12040119 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20659 SHELLY DR CONTRACTOR:SQUARCIA LARRY G AND PERI%IIT NO: 12040119
YOLANDA
OWNER'S NANIE: SQUARCIA LARRY G AND YOLANDA 20659 SHELLY DR DATE ISSUED:041232012
OWNER'SPHONE: 4083147575 CUPERTINO.CA 95014-2923 PHONENO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic q
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 308 DESCRIPTION:21NCH DRAIN FROM KITCHEN SINK TO MAIN,15 CAN
(commencing with Section 7000)of Division 3 of the Business&Professions LIGHTS IN MASTER BEDROOM,WIRE T1IREE OPENING
Code and that my license is in full force and effect. SKYLIGHTS,REPLACE THREE SKYLIGHTS AND TWO SLIDING
I hereby affirm under penally 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.
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:$5800
permit is issued.
APPLICANT CERTIFICATION APN Number:35911024,00 Occupancy Type:
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
PERMIT EXPIRES IF WORK ISNOT 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 =YSOM LAST CALLED INSPECTION.
with all non-point source regulatims per the Cupertino Municipal Code,Section r
9.18.
49
Issued by Date:
Signature Date
�\ OWNER-BUILDER DECLARATION
V\ RE-ROOFS:
1 hereby affirm that 1 am exempt from the Contractor's License Low for one of All roofs shall be inspected prior to any roofing material beug 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 the work.and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Dale:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044.Business&Professions Code)- ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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 Health&Safely Code,Sections 25505,25W.and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Qualify Management District 1 will
I 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 Cali forma. If,alter making this certificate of exemption,I
become subject to the Worker's Compensmmon provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information 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 and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
grunting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations Peptic Cupertino Municipal Code,Section
9.18. r 1 understand my plans shall be used as public records.
Signature /�� ate -'�� 2'� Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20659 shelly drive DATE: 04/23/2012 REVIEWED BY: larrys
APN: BP#: "VALUATION: $5,800
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
wORK 2 inch drain from kitchen sink to main 15 can lights in master bedroom wire three opening skylights,
SCOPE, replace three skylights and two sliding doors.
Ifecii. Plan('he.k Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check 0.0 hs $0.00
dl::ch.I4•rmit/gee: Plumb. Permit Fee: IPPERMI7' Elec. Permit Fee: IEPERM11'
o ,cr I1�ch. /,r.,P. Other Plumb Insp. 0.0 hrs $44.00 Other Elec. Insp. 0.0 hrs '$44.00
d
Mach, 7nap. her: Phmrh. Insp.1,ee' I'!e::. hl'r'. M"'.
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are only an estimate. Contact lite De 1 or addn'l info.
FEE ITEMS (Fee Resolution 11-053 EV 711/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 T-1 # Plumbing
Suppl. PC Fee: Q Reg. O OT 0.0 hrs $0.00 $22.00 IPRSEIVER Sewer, Sanitary
PME Plan Check: $0.00 18 Electrical
Pennit Fee: $0.00 $65.00 IRRainvl' Fixtures, Lighting
Suppl. Insp. Fee:Q Reg. Q OT F0.0 hrs $0.00 = # Window/Sliding Glass Door
PME Unit Fee: $0.00 $392.007AONRE'P Replacement
PME Permit Fee: $88.00
C'nnsnuerinn lar:
Administrative Fee: IADAHN $41.00 Q
Work Without Permit? Yes E) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Building or Structure
Travel Documentation Fee: ITRA VDOC $44.00 A
Strong Motion Fee: IRSEISMICR $0.58 Select an Administrative Item
Bldg Stds Commission Fee: IRCBSC $1.00
>! SUBTOTALS: $174.581 $479.00 TOTAL FEE: $653.58
(-
Revised: 04/01/2012
t2vLi0119
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MIS C
CUPERTINppO7 (408)777-3228- FAX(408)777-3333• buildinOCa cuoertinO.orci
191FLUMBRJG ❑MECHANICAL ELECTRICAL RMISCULANEOLIS
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OWNERNAME PHONE E-MAIL) r i-7 / a
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STREET ADDRESS Zos�L '$'�Ld'y ,�Y� CITY,STATE
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CONTACT NAME //7 �� CJ PHONE V-1 eVE-MAII
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❑OwNER ❑ owm-ar=mt ❑ OwmEm AGENT ❑ CONTRACTOR ❑CONTRACTORAGFM ❑ ARCIMECT ❑ENWD ❑ DEVELOPER ❑ TWANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE Bus.TJC e
COMPANY NAME &MAm FAX
STREET ADDRESS CITY.STATE,AP PHONE
ARCHTTECTIEaGOSEFA NAME LICENSE NUMBER BUS.CIC P
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SiDmDUPLE% ❑ MLnFAMMY PROJFLTINWRDI.WD ❑ YES PROJECT IN [3 Yes IS THE BLDG AN ❑YES
3111EJ1ING: ❑GDMMERCIAL ,URRBAN INTERFACE AREA (:I NO FLOOD LONE [3 NO I� EICHLER HOME? [3 NO
DESCRIPTION OF WORK /�/�^G' �J°PJW SV F`rg Z J N�H / 2.71 N
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TOTAL VALUATION: 1 RECEWED BY:
By my signature below,I certify to each of the following: I am the property awn¢ar anthoriud agent to act as the property s chal£ I have read this
application and the I hav provided is cottect j have read the D tion of Work and verify it is accm=. I agree to co=iy with all applicable local
ordinances and state laws relating to 'din aoas thcrur es of CoperDno to enter the ab e-identified property for inspection putposes.
Sigoemte ofApplicmdAgene Date: -2 �-
SUPPLOVONITAL INFORMATION REQUIRED OFFICE USE ONLY
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❑ EXPRESS
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❑ TARGE
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❑ MAJOR
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