09010112 7777777:7'
CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'C0 v
PERMIT NO.
BUILDING ADDRESS:
10367 BYRNE DON-ALD P F
PERMIT ISSUE DATE
OWNER'S NAME:
99
A CONTROL NO.
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
u p z LICENSED CONTRACTOR'S DECLARATION Job Description
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and professions Code,and my license is I N S T L SUMP PUMP WHICH WAS RE P LCMNT
y in full force and effect.
z License Class Contractor
3—o Date
ARCIJ CTS DECLARATION
I I understand my plans shall be used as public records
D,U
O H Licensed professional
�
OWNER-BUILDER DECLARATION
<� 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Prokssions Code:Any city or county
u m which requires a permit to construct,alter,improve,dcmolich,or repair any structure Valuation
prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
Y F$ (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or rj 0
i R E that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars(5500). 35712031 . 00
❑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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
as owner of the property,am exclusively contracting with licensed contractors to
tract the project(Sec.7044.Business and Professions Code:)The Contractor's u.
cense Law docs not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a conuactor(s)lice ed pursuant to the Contractor's
License Law. __.__.i B i4.P C for this mason
❑I am r exempt under_ee:
Date
O �--•- W ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Workcr's Compen-
.,ation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation insurance carrier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hun d dollars($100)
or Icss)
I certify that in the performance afthe,work for dthis it is issued,l shall not
employ 4nypamninany m r so as to be sub' t t Workers'Compensation
La) "of Califo Da
AP�alicanl
NCfT�1C6�O.APRf�t' :!f,after Arakiag ILts ificatc of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J`Z, forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
CA I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.Q
W A Lender's Name
�Z Lendees Address
U 0 1 certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction.and hereby authorize representatives of this city to enter upon the
GTa above-mentioned property for inspection purposes
CL (We)agree to saw,indemnify and keep harmless the City of Cupertino against
►�-t liabilities,judgments,costs and expenses which may to ay accrue against said City Z
U Z in consequence of the granting of this perm' 7 Date
APPLICANT UNDER$TANes CO• PLY WITH ALL NON-POINT Issued by:
Re-roofs
Sign n pplicaDate Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? / All roofs shall be inspected prior to any roofing material being installed.
❑ `Yes �o If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as doped by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes °
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cede,Sections 25505,25 l understand that if the building
does not curtend havr_a-tctiiim that r y fes rbdny to notify the occupant of the Date
�dd
y- lo' of nraccrtirtcatcorOcenpancy. Signature of Applicant
C All roof coverings to be Class'A•'or better
Owner or authori�cagent Date
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 35712031 . 00
DATE ISSUED. . . . . . . : 01/27/2009
RECEIPT # . . . . . . . . . BS000007044
REFERENCE ID # 09010112
SITE ADDRESS 10367 BYRNE AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DONALD PLOOF
ADDRESS . . . . . . . . . . : 10367 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DONALD PLOOF
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : DONALD PLOOF
ADDRESS . . . . . . . . . . : 10367 BYRNE AVE
CITY/STATE/ZIP CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ---------- ---
1BCBSC VALUATION 500 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 500 . 00 0 .50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 .00
1TRAVDOC FLAT RATE 1 .00 40 .79 0 . 00 40 .79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 83 . 08 0 . 00 83 . 08 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -------------
CHECK 83 . 08 #7535
---------------
TOTAL RECEIPT 83 . 08
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 35 7
Date:
Building Address:
Mailing Address (if different from building address):
Owner's Name: _ Phone#:
Contractor: Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential ❑ Commercial
Job Description:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ EIII B, IV-HT, V-B 0�
ValuatioE Square Footage:
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.org
Revised 01/07/09
CITY OF CUPERTINO
CITY of GENERAL BUILDING APPLICATION
CUPERTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
1
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
IPLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
IBCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
/ IBSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
/ 1 TRAVDOC Travel &Documentation B
IBUSLIC Business License B
5 of 5
C) dol �< < �
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
A. _ All the work authorized by this permit
B. _ A portion of the work
C. ,None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
performed
............................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Date:
Property Owner's Signatur ..
Job Address: /CqI4'- `OYP Z�- Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
.; Community Development
10300 Torre Avenue
'- Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
''UPEkTINO
Building Department
JOB ADDRESS: PERMIT # G
OWNER'S NN PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontracors..\
e J Date
Please check applicable subcontractors and complete the fellowing information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date