09030213 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT � �� I� F
PERMIT NO.
BUILDING ADDRESS:
10565 SAN LEANDRO AVE ANTHONY MONTEFUSCO 09030213
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
0
u p p LICENSED CONTRACT'OR'S DECLARATION Job Description
V C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
W. with Section 70(l0)of Division 3ofthe Business and professions Code,and mylicense is BLD-OUT PNTRY,NON-STRCTRL &GRG WD FRM CONST, PER
n y in full force and effect
DUIz License Class Lic•# CBC NO MECH/ELEC
3 f p Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
�yU
n H Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.c Pi which requires a permit to construct.alter,improve,demolish•or repair any structure
yZ prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's Lilronse Law(Chapter 9 Sq.
Y.F (commencing with Section 7000)of Division 3 of the Business and Professions Cadc)or 2000
a that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). 3 5 7 0 5 O E 8 . 00
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 Required Inspections
and Professions Code:The Contractors 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.11,
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
sok
as owner of the property.a 'vely contracting with licensed contractors to
.eonstmct the project(Sec.7 .� ess and fessions Code:)The Contractor's Li-
cense Law does not apply to 'o n of p rty ho builds or improves thereon,and,
who contracts for such pro' Is t a con ctor(s licensed pursuant to the Contrac ors
License Law.
[am exempt under eL' &P C f this n
Owner / Date
K COMPENSATIO ECLARATION
I hereb trm under penalty of perjury one of the following declarations:
'have and will maintain a Certificate of Consent to self-insure for Workers Compen-
.,on,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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATEOF EXEM ON FROM WORKERS'
COMPENS INSURANCE
(ITlis cation treed not bee p d if permit is for ane hundred dollars($100)
or less.)
I certify that in the perform cc c or whic s permit is issued,I shall not
employ any person in any an omc kct the Wo rs'Compensation
Laws of-aliform-Da
Applicant
NOTICE TO APPLI :1, r making this Certificate of Exemption,you should
become subject to orkcr's Compensation provisions of the Labor Code,you must
Qforthwith comply with such provisions or this permit shall be deemed invoked.
Z" CONSTRUCTION LENDING AGENCY
E~t►�-. I hereby affirm that there is a construction lending agency for the performance of
(Yr 5 the work for which this permit is issued(Sec.3097,Civ.C.)
OW Q Lender's Name
Lenders Address
U 0 I certify that I have read this application and state that the above information is
LL►' correct 1 agree to comply with all city an unty ordinances and state laws relating to
0 V building construction.and hereb o' represcntativea of this city to enter upon the
w above-mentioned property fo . pe urposes.
L>~ (We)
agree to sa ndcm ' d kee less the City of Cupertino against
,Ft liabilities,judgments,c is and wh' ay in anyway accrue against 'd Cily
C)Zinconsequence oC th granfn is pe t -U c
�+ APPLICANT U ERST AND 1 L CO WITH ALL NON OINT Issued b`,: Date _2 I
SOURCE REG ATIONS. n
r' Re-roofs —
Signatum of ppli Co or Date
HAZARDOUS MATERIALS DISCLOSURE Type of:Zoof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mon ipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof., shall be inspected prior to any roofing material being installed.
0 Yes No
Will the applicant uture building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminan as defined by the Bay Area Air Quality Management all new i naterials for inspection.
lict? /A
0 Yes
i�
1 have read the hazard is c der r 6.95 of the Califor-
nia Health&Safctycodo, 5, an I d that if the building
docs not currently ha ren at i s 'bili tify the occu ant of e
reyui.menis whi must be t u f a ate of Occu Signator°of Applicant Date
All roof coverings to be Class'n"or better
Owner or thori ag t Date
CITY OF CUPERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 3570 U Date: Y)
Building Address: r �1 s 5c, 6
1 tj ry t-/
Mailing Address (if different from building address):
Owner's Name: �\ Uva Y V IC�4 X15 CU Phone#: H a (TS_ 99 b Sr P)
HOA: (Exterior work only) Yes ❑ No ❑
If yes, provide letter from HOA '
Contractor: O Phone: L(V& - 9 9 b_ )�'� 9 Fax: 5c,
vv-k
Contractor License#:
Cupertino Business License#:
Contact: ,, Phone:
Fax:
Residential Commercial
Job Description: ul) I I" c1� , °4
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Vv t3 f/� �'�1� `P/�lS1 11 C �;CJ'/) C S C
IAC) a V, \C-,
Building Permit Info:
Bldg LSA Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B II/III/V-A ❑ II/III B, IV-HT, V-B [g
TL -�3
Valuation: 0 0 0 O C/_ 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.builditgr een.or
Revised 02/05/09
CITY OF 11UPERTINO
CITY Of GENERAL BUILDING APPLICATION
CUPE(�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1 STUCOAP Stucco A oplications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Wir dow-structural shear B
wall/mas)nry (includes plan ck fee)
1 EPERMITFEE Electrica: Permit Fee E
1 MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing;Permit Fee P
1 ELCPLNCK Stand Al ane Electric Pln Ck (hourly) E
1 MECPLNCK Stand Al ane Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Al ane Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-sl and alone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1 BSEISMICR Seismic Residential B
/ 1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel 8.Documentation B
1BUSLIC Business, License B
5ofS
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
r
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 hire,i to do:
A. _ All of the work
B. A portion of the w irk(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
erformed
................................................................................................................................................
r
I declare under penalty of perjury that the -30 ' s 7an correct. I have read and understand the
Owner-Builder Information (reverseo'si
'� J f•'/ Date:
Property Owners Signature:
Job Address: 50 Permit#
AU changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
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Assessor's Parcel Number:
Name of owner. 40
Project address. 1 V S b S �� C1VVL-
Contact person. �O�n SCO Phone.
Fix. g
Net square footage of lot.
7
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces in aide the garage? Y>:�,N
privacy protection planting required for the project? Y
On what floor(s) is work being done? U�Ut',VA F a
Brief description of work.
YV0 RAC(t, Cnl^I (IGI d V L%leC�Y (-g�
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2008 CPC (Y -N)2008 NEC (Y -,N) ° w THE
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Plan Review Process Work Book Page-8-Revised 1/1/08
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Assessor's Parcel Number:
Name of owner. 40 5 Co
Project address.
Contact person. Av\\�()\Au �U SCO Phone. 4 U(i5 —C101 — �3
Far.
Net square footage of lot.
-7.
Existing
� Proposed
Square footage: First floor:
Second floor:
Garage: -
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y>:�N
privacy protection planting required for the project? Y
On what floor(s) is work being done? 6 tt)
W)�� �vre ���
Brief description of work. U S��I'A d"} ��'��� f JV,-A,S �C,
nein e�t� YUo e� ��, rG� d ✓ L%Icc � rg
Code editions:2008 CBC N)2008 CFC (Y -N)2008 CMC (Y-N)
2008 CPC (Y -N)2008 NEC (Y-N)
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Effective 1/1/08
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Plan Review Process Work Book Page-8-Revised 1/1/08