09040130 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
....: .:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
A CONTROL NO.
ARCHITEC IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
app LICENSED CONTRACTOR'S DECLARATION 02
ZJOb Description
Z021 hereby affirm that I am licensed under provisions of Chapter 9(commencing
m with Section 7000)of Division 3 of the Business and Professions ,and y license is
=y in full force and effect BTHRM NON STRCTRL., E/M/P, @SME LOC (55SQ)
D12— License Class Lic.
-� **KITCHEN EXPERT OF CA PD BSL $114 . 00
p„O Datc Contractor
a ARCHITECTS DECLARATION
I understand my plans shall be used as public records
5 d
40,,,, Licensed Professional
y:1 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
K,$9 which requires a permit to construct.alter,improve,demolish,or repair any structure
y Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
z<t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation, 357150�7 . 01
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 trot apply to an owner of q P
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li-
ccnse Law does not apply to an owner of property who builds or improves thereon,and•
who contracts for such projects with a contractor(s)licensed pursuant to Use Contractors
License Law.
❑I am exempt under Sec. B&P C for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,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 required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers ore ensatio sura carrier and Policy number re:
Came; Policy No.: b
C RTIFI TE O EXEMPTION FROM ORKE S'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance 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 Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
NI 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.)
OWi Q Lender's Name
a M Lenders Address
U O 1 certify that I have read this application and state that the above information is
LL. cored 1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
E",t to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date L 23—J
APPLICANT UNDERSTAND AN W L COMPLY WITH AL NON 01NT Issued by: �"
SOURCE REGULATIO S
l te Re-roof:,
Signature of Appl Contractor are /r
HAZARDOUS ATERIALS DISCLOSURE Type of Roof
Will the applicant or future ding occupant store or handle hazardous material
u defined by the Cupertino Munic' al Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof;shall be inspected prior to any roofing mate ' 1 being' st
❑Yes �6�0
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, ove
ait hazardous air contaminants as defined by the Bay Arca Air Quality Management all new naterials for inspection.
District?
❑Yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant at it is my responsibility to notify the occ�76
of the
requirements which must a prior 'ss ancc of a Certificate of Oc Signature a of Applicant Date
Owner o<authmrtzedagent All roof coverings to be Class'`'or better
ate
Moq Q -30
L CITY OF CUPERTINO
ADDITION/REMODEL
CUPEkTINO FEE SIL".HEDULE
APN# A � Date:
Building Address: cq/CS(� S-0
s�v X ao
Mailing Address (if different from building address':
Owner's Name: �� V �— C�X �`• Phone# �S61e'_'3HOA: (Exterior work only) Yes E] eNo 000
If yes, provide letter from HOA
Contractor: � �? Phone#:
(X Fax #:
Contractor License#: eF 73
Cupertino Business License#:
Contact: `` / ✓�- Phone#: �9�5 .2 eco
Fax #: 6 �--
Building Pe it Info:
Bldg. Elect. [�/]� Plumb. [ Mech. Ef/ Hillside ❑
Job Description:
Addition-What is being added?(Be Specific):
What is being remodeled (not including additior.)?
Remodel Includes Re-Roof: Yes ❑ No .P-, /If yes list number of squares
Remodel Includes Structural: Yes E] No ,
Do you have the pre-application planning approval? Yes ❑ No
If yes, please provide a copy of your planning approval letter. Planners name:
Square Footage:
Addition: Porch: Deck: Garage: Detached Attached
Remodel: Kitchen Bath Other
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B S 1- + WL
Valuation: `s- S 4� Please check this box if the project is a
second-story addition ❑
Project Size: Express Standard ❑ Large ❑ :Major ❑
Please complete relevant portion of the Green Building
Checklist& attach it to the application or if applicable, Green Building Points Achieved:
include in plan set& the sheet index.
***For Office Use Only***
Over-the-Counter ❑ Revised 02/05/09
CITY OF CUPERTINO
ADDITON/REMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Sq Ft Group
ADDITIONS 1R3SFDADD
PLLONGRNGR Long R ange PL
Plannir.g/Residential
1 R3INSP Dwellings Inspections B
1R3PLNCK Dwelli:igs plan check B
1R3REPINSP DwelHigs Repeat B
Inspection
1 R3REPPLNC Dwelli igs Repeat Plan B
Check
1 R3HINSP Dwelli Zgs Hillside B
inspection
1 R3HPLNCK Dwelli Zgs Hillside plan B
check
1R3HREINSP Dwellings Hillside B
Repeat Inspection _
1R3HREPLNC Dwellings Hillside B
Repeat Plan Check
1R3ALTINSP Dwellings Alternate B
Materi.ils Inspection
1 R3ALTPLNC Dwellings Alternate B
Materi.ils Plan Check
1 PCESS Cesspool P
1PPRSEWG Ea. Private Sewage P
DispoE al System
1 PRSEWER Sewers P
1 BPSPRINK Lawn P
Sprinkler/Backflow
1BPWSVCS Main`Nater Service P
1 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Comrr ission Fee
1 BSEISMICRE Seism:cResidential B
1RER00FRES Residential Re-roof Each B
100 SIT
CITY OF C.UPERTINO
ADDITOTSUREMODEL
FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Sq Ft Group DECKS 1R3SFDADD OR
1R3SFDREM
1DECKWOOD Deck (V'lood)-Each B
(Each)
1DECKRAIL Deck Railing-Each B
(Each)
GARAGES 1R3SFDADD OR
DETACHED 1R3SFDREM
1GARDTW<=1K Wood Frame up to B
1,000 S F (each)
1 GARDTM<=1 K Masonry up to 1,000 SF B
(each)
BCONSTAXR Construction Tax Res
(new detached garage)
PATIO'S OPEN 1R3SFDADD OR
1R3SFDREM
1PATIOWOOD Wood frame up to 300 B
SF
1 PATIOMETAL Metal Frame up to 300 B
SF
1 PATIOOTHER Other Frame up to 300 B
SF
PATIO'S CLOSED 1R3SFDADD OR
& SUN ROOMS 1R3SFDREM
1 PATIOENCLW Enclos(;d Wood up to B
300 SF
1 PATIOENCLM Enclos,;d Metal up to B
300 SF
1PATIOENCLO Other I?nclosed Patio up B
to 300 5F
1 COVPORCH Porch Covered-Each B
(Each)
REMODELS 1R3SFDREM
1REMRESKIT Kitchea Remodel up to B (Deduct "$"for ea plan
300 SF check)
1 REMRESBAT Bath Remodel up to 300 B "
SF
1REMREOTH Other-Zemodel up to 300 B "
SF
RESIDENTIAL PROJECT;COVE.R SHEET
Assessor's Parcel Number:
Name of owner. 6
Project address. '��
Contact person. � � _ Prone.
Fax. Zr
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
10 foot b 20 foot clears aces in3ide the garage? Y/N
re there at least two y P
Is privacy protection planting required for the project? N
On what floor(s) is work being done?
Brief description of work.
Code editio :2008 (LP-N)2008 CFC (-Y -N)2008 CMC -N)
8 P -N)2008 NEC 1-N)
Effective 1/1/08
Plan Review Process Work Book Page-8-Revised 1/l/0E
i
curl Abih - — --t—
/S �
"y`j 4
RESIDENTIAL PROJECT COVER SHEET
Assessor's Parcel Number:
Name of owner. 6
Project address.
�G! Phone.
Contact person. � d
Fa:c. Zr
Net square footage of lot.
Existing Proposed
Square footage: First floor:
Second floor:
Garage: --
TOTAL:
o 10 foot b 20 foot clears aces imide the garage? Y�N
re there at least two y p
Is privacy protection planting required for the project? N
On what floor(s) is work being done? /
of work. a2�q,61rl �G�/adC�/ /��Jy1197 00ic'ell
Brief description 14,
Code editio : 2008 ( -N)2008 CFC -N)2008 CMC -N)
8 P 0-N)2008 NEC -N)
Li
Effective 1/1/08
J
ASSESSOR COPY
Plan Review Process Work Book Page-8-Revised 1/1/08
i
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$ �� -75
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
as
CITY OF Fax(408)777-3333
XPEkTINO
Building Department
JOB ADDRESS: PERMIT #
c2 4- 090YO136
OWNER'S NAME: G PHONE # E
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Sil, e Date
Please check applicable subcontractors and complete to the followin 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