12040074 CITY OF CUPERTINO BUILDING PERMIT
BILI LDING ADDRESS: 10434 SCENIC CT CONTRACTOR:ARGONAUT WINDOW& PF.Rh11T NO: 12040074
DOOR,INC
OWNER'S NAME: 13AUTISTA DONALD JR AND ALICE M 1901 S BASCOM AVE STE 800 DATE ISSUED:04/132012
OWNER'S PHONE: 4082550826 CAMPBELL,CA 95008 PHONE NO:(408)3784018
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALU COMMERCIAL,
11
License Class_ Lie.N pg��0�Jg REPLACE 3 FRENCH DOORS LIKE FOR LIKE
Contractor�{�P��,(�Nd,v1 V/�U W13atc L -
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
(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 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 whichthis permit is issued. Sq.Ft Floor Area: Valualion:$15951
1 have and will maintain Worker's Compensator Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
pcnnit is issued APN Number:35707019.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above in ormamion is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and comfy ordinances and stale laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentiared property for inspection purposes. (We)agree to save 180 DAOM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments. ,
costs,and expenses which may acerae against said City in consequence of the [(r
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point sour rr-gulali s per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature u. Date �3 Z. All roofs shall be inspected prior to any roofing material berg installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BIIILDF.R DECLARATION
I hereby affirm that I em exempt from the Contractor's License Lew for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO 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)
h as owner of the property.am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE:
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapler 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&Safely Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-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 Quality Management District 1
performance of the work for whichthis permit is issued. will maintain compliance with the Cu rtino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code.Section 50 ,25 3 ,a 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Z
Owner or authorized agent r
pcmhil is issued. Dele:
I certity that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of Cali forma. If,after making this certificate of exemption,I CONSTRUCTION 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
forthwhh 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
cored.I agree to comply with all city and county ordinances and state laws relating
to budding construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgmenls, ARCHITECT'S DECLARATION
costs,mid expenses which may accrue against said City in consequence of the I 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 Dale
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DMSION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)7773228• FAX(408)777-3333• building(ftuoertino ora Ic?-E,y W74
❑NEW CONSTRUCTION ❑ ADDMON ❑ ALTERATION I TI ❑ REVISION I DEFERRED ORIGINAL PERMIT 0
PROJECT ADDRESS _vV- C G APNH .01- 0
OWNER NA.HE y PHONE E-MAR
L� AJ �e2b- 1: V
FAX
CON G T STATE 'N� �l�\
cor�ALT NAME PHONE
1Y 0 �' ZSZ-G$2 ¢ t
STREETADDR25SCISY,STATE, ZIP, FAX
u SIS�N �C r -fir 0
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑COYMACTOR AGENT ❑ ARcm= ❑ENoNFat ❑ mEvEwFEI ❑TLNANT
CON17tA RNAME �•� 6 W� Il u 'ITE HUS.LIC#
COMPANY NAMEE-MAR FAX
� E
STREETADDRESS 10 S.Isc6m Ave, .STA 1 ppTt(`
3 10—
ARCHITECT/ENGINEER.NAME LICENSENUMBER HUS.UCH
COMPANY NAME E-MAIL FAX
STREET ADDRESS QTY,STATIL ZIP PHONE
DFSCMMON OFWILE
Ljag
EXISTING USE PROPOSED USE CONSR.TYPfi - SM.—
USE. TYPE OCC SQFT. VALUATION(S)
EXISTa NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM RD4itN OTHER
REMCDELAREA REMODELAREA RF]NODEL AREA
FORCHAREA DECI(ARZA TOTAL DECY4MR4zrAAEA GARAGE ARFA DETACH
AIT GN
0 DWELLNG UNITS: SASECOND DNTT YFS SECONDSTORY YES
HaINaADn®r []No A"MONt NO
PRE-APPLICATION ❑YES IF YES,PROVIDE CC"OF 0THE araC AN ❑YES RECEIVED BY. TOTAL VALUATION.
PIANNINCAPPLA
EI PLANNING APPROVAL IETlf7l ffiCHt.BR HObtRr ❑NO
i TLC?, 7/
By ERY Signature below,I certify to each of the following: I am the property GWacr or authorized anent to act on the prpatymvners behalf,f have read this
application and the mfarmatiou 1 have vided is ourrecL I hap read rhe Deserip5=of Work and verify it is accurate. I agree to comply with all applicable local
alai®ees and state laws relating to g cor stractigeJarize represe of Cupertino to enter the above-identified property fpr inspection purposes.
Signature of AppficandAgent Date: .3
SUPPLEMENTAL INFO TION REQUIRED PUN CHECKTYPE ROUTING SLEP
New SM or Multifamily dwellings: Apply for demolition permit far ❑ OvsR-THP,cODTSR N13BUILDUIc PUN Rrymw
existing building(s).
g(s). Demolition permit is required prior to issuance of building
permit for new building. Cl Enwas ❑ PLAmwc PLAN RHvrew
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ POHUC WORM
farm if say Hazardous Materials are being used as part of this project ❑ LARGE ❑ FIRE nErr
Copy ofPlaming Approval Letter or Meeting with Planning prior to ❑ MA.roR ❑ sANrrARYSRweR DLmucr
submitral of Building Permit appliealiou.
❑ ffiYYTRONMSNTAL SAI TH,
BldgApp 1011.doc revised 06121171