12020061 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10178 CASS PL CONTRACTOR:BROTHERS HOME PERMIT NO: 12020061
IMPROVEMENT
OWNER'S NAME: ALICE LEE 2510 DOUGLAS BLVD DATE ISSUED:02/14/2012
OWNER'S PHONE: 4082572402 ROSEVILLE, CA 95661 PHONE.NO:(408)295-0680
LICENSED CONTRACTOR'S DECLARATION F
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class ic.# mo 9 f— 1— F.
MECH RESIDENTIAL COMMERCIAL
Contractor Datet, -->—
I hereby affirm that I am licensed under the provisions o Chapter 9 JOB DESCRIPTION: REPLACE 17 WINDOWS AND 2 PATIO DOORS AT SFDWL
NON-STRUCTURAL
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two 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.Ft Floor Area: Valuation:$12500
1 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 APN Number:35701032.00 Occupancy Type:
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 and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
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 accrue against said City in consequence of the
granting of this permit. Additionally,t applicant understands and will comply Issued by Date:
with all non-point source r ulatio er the Cupertino Municipal Code,Section
9.18.
RF,-ROOFS:
Signatur Date L 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:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGSTO BE CLASS"A"OR BETTER
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 for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to sell'insure for Worker's material. Additionally,should 1 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 uality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupert' icipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 3,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent,-1
permit is issued. Date? Y
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,alter making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must 1 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
APPLICANT CERTIFICATION Lender's Address
I certify that I 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 ARCHITECT'S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records.
granting 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
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10178 sass pl. DATE: 02/14/2012 REVIEWED BY: bobs.
APN: BP#: VALUATION: 1$12,500
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD or Du lex PENTAMATION
USE:
p PERMIT TYPE: 1GENRES
WORK replace 17 windows and 2 patio doors non structural.
SCOPE
_FT I T L I
Ll Ll --I_ Li
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). TheseLees are based on the relinina information available,and are o!A an estimate. Contact the De t or addn 7 info.
FEE ITEMS c t .s > 'lcxr , '. 3, ''' 1 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 19 # Window/Sliding Glass Door
Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $652.00 1 wINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-0 Reg. Q OT El hrs $0.00
PME Unit Fee:: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? 0 Yes 0 No $0.00
$0.00 Select a Non-Residential Q
Building or Structure Q
Sts",-)o2 i��W_.' t •e 1BSEISNIICR $1.25 Select an Administrative Item
_ILJ; ._ °fells .'owin, ission Fee 1BCBSC $1.00
SUBTOTALS: $2.251 $652.00 TOTAL FEE: 11 $654.01
Revise 1/1 12
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35701032 . 00
DATE ISSUED. . . . . . . : 02/14/2012
RECEIPT # . . . . . . . . . : BS000016008
REFERENCE ID # . . . : 12020061
SITE ADDRESS . . . . . : 10178 CASS PL
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . ALICE LEE
ADDRESS . . . . . . . . . . : 10178 CASS PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2728
RECEIVED FROM . . . . : SEAN FERGUSON
CONTRACTOR . . . . . . . : GENE V. CAVANNA LIC # 27964
COMPANY . . . . . . . . . . : BROTHERS HOME IMPROVEMENT
ADDRESS . . . . . . . . . . : 2510 DOUGLAS BLVD
CITY/STATE/ZIP . . . : ROSEVILLE, CA 95661
TELEPHONE . . . . . . . . : (408) 295-0680
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 12 , 500 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 12 , 500 . 00 1 . 25 0 . 00 1 . 25 0 . 00
1WINREP EACH 8 19 . 00 652 . 00 0 . 00 652 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 654 .25 0 . 00 654 . 25 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 654 .25 me
---------------
TOTAL RECEIPT 654 .25
CONSTRUCTION PERMIT APPLICATION
12 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408) 777-3333• building(Dcupetno.orq
CUPERTINO �- U
[_1 NEW CONSTRUCTION El ADDITION 2 ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS Z AFN# �� C) „
OWNER NAME ( d I - , 7 _
PHO - E-MAIL a Lt
STREET ADDRESS l CITY, TATE,ZIP FAX
r!
CONTACT NAME PHONE
- _ E-MAIL
STREET ADDRESS � CIIY STATE, IIP � 1 FAX
❑ OWNER ❑ OwNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARC •RITE(CT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LI SE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
QV) /A r -
ARCHITECT/ENGWEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK 17
lA U 4 f-w/ ,fo —
l
EXISTING USE PROPOSED USE CONSTR.TYPE #STORES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMOTOTAL
AREA AREA AREA NEI AREA J 1? UG i
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AR.5:70 DETACH
[]ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? []NO ADDITION? []NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: / TOTAL VALUATION:
PLANNING APPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO J/ M0
By my signature below,I certify to each of the following: I 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 provi is correct. I e read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil ' constructi authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQLA, ED PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for _
existing building(s). Demolition permit is required prior to issuance of building
o -COUNTER B�G PLAN REVIEW
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANnARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ MZ DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
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