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12050003 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22881 STONEBRIDGE ST CONTRACTOR:ANDERSON PERMIT NO: 12050003 CONSTRUCTION OWNER'S NAME: THOMSEN I-IARRY A III AND MARY 1 939 KENNARD NSU' DATE ISSUED:05/012012 OWNER'S PHONE: 4082571870 SUNNVVALE,CA 94087 PDONE:NO:(408)733-8271 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB F License Class Lic.N .,J r r r i, /I_ / ,yam pre MECH RESIDENTIAL COMMERCIAL Contractor {�kseyoj 01h 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: KITCHEN REMODF-L(120 SQI'T)TO REMOVE AND (commencing with Section 7000)of Division 3 of the Business&Professions REPLACE Code and that my license is in full force and effect. APPLIANCES AND SINK.NEW 1-IGI ITING AND GFCI OUTLETS 1 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 0te work for which this Sq.Ft Floor Area: Valuation:$28000 permit is issued. APPLICANT CERTIFICATION APN Number:34213033.00 OccupancyType: 1 certify that I have read this application and stale that the above information is coffee( 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 f'or inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupenino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting ofthis permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ,! / Issued by: JGr�/✓ f7/9T6sf Date: -.:r •/-/� Signature� Dale ❑ OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that I 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 fust obtaining an inspection,I agree to remove all nrnv 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. Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). Al.l,ROOF COVERINGS TO RF CLASS".\"OR BEITER I 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 1 have read the hazardous materials requirements under Chapter 6.95 of the performance ollhe work for which this pernil is issued. California Ilealth&Safety Code,Sections 25505,25533•and 25534. 1 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 Ileallh& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code.Section 25532(x)should 1 store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air pemtit is issued. contaminants as defined by the Bay Area Air Quality Management District I 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 Ileallh&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,alter making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,1 must Owner or�,plhorized agent: forthwith comply with such provisions or this permit shall be deemed revoked. DD Date: ' ( I i APPLICANT CERTIFICATION CONSTRUCTION LENDING AGF-NCV I certify that I have read this application and slate 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 hamdess the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18- 1 understand my plans shall be used as public records. Signature Date Licensed Professional - N FIS. e� CUPERTINO I ✓jA PCpdp% MAYO 1 2012 Building DepartmentB M REVIEWED c0 d P AMM 6{�v L oaknip Reviewed By: i � fxs+1 DOMMB EVEIOPMENTDEP 0 EMr ti " ` LD PROVED-' Is p� d speciilcatioris M be kept at e 11��1ob site duriri ction. it Is unie Ito make 1 �� / changes c teratlons on same, to deviate Yd`therefrom,w app oval from jhd uilding Officl /TGf�E/✓ Iri Is plan and specifl Ions SHALL= The stamp 9 r of the vlolatio / beheld to a.to be im aPP. of any Pro of any City Ordin or State Lat I COP BY FDATE PERM R NO. U GO /i✓jTAGG �A77�IOQPFc�9TE/�_ �ilOolGG 4 �fGn/ Firrect Doe ihi �.ar � ; Vfh a► vn" 1 -wes% ul' rrovct D0or ptir.t ti� CITY OF CUPERTINO. 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34213033 .00 DATE ISSUED. . . . . . . : 05/01/2012 RECEIPT #. . . . . . . . . : BS000016670 REFERENCE ID # . . . : 12050003 SITE ADDRESS . . . . . : 22881 STONEBRIDGE ST SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER THOMSEN HARRY A III AND MARY J ADDRESS . . . . . . . . . . :. 22881 STONEBRIDGE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5639 RECEIVED FROM . . . . : BRIAN T ANDERSON CONTRACTOR . . . . . . . : ANDERSONCONSTRUCTION LIC # 33316 COMPANY ANDERSON CONSTRUCTION ADDRESS 939 KENNARD WAY CITY/STATE/ZIP . . . : SUNNYVALE, CA 94087 TELEPHONE (408) 733-8271 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 28, 000 .00 . 2.00 0 . 00 2 . 00 0 . 00 1BSEISMICR VALUATION 28, 000.00 2. 80 0.00 2 .80 0 . 00 1REMRESKIT SQ FEET 1. 00 588 . 00 0. 00 588 . 00 0. 00 ---------- -------—- --—------ ---------- TOTAL PERMIT 592 .8.0 0 . 00 592 . 80 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 592. 80 VISA --------------- TOTAL RECEIPT 592 .80 c� Pr 4 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•'FAX(408)777-3333• buildina(la cuoertino ora CUPERTINO ❑NEW CONSCRUCRON ❑ ADDITION IL ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL FE tNC T p 1 PAOIECiAODAESS Z� y,Y APNa 3K Z- 13_ 33 s 0o .1 OWNER NAME " ;moi ONE%..L✓ rV. -MAIL r SIREEFADDEESS CITY.STATE 7�PtJ-v d I}a tr CONTACT NAME PHONE S-uert STREET ADDRESS CITY.SPATE ZIP FAX ❑oW ❑ oWNET4aUQDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑PNGWEEK ❑ DEVELOPER ❑TENANT OONTRACfORNAME / Ctiq G .��ISO^ U024SENUMEER /� /^ LI/C{EENSE TYFE BUS. .rrICN E COWANYNAME MAn. Ll FAX STREET ADDRESS CITY.STATE IIP PRONE enrG ✓nny d (C CA `«�c �(� 733 dL t/ ARQDTECf/ENGINEER NAME LICENSE NUMBER (5-Z BUS.TIC Y COMPANY NAME E-MAR FAX 3 STAWr ADDRESS CITY,STATE.ZIP PHONE DESCRIPTION OF WORK 11 /=G TLG7- EX6TN U PROPOSED USE CONSTA TYPE SSTORa3 USE TYPE OCC. 5 Ff. VALUATION 5 �T7 f-2 V t�j Q ( l DEMO TOTAL AREA AREA OR AREA NET AREA �r / .le O / aATHROOM KITCKEN ^ REMREMODEL AREA REMODAREA REMODELAREA PORCH AREA I DFALARFA TOrALDECK/PORCH AREA GARAGE AREA DETACH ATTACH I DWE.LU4G UNITS: ISASECONOONTr YES sxcoNDSTORY YES aRDSG ADDED? -W ADDTROM. ;PO PRE-MPLICArtm ❑YES IF YEA PROVIDE COPY OF LSTBERLDGAN f YES RECElVID BY: TOTAL VALUATION: PLANNPLGAPPLR 'SL NO PLANNING APPROVAL TETTER EXCHIM ROME? NO _/ By my siPat=below,I certify to each of the fDIlowiag. I am the property owner or atrthotized agent to act oo the VM.crty,o"e's behalf.•s have read this application and the information I 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 Stam laws telatiog to buil ' coostractiau. I amborize representatives of Cupatmo to enter the above-identified Property for inspection purposes. Signalme ofApplieeut/Agent Data: SUPPLEYEENTALINFORMATIONREQUIItID PLANC>aogTYrE ROUONGSLEP New SFD or Multifamily dwellings: Apply for demolition permit for ova-THE{OONIEA ❑ ZUU.DiNO PLAN IOW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ REPRESS ❑ PtANNBSGPLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosbm ❑ STANDARD ❑ PUBLIC WORKS form if amt Hazardous Materials are being'used as part of this project ❑ LARGE ❑ Fm uPrr Copy of Planning Approval Letter or Meeting with,Planning prior to CI MAJOR 11SAMARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIROMKE11TALHEALTH. BtdgApp 201 Ldoc revised 06/21111