12050043 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20833 GREEN LEAF DR CONTRACI"OR:SEARS HOME PP:R?II"I'N'U: 12050043
IMPROVEMENT'
OWNER'S NAME: TAMAR&AMIT'AY LEVI 1024 FLORIDA CENTRAL PKWY D,\'rE ISSUED:05/03/20 1 2
OWNER'S PHONE: 4088924877 LONGWOOD.Fl, 32750 PDONE NO:19251245-2000
� .41 LICENSED CONTRACTOR'SDECLARATION BUILDING PERMIT INFO: BLDG F ELECT F PLUMB F
License Class Gy �tJ Lic,q 7 Z 3 7 9 r
7 to MECH RESIDENTIAL F COMMERCIAL r
Contractor CSM IMI Date 5 lZ—
hereby affirm that I am licensed un er the provisions of Chapter9 JOB DESCRIPTION: INS"I'ALL I"WO REfROFI'I'VINYI.WINDOWS-NO SI%I!
CHANGE
(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 or consent to self-insure for Worker's
Compensation,as provided for by Section 3700 orthe 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 Sq,Ft Floor Area: Valuation:$1790
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued
APN Number:32609006.00 Occupanry'1ype:
APPLICANT CERTIFICATION
I certify that I have read this application and stale 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 orthis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned propeny for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code.Section /TG�
9.18, Issued by: /G/9/✓ /�� Date:
Signatur tate�Z
❑ ON':' - - GILDER DF-CI.ARATION RE-ROOFS:
All roofs shall be inspected prior m any rooting material being installed.If a rooris
I hereby affirm that 1 am exempt from the Contractor's License Low for one of installed without first obtaining an inspection.I agree W remove all new materials for
the following two reasons: inspection.
I,as owner of the propeny,or my employees with wages as their sole compensation,
will do the work,and die structure is not intended or offered for sale(Sec.7044. Signature of Applicant: Date
Business&Professions Code)
I,as owner or the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BF;CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Proressions Code).
1 hereby affirm under penalty of perjury one of the following three IIA%ARDOUS MATERIALS S DISCLOSURE.
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Qualilvdlanagement District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,I shall Health&Safely Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation Imus of California. If,after making this certificate orexemptiun.I Owner or authorized ,em:
become subject to the Worker's Compensation provisions of the Labor Code,1 must Dale. /r1_
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS'FRIICI'ION LENDING AGENCY
APPLICANT F CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of w'ork's
1 certify that I have read this application and state that the above information is for which this pemtit is issued(Sec.3097,Civ C.)
correct.1 agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCIIITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Dale.
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Front of home only
EO4/370/2071;
Customer signature
Dow Customer signature Date
0JIVI;�V-�LttEMENT DEPARTMENT
;IC.
. -CUPERTINO
, e
qUILDING UIVISIC
YC) x s7 APPROVED
This set of plans and specifications MUST be kept at the
Job site during construction. It is unlawful to make any
changes or alterations on same,or to deviate
DD &—refrom,without approval from the Building Official.
E/-;:L 11'X-I 110 bl stamping of this plan and specifications SHALL NOT
held to permit or to be an approval of the violation
of any provisions of any City Ordinance or State Law.
BY Z�
DATE
PERMIT NO. 1,2e 5 00
OFFICE Copy 2 of 2
4
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
172 ADDRESS: 20833 Greenleaf Drive DATE: 05/03/2012 REVIEWED BY: Sean
APN: 00 B #: / US-�(� 3 'VALUATION: $1,790
*PERMITTVPE: Building Permit PLAN CHECK TYPE: Alteration Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK Remove and replace 2 windows in office.
SCOPE
.1/,•,.h. l7<,: C'hrrA Phmrb_N..I ChcrA l7ce. P/""(hr.G
,LIrJi. /tamrit Frr: l7rrmh, 1'crnrir F:r: likr. 1':m...if lir'
oil,, hrc/, Orher Plwnh Imp, Li 1 Uihrr I1c, br,p.
I h c/v /n yp I'.'. I'hnnh. bhjl. Fe,r parr. In>p. F"
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are only an estimate Contact the De t or addn7 info.
FEE ITEMS (Fee ltesolulion //-053 tiff 7/I/l I) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Window/Sliding Glass Door
Suppl. PC Fee: Q Reg. Q OT FO.OThrs $0.00 $392.00 I{VINRF.P Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee.0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C.rAc/rHrlioil %cIC:
;IrLninisntuinr l-;rr: O
Work Without Permit? O Yes (F) No $0.00 E)
Advanced Plannin_ Fec: $0.00 Select a Non-Residential 0
Building or Structure O
7nrrrl 7?loam«nlalinrr /'itc.i: �
Strong, Motion IFce: IBSEISMICR $0.50 Select an Administrative Item
I31de Slds Commission Fec: IBCBSC $1.00
SUBTOTALS: $1.50 $392.00 TOTAL FEE: 1 $393.50
Revised: 04/01/2012
CONSTRUCTION PERMIT APPLICATION✓ /
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO f��✓L- QO� �j
(408)777-3228• FAX(408)777-3333•buildinglaDcuoertino.org / —/
' ' AIERI[ON/ 1 iRIONA❑ WRUCIION El IiIPIiRMI'1'q
I'ROIE("I'AOBRILSS7•0933 12 - APNn �
OWNER NAME MR 1IZ / I ,C
7H pgo9 grf - �q 77 EMAIL C/
S WiISI'ADDRESS i+ r,I L CITY,51'A'II ZIP VAX
6rzL� . 9 SO/
(OXIAC'I' NAME LIZ GONZALES POONI1916-830-3423 EAIAII'
S IREV.I ADDRESS 1200 DEL PASO RD CITN,%TATE, zIPSACRAMENTO,CA 95834 VAX S� 3c q5
❑ OWNER ❑ OWNER-IIIIILDI:R ❑ OWNERAGEN'T TJ COMRAC"IUP ❑CONTRACTOR AGE NI ❑ Alu'lirECT ❑I(NGINIiI:R ❑ DI;Vli,1PIiR ❑ TENANT
('OYIRAC'IORNAMIi LICENSE NUMBER 721379 LICENSRII'PE 111151.1('✓
(99W96ME IMPROVEMENT PRODUCTS E'sIAB 1A 407-551-3085
SRrrr ADDRESS
1200 DEL PASO RD cnY,S1 At SACRAMENTO,CA 95834 PpOX'916-830-3423
ARCIIHIA-DENGINEER NAME LICENSE NUMBER [ills LIC.
n
('OMPASY NAME. GAIAII. EAX
SFREIa'ADDRESS Cl IY.ST At F.ZIP III IONR
I)PSCRIPIO!s 01;W'ORA I I T(P.lU �F9ikjrf 11�• /
V J Ibz J - Z
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ESISI'I ' ISP PROPO ISI? CONSTR.TYPE pS'RIRII-S OFFICE USE ONLY
��- �- O A)r OCC TYPE DIESCRIPTON so IT VALEJAJ ION
I:XKI(; NEW FLOOR DEMO TOTAL
AREA AREA AREA N1:1'AREA
IIAIIIRODM RIT(IIEN 0111ER
REMODEL AK17A REMODEL AREA :L ARBA
POR('II AREA I)F('R ARRATOTALDEC" 1AREA GARAGIi AREA'.❑ Dm'ACII
_ _ ❑ AI'TACII
/IINIIlisruNIIS .i SCC D-1a ❑YDS 5[fONO S1TNY ❑YI'A
91.1X4 ADOno ❑MI AlElon0N" ❑M�
IWLMN.I(AII( ❑ YIS I IFYIIINOVIIR!IWYUF 1-NIN'YNM9i: RECEIVED fly: � TOTgL Vp I,in,3.
o.ArvYwc AA1.. El -1 AANNm4AANuvAI-uS
By mo.signature below.I certify to each of the following: I am the property owner or authoriad agent to act on the propenv owner's behalf. I have read this
application and the inlonnalion I have provided is corset. I have read the Description of Work,and verily it is accurate. I agree to comply with all applicable Ilial
ordinances and slate laws relating to building cons thorine re re • u upemino to enter the above-identified pmpenT for inspection purposes.
Signature ol'Applicant/Agenc Date: 51,1311 z--
SUPPLEMENTALIN� �9WREQUIRED yy,,�� PLAN CHECK TYPE ROUTING SLIP
_New SPD or Mullilamily Ings: Apply for demolition permit for IN OVER-TIO-COUNTER ❑ BUILDING PLAN RF-VD:W'
eXisling building(s). Demolition permit is required prior to issuance ofbuilding T
penult for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a Lwmpleled Hazardous Materials Disclosure ❑ STANDARD El PUBLIC WORKS
fom)if any l ivardous Materials an:being used as part of this project.
❑ LARGE ❑ FIRE DEE
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ILNVIR(INVIF;NTAI.III:ALTII
6/ref:I pp_'0/Ldn('i ci ocd 03116///