The URL can be used to link to this page

12050065CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19363 GREENWOOD DR CONTRACTOR: VAUGHN DENNIS D AND I PERSII'1' NO: 12050065 TSEH -SIEN K TRU OWNER'S NAME: VAUGI -IN DIiNNIS D ANDTSEH -SIEN K TRU 19363 GREENWOOD DR DA'Z'E ISSIl ED: 0510412012 OWNER'S PHONE: 4084461918 I CUPERTINO, CA 95014 I PI ION P, NO: ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic.4 Contractor 1 herebv affirm that 1 am licensed under the provisions of Chapter (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. 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 permit is issued. APPLICANT CERTIFICATION 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 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, the applicant understands and will comply with all non -point source regulation per the Cupertino Municipal Code, Section 9.18, Date ❑ OWNER - BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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 (Sce.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044. Business & Professions Code). 1 hereby affirm under penally of perjury one of the following three declarations: I have and will maintain a Certificate of Conscnt 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 permit is issued. I certify that in the pertonnance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Worker's Compensation laws ol'California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply will, such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accme 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 9.18. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: INSTALLATION OF ( I5) LIGIiTS. (2) TAMPER RESISTANT OUTLETS, INSTALL ADI IERED ROCK VENEER AT FIREPLACE. ENLARGE BEDROOM CLOSET Sq. Ft Floor Area: I Valuation: $1750 APN Number: 37543016.00 1 Oeeupaney Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: /� r Date: � • I/-/ ?— RE: ROOFS: All roofs shall be inspected prior to any roofing material beug installed- If a roof is installed without fast obtaining an inspection. I agree to remove all new materials for inspection. Signature of Applicant: Date: ALI, ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE: I have read the hazardous materials requirements under Chaplet-6.95 of the California Ilealth & Safely Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the Ilealth & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health & Safely Code, Sections 25505, 25533, and 25534. Owner or wua .. d agent: Date: g' �• 12-- CONSTRUCTION LENDING AGENCY I hereby affirm this there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCIIITF.Cf'S DECLARATION I understand my plans shall be used as public records. Dale J y fZ I Licensed CUPERTINO OWNER- BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildingecuoertino.ora Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS /'� C.,,Jo'�r)^-0 APN aP# OWNER NtME iiQ.v�v� U Gn1 •� OWNER ADDRESS s 3- PM Azow DESCRIPTION OF WORK: tN 5�` Q�Cr -SS �O LICaaT elf f?t ('M.iO C.�wSS We are providing you with an Owner - Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner - Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. Please read and initial each statement below to signify you understand or verify this information.) // kl. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner - Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner - Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. _6 I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. N. I understand as an "Owner- Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. dQ. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. PIL/5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" understate and federal law. N. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. ` r" 7. 1 understand under California Contractors' State License Law, an Owner - Builder who builds single - family residential structures cannot Iegally.build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 1 t" 8. 1 understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OirnerBvilderFa'm 2010.doc revised O4114110 CITY OF CUPERTINO 8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . ........: 37543016.00 DATE ISSUED........: 05/07/2012 RECEIPT - # ......... : BS000016729 REFERENCE ID # ...: 12050065 SITE ADDRESS .....: 19363 GREENWOOD DR SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER VAUGHN DENNIS D AND TSEH -SIEN ADDRESS 19363 GREENWOOD DR CITY /STATE /ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: DENNIS DEAN VAUGHN CONTRACTOR ........ LIC # *OWNER* COMPANY ..........: VAUGHN DENNIS D AND TSEH -SIEN ADDRESS 19363 GREENWOOD DR CITY /STATE /ZIP'...: CUPERTINO, CA 95014 TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT - -- - -- THIS REC -- -- --- - -- NEW BAL ---- -- - - -- ---- - -- --- lADMIN - -- ---- - - -- -- HOURS --- - - - -- -- 1.00 ---- - - - - -- 41.00 ---- 0.00 41.00 0.00 1BCBSC VALUATION 1,750.00 1.00 0.00 1.00 0.00 1BREMFIXT NO. FIXTURES 15.00 65.00 0.00 65.00 0.00 1BREMRECEP NO. OUTLETS 15.00 44.00 0.00 44.00 0.00 1BSEISMICR VALUATION 1,750.00 0.50 0.00 0.50 0.00 1EPERMITFE FLAT RATE 1.00 44.00 0.00 44.00 0.00 1STINSP UNITS 1.00 130.00 0.00 130.00 0.00 1TRAVDOC FLAT RATE - 1.00 44.00 0.00 - - -- -- 44.00 --- -- - - --- 0.00 ---- - - - - -- TOTAL PERMIT - --- - - - - -- 369.50 ---- 0.00 369.50 0.00 METHOD OF PAYMENT --------------- -- CREDIT CARD TOTAL RECEIPT : AMOUNT ---- -------- --- 369.50 --------------- 369.50 VOICE ID DESCRIPTION -- - - - - -- -------------------------.--- 304 ROUGH ELECTRICAL 512 FINAL HANDI -CAP REFERENCE NUMBER --------------- - ---- VISA VOICE ID DESCRIPTION -- - - - - -- ---------------------- - - - --- 505 FINAL ELECTRICAL CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These fees are based on the nreliminary information available and are oniv an estimate . Contact the Dept for addn7 info. FEE ITEMS (Fee Rerolulion 11 -053 EIZ 711111) ADDRESS: 19363 Greenwood Drive DATE: 05/04/2012 REVIEWED BY: Sean ,tlrrh. I'e...'a Fee: APN: BP #: 'VALUATION: $1,750 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: fart. Lnp. Fee: PENTAMATION 1REAP10 PERMIT TYPE: WORK Installation of 15 lights, 2 tamper resistant outlets install adhered rock veneer at fireplace, enlar e SCOPE bedroom closet. NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These fees are based on the nreliminary information available and are oniv an estimate . Contact the Dept for addn7 info. FEE ITEMS (Fee Rerolulion 11 -053 EIZ 711111) .tlech. Plan (.heck Phunb. Plan Check Elec. Plan Check 0.0 1 hrs $0.00 ,tlrrh. I'e...'a Fee: Plumb, Permit 1-re: Elec. Permit Fee: IEPERMIT Oihv, I iech. Insp. Other Plumb Insp. Other Elec. Insp. 0.0 hrs $44.00 ,bkch. beep. FCC: Plumb. bep. Fee. fart. Lnp. Fee: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). These fees are based on the nreliminary information available and are oniv an estimate . Contact the Dept for addn7 info. FEE ITEMS (Fee Rerolulion 11 -053 EIZ 711111) FEE QTY/FEE I MISC ITEMS Plan Check Fee: $0.00 —27 # $44.00 Electrical IBREMRECEP I Recep /Switch/Outlets Suppl. PC Fee: 0 Reg. () OT 0.0 hrs $0.00 PME Plan Check: $0.00 F-15-1 $65.00 Electrical IBREMFIRT Fixtures, Lighting Permit Fee: Hourly Only? 0 Yes 0 No $0.00 Suppl. Insp. Fee-.0 Reg. 0 OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 Conn urlion Tar: Administrative Fee: IADMIN $41.00 0 0 Work Without Permit? O Yes 0 No $0.00 Advanced Planning Fee: $0.00 1 hours $130.00 Inspections ISTINSP Inspection, Hourly 0 0 Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $130.50 $239.001 TOTAL FEE: $369.50 Revised: t14/01I2012 CONSTRUCTION PERMIT APPLICATION COMMUNfTY DEVELOPMENT DEPARTMENT • BUILDING OMSION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777 -3228 • FAX (408) 777 -3333 • buildina(c)cuoertino.orD n NEW CONSTRUCTION F ADDMON bkALTERATION /17 M RMTMTnNrnFb 2F nwnm.t ecDaarra PROIECi ADDRESS APNS 3(7D — { ✓— 7' v OWNER NAM �J�� 4 k v'pr{j(salN PH 0P /SIt , E /� T±v Yy6- d/74- ilau A4/// sTRFET' AnSAres' I'M AR�- T ZIP / -m.J o cA 9se 4 FAx J/oi' A/6 - 19 1p CONTACTSA�lE A-s A&O� PRONE E.E-MAIL SCRFETADDRESS SA-%�- /4S PK{ G LAf CITY. STATE, ZIP S �v FAX DOWNER ❑ OWNER- BURDEA ❑ OWNERAGENT ❑ COMAACIOR ❑CONTAACIORAGFM ❑ ARCB<TECr ❑ ENGR4=R ❑ DEVELOPER ❑TENANT CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS. LTC0 COMPANYNAME E -MAIL FAX STREET ADDRESS CITY, STAl$ EIP PHONE ARCEUTECT/FNGINMNAME LICENSE NUMBER BUS. LTC M COMPANY NAME E-MAD. FAX STREET ADDRESS CITY, STATE, ffi PHONE DESCRIPTION OF WORK I N LTvk_ .a.- VA+El_- oN tt= Locv � 9_xv --c vw U r��t� 4QC)k{ ti tLs'Fwcs CN(- /9'fL�c: (..(,oft'` J4 Qc4 c"b lrlCwl T1N(r y 13 c-7R-L. R.:, 'n c.t��. 4- w exyn e v ro, CoL4 -,. � M - GL--✓i w EXMMG USE PROPOSED USE' - CONSTR.TYPfi SSTO Ti i� I USE TYPE OCC SQFr. VALUATION (S) Exam AREA NEW FLOOR AREA DEMO AREA TTrf RATRRCOM I KITUiEN - UMER REMODELAREA - REMODEL AREA PORCH DECXAREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ATTACH A DWEZLOIG IJNUS: 13 SECONln MT YS SWON70 STORY // BEING ADDaO} �'tf0 ADDMOM. RNO PRE - APPLICATION OYES IF YES PROVIDE COPY OF 13 TEE BLDG AN REBID TOTAL VALUATION: FLVJNLNGAPPLP NO PLANNING APPROVAL LETTER EICBLOI BOSST. NO �� / d/ By my signature below, I certify m each of the fo9cwmg. I am the property owner or amhorized anent to act an the pripertyowner'.v behalf., I have read rho application and the info®adon I have provided is correct I have read the Description of Work and verify it is acewate. I agree to comply with all applicable local ordinances and state laws relating to bntldm a rnertives of Cupertino to eater the above - identified property for inspection purposes. signa[me of Applirat/Agent Dan: 5_' Y' / 2 SUPPLEMENTAL INFORMAIIONREQUIRED PLAPtCEIECKTYPZ RGVmvcst.LP New SFD or Multifamily dwellings: Apply for demolition permit for ;; i tmg bmldiag(s). Demolition permit is required prior to issuance of building OVER- TEL"OUNTIER ¢nivG PLAN EZVEM permit for Dew bnldmg. ZXPRFSS ❑ PL.fNNNG PLANtarvaw Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PORLIC WORKS form if any Hazardous Materials ate being used as part of this project ❑ LARGE ❑ Fina DEFT Copy of Planing Approval Letter or Meeting with Planning prior to ❑ 6W0R ❑ sANrraRY sKwElt DrsTHlcr submittal of Building Permit application. ' ❑ IIWmoNMxvTAL HEALta_ BldgApp_ZOl I.doa revised 06121171 .60� THE 'Fi ue F,.acr (t) P s , /� QcYno,ks C7ClS"T?^lr PA UC- � \ Vt w>t fiyl_ �61e 3 \ v fix 6 66 M O ,��. V, fair,, . Sa COMMUNIT/ DEV2COPMENT DEPARTMENT BUILDING DIVISION - CUPERTINO APPROVED set of plans and specifications MUST be kept site during construction. It is unlawful to makc changes or alterations on same, or to deviate 3refrom, without approval from the Bulldingcl stamping of this plan and specifications ALL 17,1" Irg e ` �R 3 held to permit or to bean approval rhSe violation iJ`.R '� any provisions of any City Ordinanc r tate Law. h Y WilT Nu. 3t'Ar1IT' I ��1 5- y Zo /Z MAY 10 4 2012 �C) A opy: A--1- 7-;q1WP'5�V �' T�I✓T- ;Lr • I1 4. ! y _ P ° u' U J J 3 J IL it Ll OD lu'� qq I di I I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19363 GREENWOOD DR CONTRACTOR: VAUGHN DENNIS D AND PERMIT NO: 12050065 TSEH -SIEN K TRU OWNER'S NAME: VAUGHN DENNIS D AND TSEH -SIEN K TRU OWNER'S PHONE: 4084461918 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor Date I hereby affirm that I 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. 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 3100 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insaance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 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 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, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature. Date OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain aCertificate 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 permit is issued. 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, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 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, the applicant understands and will comply with all non -point source regulations per, the Cupertino Municipal Code, Section 9.18. Date 19363 GREENWOOD DR ( DATE ISSUED: 05/04/2012 CUPERTINO, CA 95014 1 PHONE NO: JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL INSTALLATION OF 15 LIGHTS, 2 TAMPER RESISTANT OUTLETS, INSTALL ADHERED ROCK VENNER AT FIREPLACE & ENLARGE BDRM CLOSET 4/11/2013 - REV # 1 TO MOVE 3 LIGHT FIXTURES & 1 LIGHT SWITCH TO MASTER BEDROOM FROM BDRM # 2 APPV'D & ISSUED ON 4/11/2013 Sq. Ft Floor Area: I Valuation: $1750 APN Number: 37543016.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FRO �ED INSPECT �ON. y: Date: 7 j RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Dafe: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed CUPERTINO GENERAL PERMIT APPLICATION Te COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 (408) 777 -3228 - FAX (408) 777 -3333 - building (d)CUDertino.org F�PT.ITMRTNG r_IMECHANICAI 'BLECTRICAI '1_5_�� 11h I =1 ;� MISC (� lZosoob� MISCELLANEOUS PROJECT ADDRESS 3 c.�w APN ^ 2 3 / T L b OWNER NAME 1/� \ \LAAIA PHO nci r / `A f3, V r E-MAIL STREET ADDRESS 6Q9 Or CITY, STATE. ZIP , V� � L+ �o ft, [ 7 FAX 0O'N7ACT NAME - PHONE Sal-.- wJ w' = pennls d Blau h e w� I STREETADDRESS SO`v� JL Cs-O C3 CITY, STATE, ZIP \�� FAX OWNER ❑ OWNER - BUILDER ❑ OWNTERAGETT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENTSE TYPE BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINTEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI- FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WII.D 97) ❑ YES URBAN INTERFACE AREA []NO FFLOOD TECT IN YES ZONE ❑ NO IS 77-IE BLDG AN YES EICHLER HOME? ❑ NO DESCRIPTION OF WO nA_0 l I `C � ��" �� n, �_ 1. ,LZJL / ) b �J TCad c 1 of tv&R3A- '��i9 �l oar r-� 3321-no- TOTAL VALUATION: CEIVED BY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on -t erty a is behalf. I h read this application and the information I have provide ect. I have read the Description of Work and verify it is accurate. I agree to com ;a all applicable local ordinances and state laws relating to buildi structio—n-7le4orize representatives of Cupertino to enter the above-identified pro eery for inspection purposes. Signature of Applicant/Agent: Date: "`< SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER- THE - COUNTER ~ v ❑ EXPRESS U U ❑ STANDARD ❑ LARGE ❑ MAJOR kEP4&cApp_2011.doc revised 06121111 I rco•M