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09040118 CITY OF CUPERTINO BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 10110 WESTMI I TER K DESI Iy�_ PERMIT ISSUE DATE OWNER'S NAME: 'DAO0 TL SA CONTROL NO. BUILDING PERMIT INFO ARCHiTECT/ENGINEER: BLDG ELECT PLUMB MECH RETROFIT 1 PATIO DOOR, 1 Cd c LICENSED CONTRACTOR'S DECLARATION WINDOW Job Description v 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing z w with Secdon 7000)of D'ision 3 of the Business and Professions ode,and my license is a a- in full force and eff¢ tic.N �9 � Dig!vLicen Lasa NN 1e �P-?l PC- Date - Z.- Contractor I ARCHITECTS DECLARATION < l understand my plans shall be used as public records D U rt; Licensed Professional nOWNER-BUILDER DECLARATION 1 hereby affirmfollowing reason.(Section 7031.5,Buthat I am exempt from the Contractor's License Law for the p O Business and Professions Code:Any city or county ( which requires a permit to construct < alter,improve,demolish,or repair any structure Valuation prior to its issuance,also requires the applicant for such permit to file a signed statement jq,Ft.Floor Area Z that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ts- (Comm enring 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 APN Number Occupancy Type Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). 0 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.). O 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's U. cense 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 the Contractor's License Law. ❑1 am exempt under SeB&P C for this reason Sec. Owner Date 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 Workces Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ave 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 omppe�nsCauu insurance carrier and Policy nuom am:��-e Cartier. ✓�✓' Policy No.: /�r�//ffrr Y•-� CER11Ft TE OF EXEMPTION FROM WORKERS' 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.I 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,atter making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the labor Code,you must �Z forthwith comply with such provisions or this permit shall be deemed revoked. Z� CONSTRUCTION LENDING AGENCY HI hereby affirm that there is a construction lending agency for the performance of .7 the work for which this permit is issued(Sec.3097,Civ.C.) W Q L.enrices Name Z Lender's Address U 0 1 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 0 V building construction.and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. (we)agree to save,indemnify and keep harmless the City of Cupertino against la4H to liabilities,judgments,costs and expenses which may in any way accrue against said City U 2 in consequence of the granting of this permit Date -+ APPLICANT UNDE TA, S AND WILL COMPLY WITH ALL NON-POINT Issued b',: SOU RiUL s as_0 c/ ,r....... V- Re-roofs Signature of A plicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Type of'Zoof Will the applicant or future building occupant store or handle hazardous material as deftned by the Cupertino Munrci al 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. 0Yes No 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 .mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new 1 naterials for inspection. District? - ❑Yes u 1 have mad 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,that it is my responsibility to notify the occupant of the Date requirements which must be met prior to issuance of a Certificate of Occupancy. S lgnatur,-of Applicant �• r��w 11-2,2- ef � I All roof coverings to be Class'"or better Owner or authorized agent Datc CITY OF CUPERTINO ADDITION/REMODEL CUPEkTiNO FEE SCHEDULE APN # Date: Building Address: Mailing Address (if different from building address): Owner's Name: Phone# HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Contractor: Phone#: Fax #: Contractor License#: Cupertino Business License#: Contact: Phone#: Fax #: Building Permit Info: Bldg. ❑ Elect. ❑ Plumb. [I Mech. ❑ Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? Remodel Includes Re-Roof: Yes ❑ No [] If yes list number of squares Remodel Includes Structural: Yes ❑ No [] Do you have the pre-application planning approval? Yes ❑ No ❑ If yes, please provide a copy of your Tannin ; approyal letter. Planners name: Square Footage: Addition: C_ Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV-HT, V-B—S Valuation: Please check this box if the project is a second-story addition ❑ Project Size: Express ❑ Standard[�] Large ❑ Vlajor❑ 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*** ElRevised 02/05/09 Over-the-Counter CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Sq Ft Group 1REMRES2 Remodel Residential B Greater thEn 1000 sq ft 1REMRES3 Remodel R.-sidential B Greater tha z 2500 sq ft. 1REROOFRES Residential Re-roof Each B 100 SF REMODEL PLNCK 1STPLNCK (1-3 for Standard Plan Check B NOT FOR OVER THE remodel) COUNTERMAN CKS. WINDOW/SLIDING 1R3SFDREM GLASS DOOR 1 WINREP Replacement windows B l (ea 8 windows) 1 WINNEWNSTR New Window (non- B structural) 1 WINMEWSTR New Window (Structural B Shear Wal./Masonry) 1 WINBAYSTR Bay Window (Structural) B SKYLIGHTS 1R3SFDREM 1 SKYL<10 SF Skylight lf:ss than 10 sf B 1 SKYL>10SF Skylight greater than 10 B sf or strucl ural 1 STAIRS Stairs-first flight/ea B addt'1 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanic TPermit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alc ne Electric Pln E Ck (hourly) CITY OF 41UPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Permit Type Sq Ft Group 1MECPLNCK Stand A.one Mechanical M Pln Ck (hourly 1PLMPLNCK Stand Axone Plumbing P Pln Ck (hourly) 1 BCBSC Cal Bldj; Standards B ALL PERMIT TYPES Commi,sion Fee 1 BSEISMICRE Seismic Residential B 1 TRAVDOC Travel &Documentation B 1 BUSLIC Busines 3 License B ��- • CITY OF C UPERTINO CSW OF PERMIT APPL[CATION FORM CUPEkTINO Rbc d)I � APN # Date: 1 �3,Yz 12- 113 y`aa- d9 Building Address: %d / Owner's Name: _ Phone#: F,2�W k J EL C yd 72--6 V2 Z/ Contractor: License #: 1/96W6 IContact: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ ?lumb ❑ Mech ❑ Job Description- V610 eb J1Zw-770th Residential I]Q F ,i � ,x120 dee :7 j�i/jv;�LJ Commercial ❑ Sq.Ft. Floor Area: i S/Sq.Ft.: Cost of Projecue I Occupancy Group: Tv pe of Construction: quantity I Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances ! MECHANICAL i BBLDGFEE I Bldg Permits . foot i BUILDING BBOILERI i B,)iler<= 100,000 Btu MECHANICAL BBOILER? Boiler> 100K to 500K Btu i MECHANICAL BBOILER3 I Bo ler> 500K to 1M Btu I v1ECHANICAL BBOILERI Boi er> 1M to 1.75 M Btu ! MECHANICAL i BBOILER55 3oiler> 1.75M Btu MECHA�'�'ICAL BCONSTAX Construction Tax BUILDING BCONSTAX ( Iid/Off/Comm/Quasi BUILDING BCONSTAkBQ j Con. Tax for BQ Zone i BUILDING i r i BCONSTAXH i Hotel and Motel _ BUILDINTG I I BCONSTAXR i Constax — Resi/Mobile BUILDING i BELEC 1000 j Elec 600V <= 1000A I ELECTRICAL BELEC 1001 Elec 600V > 1000A ELECTRICAL BELEC200 j Elf:c Secs 600V <= 200A ELECTRICAL r_ BENT1ERGY i _ Energy i BUILDING i 1 BENERGYADD Energy Add :Multi BUILDNG i i BINVESTIGA Investigation fee BUILDING i BMITIGATC i Comm. Housin, Mit. Fez BL"ILDNG 1 c �_