~ O J - r3 O N m mc 1 o n Cl) m Cyt O z c M2 c° c 1 C7 N a C s 0M r 'a m m Z ao iao3�o3� CD -- , _-_- J •J �1 •J �1 J� O cL CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11143 WILKINSON AVE CONTRACTOR:WEI JOHN S AND WEN- PERMIT NO: 12030036 LING OWNER'S NAME: WEIJOHN S AND WEN-LING It(43 WILKINSON AVE DATE ISSUED:03/082012 OWNER'S PHONE: 4082578948 CUPERT'INO.CA 950144733 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT I- PLUMB r License Class Lic.q tr1ECH r RESIDENTIAL r COMIh1ERCIAL r Contractor Dale 1 hereby affirm that 1 am licensed ander the provisions of Chapter JOB DESCRIPTION:REPAIR THE STUCCO AT THE EXISTING CHIMNEY. (cornniencing with Section 70011)of Division 3 of the Business&Professions REMOVE Code and that my license is fn full force and effect. AND REPLACE EXISTING 322SQFT TRELLIS 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain certificate of consent to self-insure for Worker's Compensation;as provided for by Section 3700 of the Labor Code.for the perfor ince of the work for which this permit is issued. I have and will maintain Worker's Cnntpensation Insurance,as provided for by Section 3700 of(he Labor Code,for the lerformahce of the work for which this Sq.Ft Floor Area: Valuation:$3000 Permit is issued. APPLICANT CERTIFICATION APN Number:35617042.00 Occupancy Type: I certify that I have read this application mid state that(he above infommtion is correct.I agree in comply with all city and county ordinances mid state laws relating to building construction,and hereby audnorize representatives of this city to enter upon the above mentioned property lir inspection purposes. (We)agree to save PERMIT EMPIRES [F 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 tile WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,(he applicant understands mid will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code.Section 9.18. Signature Date Issued by: �E Ily NfITGtf Date: 3-9-/p;7 ❑ OWNER-BUILDER DFCLARATION RF.-ROOFS: 1 hereby affirm that I ani exempt from the Contractor's License Law for one of All roofs shill be inspected prior to any roofing material beiig installed If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do(he work,mid(he structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1 hereby affirm raider penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERLV S DISCLOSURE Compensation,as provided for by Section 3700 of the LNior Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of(lie performance of the work for which this pemmi(is issued. California Health&Safety Code.Sections 25505.25533,and 25534. 1 will maintain I have and will maintain Worker's Cmnpenso(ion Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health& Section 3700 of the Labor Code,for(lie perfommnce of die work for which(Itis Safety Code.Section 25532(a)should 1 store m'handle hazrrdous material. Additionally,should 1 use equipment or devices which call(hazardous air permit is issued. coulanrinnnts as defined by the Bay Arco Air Quality Managentent District 1 will I certify(hat in the performance of the work for which this permit is issued,I shill maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ nay person in any manner so as to Ieaxne subject to the Worker's Health&Safety Code,Sections 25505.25533,and 25534. Compensation laws of Califomia. If,atter making this certificate of exemption,I 3 become subject to the Worker's Compensation provisions of(he Labor Code,I m �uss wn ora Ihori antr torthwith comply with such provisions or this permit shall he deemed revoked. - Date: `-' Z APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCI` I certifi•that I have read(his application and slate that the above infornation is I hereby affirm that there is a construction lending agency for the performance of%work's correct.I agree to comply with all city alt county ordinances and state laws relating for which this permit is issued(Sec.3097,Cir C.) (o building construction,and hereby authorize representatives of this city to enter Lender's Name upon(he above mentioned properly for inspection purposes.(We)agree to save indet niN and keep harmless the City of Cupenino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of(his permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all nom-point source regulations per the Cupertino Municipal Code,Section 4.18. o� 1 understand my plans shall he used as public records. Signature Date o 2/ Licensed Professional City of Cupertino n o v � 'A 1 Basemap Labels y� - • T� ` r!!. .'� Abc Street Names Secondary Address Labels Primary Address Labels Freeway t, 1 . 9 . . I 9 Basemap •, �' f 01. ' a Street Centerline County Major Roads «, , County Freeways •n2� � ^j - ��Y . Right of-Way ;J¢t Community Development ❑O City Boundary ® Aerials April 2011 r iia �� �k --t �,,•f. ��''��Sj V Ug •- rry F4 I -. J -.y r-... r 'C O C FO, p+0 O CC N S A 1003 EF �$ 5z _ gra 0a cZio /\ 0 0 dao o a o% 95 Ogm 'D z ✓J p4gH O ' O z� a.0 , 3 N u 5 M 2� r I � giA. g mm £mKvD1 S s:.n� �VS � e P, a 0 g 0 D m � aF P DE 30 ` I s � fno K S - tAIaA—e a.... AA,a, m onto in-AA e -` COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION-CUPERTINO Chimney Stucco Exterior Work APPROVED This set of plans and specifications MUST be kept at the 1 1 143 Wilkinson Ave, Cupertino lob site during construction. It is unlawful to make any changes or alterations on same,or to deviate therefrom,without approval from the Building Official. —♦ The stamoIng of this pian and specifications SHALL NOT l2„ be h I pamit or to be an approval of the violation S.S. vent and cover f ovisions of any City Ordinance or State Law. By Proposed stucco exterior DATE section with plywood frame 56" PERMIT No . and S.S. vent y ,Y Roof line 10' s" 72„ -- - - -- ---- MAR 0 7 2012 Pre-existing BY:____--- � brick & mortar 24+• 78" CU . . . . . . . . . F KC E rp 61" \ 27" \ COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION-CUPERTINO APPROVED nece kept at the Exact Replacement of Patio Woa''° S , ; `:ctioi. ItissMUSTbomakeany itc+dl r. � S-ction. It is unlawful to make any changes or alterations on same, or to deviate (Bird's Eye View ) therefrom, without approval from the Building Official. Back wall of The stamping of this plan and specifications SHALL NOT house 1 1 143 Wilkinson Ave, Cupertino be held to permit or to be an approval of the violation of any provisions of any City Ordinance or State Law. 23' 4" BY DATE _ .. • _ - tc, mii Nil. Horizontal beam. -- - 2x8 Trellis 2x } @ 6" 'spacing Trellis 2x6 14'•• @ 18" spacing Horizontal beam_' 4x8 • i. _ is ' I Concrete pre- existing base MAR 0 7 2012 / I0'81, �� Posts 4x4 718" Y All wood material: Redwood OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE"CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333- buildinaOCUoertino.ora Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADD ESS APN Z BP# 6- —U OWNER NAME S),i SLcti j,,,lej. Q-c.ct� OWNER ADDRESS DESCRIPTIO OF WORK: S i i We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities,and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) _1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as,an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her, employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for he construction and are not hiring a licensed Contractor to assume this responsibility. 3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. %�) 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license Wumbers on permits and contract's. 05. 1 understand if l employ or otherwise engage any persons, other than California licensed Contractors, and the value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. le6. I understand if l am considered an"employer" under state and federal law, I must register with the state and deral government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. *residential 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family DDD residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. )a}1�8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for ny financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 It 9. I understand I may obtain more information regarding my obligations as,an "employer"from the Internal venue Service, the United States Small Business Administration, the California Department of Benefit-Payments, and the California Division of Industrial Accidents. 1 also understand I may contact the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. 410. 1 am aware of and consent to an Owner-Builder building permit applied for in my;,name, and understand that I t_he parry legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide y all applicable laws and requirements that govern Owner-Builders as well as employers. 12. 1 agree to notify the issuer of this.form immediately of any additions, deletions, or changes to any of the iriformation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract.with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible,for verifying whether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following,construction lending agency information.) 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.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A'copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the roeowner's s' ature. Property Owner's Signature: Date: ------- - - -- ---- - - - ---------------- --------------------- ------------------------ -- -- ------------- --------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OH,nerBuilderForm 2010.doc revised 04/14/10 CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35617042 .00 DATE ISSUED. . . . . . . : 03/08/2012 RECEIPT #. . . . . . . . . : BS000016218 REFERENCE ID # . . . : 12030036 SITE ADDRESS . . . . . : 11143 WILKINSON AVE SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : WEI JOHN S AND WEN-LING ADDRESS . . . . . . . . . . : 11143 WILKINSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4734 RECEIVED FROM . . . . : JOHN WEI CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : WEI JOHN S AND WEN-LING ADDRESS . . . . . . . . . . : 11143 WILKINSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4734 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 .00 41.00 0. 00 41 .00 0 .00 IAWNATTBLD EACH 1 .00 327 .00 0. 00 327 .00 0 .00 1BCBSC VALUATION 3, 000 . 00 1 .00 0. 00 1 .00 0 .00 1BSEISMICR VALUATION 3, 000 . 00 0 . 50 0 .00 0 .50 0 . 00 ---------- ---------- ---------- --- TOTAL PERMIT 369 . 50 0 .00 369 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 369. 50 #2861 --------------- TOTAL RECEIPT 369.50 I SUBTOTALS: $1.50 $368.001 TOTAL FEE: 1 $369.50 Revised: 1/19/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE,AVENUE • CUPERTINO, CA 950143255 CUPERTINO (408)777-3228• FAX(408)777.3333 • building(pcupertino-ora ❑NEW CONSTRUCRON ❑ ADDITION & ArTERATIONITI ❑ REVISION/DEFERRED ORIGINAL PERI a7 k PROTECT ADDRESS-St++ np_ OWNER NAME lJO)t It ��t Su YI we-7 a^'/"il PHONE -ZS �� - 71 Q 1QQr CO STREET ADD cn-YZArE ZIP �l HU S U FAX i V t� CONTACT NAME PHONE E-MAIL n^ -(t _ _ Yl C 7/, �!J STRHETADDRESS CITY,STATE IIP r/' FAX ❑OWNER ❑ OWNER-BUILCLR ❑ OWNERAGENT ❑ CCNTRACroR ❑CONTRACTORAmM ❑ ARCHTTECr ❑BNGIN'EER ❑ DEVELOPER ❑ TL+JANT CONTRAROR NAME / LICENSE NUMBER LICENSE TYPE BUS.LICA COMPMEANY NAE-MAR FAX STREET ADDRESS CrrY,STATE Z27 PHONE ARCHIlECIENOWEER NAME ^ I LICENSE NUMBER I Bus.LIC# COA ANY NAME f1 E-MAIL FAX STREET ADDRESS LTrY,STATE ZIP PHONE DFSCR71 ON OF WORK TUCt d �ci^�qi�z r/n/ �i n/ ylit/E� ��c✓c ErUS OUSE PROPOSED USE CONSTRTYPE aSTORffS 9 .3 t/y'j USE TYPE OCC. SQ.F r. VALUATION(S) KIISTG NEW FLOOR DEMO v 'l TOTAL ^� AREA AREA AREA NET.AREA BATHROOM KITCMzV OTHER V REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGEAREA: DETACH a A ACH 9 DWFL,DrG UNITS: LSA SECOND UNIT U YPS SECONDSTORY LJ YES BELYGA➢DED? ONO ADDITION? []NO PRE-APPLICATION ❑YES G YES.PROVIDE COPY OF I IS THE eLDC AN ❑YES CHLERREC-E DBY; TOTAL VALUATION: PLANNINGAPPLO ONO PLANNINGAPPROVALLEfrER E/ HOME? ONO _ G U!/ By my signature below,I certify to each of the following: I am the property owner or authorized agent to act an the prpperty owner's behalf.•I have read this application and the information I have provided is correct I have mad the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relan .buil 'ng cans, C60M I u oris = natives of Cup e. o to enter the above-id tified property for inspection purposes. Signature Signaoof Applicam/Agent 1� I Date: 1 —2 SUPPLEMENT 1 ORbf ATION REQUIRED PLAN CHECK TYPE I ROUTING SLZP New SPD or Multifamily dwellings: Apply for demolition permit for IE(OVER-.TBPrOUNTER ❑ existing building(s). Demolition permit is required prior to issuance of building BUD.DING PIAN REvaw permit for new building. ❑ EXPEPss ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Els-rA,YDARD ❑ PUBUc WORKS T—=if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE hEPT _Copy of Planning Approval Letier or Nlee$ng with Planning prior to submittal of Building Permit application. ❑ M, OR ❑. SA.NrTARYSZWER DMTuCr ❑ E,WIRON.M2NTAL HEALTH. Bldglpp_201 Ldoc revised 06/21/11