12050005 CITY OF CUPERTINO BUILDING PERMIT
I)UI LD INC ADDRESS: 22881 S'fONEBRIDGI:ST CON"IRAC 1014:AND1.RSON PLRNIIINO: 12115110113
CONS'I'RI1C IION
O%%'NEIt'S.\A.\IF: TI IOMSEN HARRY A III AND MARY 1 739 KENNARD\VA1' D,\"If: ISSULD:IIS/01/2_011
OWNER'S PllONE: 4082571870 SUN'N'I'VAIs:.CA 9411117 PRUNE.NO:(41M)733-8271
❑ LICENSED CONI'RAC'I'OR'S DECLARA"1-108 — � f
BUILDINGBUILDINGPERMIT INFO: BLDG ELECTELECTI'Ll1JIR
License Class Lic9 Y1J//r t-(-�r F F-
r
qLyQn NIECII RESIDENTIAL COMMERCIAL
(:Plllrllllllr /�/I(Jli'A�7 '/�'- ����DBI,, /—)'� _ i2
I hereby affirm Thal I am licensed under the provisions of Chapter 9 JOB DESCRIPTION', KI'I'CI IIfN RIiMODLL(I10 SOF'1')'1'0 kI.%IOVI!ASU
(commencing%tilh Section 7000)of Division 3 of the Business&Professions RiT[.ACI(
Code and that my license is in full force and eRecl. AI;PLIANCFS AND SINK.NEW LIGH IINIi AND CIVI
7/02/12_REVISION NI OVERT HE COUN IIiR HEAN IN KI'I CI It N ISSIAM 7/2/12
I hereby nlBnn under pen:dlr mf perjury one of the following two declarations: SUliW
I have and still maintain it certilicnle of consent to self-insure for Worker's
Compensation,as provided Ibr by Section 3700 of the labor Code,for the
per linntnnce of the stork lin which Otis permit is issued
I have and will maintain Worker's Compensation Insurance,as provided for by .�EWMIN
Scc I on 3700 of the Labor Code,Ibr the perl'orman cc ofill e work for which this FiC�f�'�'�
perntil is issued. Sq. FI Flour Area: DATE - um:5280(1(1
APPLICAN'"I CERTIFICATION
I certify that I huvc read Thu application and stale that the above information is .M'N Number:31213033.00 Occupancy"1)pe:
correct. I agree lu comply with all city and counly ordinances and state Ilnys rdmine
to building construction,and hereby authorize representatives of lllis city to enter
upon the above invmiuned properly lox inspection purposes. (We)agree m cme
indemnifi :mJ keep harmless the City of Cupertino against liabilities,judgntnols' PERMIT EXPIRES IF WORK IS NOT SI-ARTE )
costs,and expenses sOucll may accrue against said Cin'in consequence of the
maniineof this pcnnil. Additionally.tile applicant understands;aid mill comply WITHIN 180 DAYS OF PERNIFIASSUANCE OR
all all mnn-pminl5umce fcgulalions per me Cupertino Municipal Code.Section 180 DAYS FROM LAST CALLED INSPEICTION.
9.I X.
SignatureDate�l� Issued by: f��/� �(�T(/� Date:
❑ O\1:NER-BUILDEM DECLARATION
I herehv affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following Ill.,reasons: All roofs shall be inspected prior to an)'roofing material beim_Inswllcd. If a roof is
L as os.ner ol'the properly.or 111y employees with%cages m their sole compensation, installed%%RIME lira obtaining all inspection.I a^_ree R,tenw%e all nese macnals lin
will du the work and the structure is not intended or offered for sale(Sec.7044, inspection,
Business&Professions Code)
I,its usenet of the properly.ten exclusively contracting svilll licensed contraciors to Signature of Applicant Date:
construct the project(Sec.7014.Iiusincss&Professions Code),
hereby affirm under penally of perjury one of the following three ALL ROOF CON FRINGS'10 BE CLASS"A"Olt I3F 1-Ilii
dcclaraliuns:
I leve and%gill maintain n Certificate of Consent in self-insure for Worker's
Compensation.as pmcidcd Ibr M'Section 3700 ol'Ihc Labor Code.lipr the IIAZARD01 S M:\'l LRIALS DISCLOSE RF.
IC1101mnncc of the cork lit%%11 Ch Ill is perntil is issued I have read the hazardous materials requirements tinder Chaplrr 6e75 of the
I have and will maintain Worker's Contpcnsation Insurance,as pmv ided(opt by Califimnia I Ieallh&Salviv Code,Sections 2550.,,25.,33.and 25534. I%,ill maintain
Section 3700 of the Labor Code, lin Ilseerformance of the%work lox which this Compliance wish Ole Cuperlinu Municipal Code.Chapter 9.12_and the Health&
p Safety Cade.Section 25532(x)should I store or handle hazardous material.
)coni(is issued. Addilionallr,should 1 use equipment or dc%ir'wn%%Inch vatic h:rzardnus air
I certil% Ilml in the p r inns:race of the work for which this permit is issued,1 shall contaminants as defined by the Tiny Area Air Quality Managenuml District I tit ill
not employ any person in any manner so as to become subject to the Workers maintain compliance%wilh the Cupertino Nlunuipal Code,Chapter 212 and Ihv
COInpeuul ion laws of California. 11;after making this certificate of exemption.I Ileal lh&SefeIN.(:ode,SecI ions?5505,25533.;1 2_5534.
become Subject to the Worker's Compensation provisions of the labor Code.I must
Owner or thnrized agent:
Ibnh%yith cumplr with such provisions or This permit shall be Jccmcd revoked
APPLE CANT CER'17FICAIION CONS"1RUC"ZION LENDING AGENC\'
I cerlily that I lure read this application and slate that the above information is
correct. I agree to comply with all cis,and county ordinances and state laws relating I hereby allirm that there is it construction lending agent%lilt the perlimnanec of%%oi Ks
w handing Ctmsrucoon,and hereby authorize representatives of this city to enter for%which this pcnnit is issued ISec.3097,Cir C.)
upon Ilse above me it s ion cd properly for inspection purposes.(We)agree to save Lender's Nanalt'
iTitle Ili i l N'and keep harmless the City'o Cupertino against l iabiI iIies,judgntenis.
costs,and expenses which may accrue against said Cit%in consequence of ilic Lender's Address
,,ranting til this pcnnit.Additionally,the applicant understands and%%ill comply
syilll all lion-point source regulations per the Cupertino Municipal Code.Section
9.18. AIlk:I I I EC I"s DEC LA RAIL ON
I understand nn'plans shall be used it public records.
Signature Dale
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX(408)777-3333 • buildin cu ertino.or
CUPERTINO
❑NEW CONSTRUCTION ❑ .ADDITION AL�/TERATION/TI REVISION/D ORIGINAL PER.wfll'i♦ ��O DOp 3
X PROIECT.ADDRFSS/J /� a�I O �Y // ' APN p
X OWNERNAME �CL_OM CQN r/. PHONE
)r/ STREET ADDRESS r I J`--/1 CITY. STATE ZIP / L FAX
CONTACT NAME PHONEOq 2 rJ G� 2q- E-MAIL
ST,- ADDRESS ^ CI Y.5TATE. ZIP////�J^G C/Ct�6Q
❑OWNER ❑ OW -BUILDER ❑ ONTIEA AGENT I CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCTBTECT �❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE Bus.LIC a
COMPANY NAME E-MAD. FAX ,
STA&.T ADDRESS CITY,STATE,IIP PHONE
ARCHMEC,-/ENGINEER NAME LICENSE NUMBER BUS.LIC p
COMPANY NAME E-MAE FAX
STREET ADDRESS CITY,STATE IIP PHOONE
DESCRIPT
ION OF WORK
E)STIG USE PROPOSED USE CONSTR.TYPE #StORffS
USE TYPE OCC SQ-FT. VALUATION(S)
E'ASTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET.AA&1 -
BATIc OOM KITCHEN OTHER
REMODELAREA REMODELAREA REMODELAREA
FORCHAREA DECK Aqc♦ TOTAL DECK/PORCH AREA I GARAGE ARIA DETACH
ATTACH
g DWELLING II,M, ISA SECOND UNIT YES SECOND STORY YES
BE1N0 wDDan ❑NO ADDITION? ❑NO
PREAPPLIGTION ❑YES rF YES,PROVIDE COPY OF STHE aLDG AN ❑YES �RECaVM BY: TOTAL V Ti N:
PLANNING APPL4 []NO PLANNING APPROVAL LEITER EICBLER ROME? ❑NO - /
By my signature below,I ccrdfy to each of the following I am the property owner or authorized agent m act on the prpperty owner's behalf. I have toad this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws[elating to bul/dV construction I authorize representatives ofCuperiino to enter the above-identified property for inspection purposes.
Signanmof Applicanr/Agene — ' — Date: ydcJti
SUPPLEN=AL DZTFORMATTON REQUMED PLAN CHECK TYPE Tq( ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ovFa-THE-COUNTER I�BU¢OnNG PLAN REVmW
existing building(s). Demolition permit is required prior to issuance of building / 1 .
permit for new building. EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11 STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE ❑ =DEFT
_Copy of Planning Approval Letter or Meeting with Planning prior to
❑ NAJOR ❑ SANrrARY SEWER DISTRICT
submittal of Building Permit application.
❑-ENvmoN.VIE.Nr.AL�u.rs
BfdgApp_2011.doc revised 06121/11
I I�
y
,CA ffl Olt%
.7 11 t . p p
ie
CZ-
16 16
i N a V
COMMU TY DEVELOP ENT DEPARTMENT I I
BUIL INGiDIVISIO -CUPERTINO 1 �''� i
APPR ED
This set of plans d specifics ions MUST be kept at the ? I ���C+�®Ip p Bg I I
Job site during c nstruction. is unlawful to make any eI I REVISION 8�
changes or Iter tions on same,or to deviate 1 CU ER���0
therefrom,w rt
uta proval from the Building Official. Building Department
The stamping p.an and specifications SHALL NOT - -- -- -
be held to permit or to be an approval pproval of the violation JUL 0 2 1011
Li
of any provisions of any City Ordinance or State Law.
By REVIEWED FOR PLIANCE
DATE Reviewed By:
PERMIT NO. Gi�.VO 3 ------- -�'--- -- -- -
ICITY OF CUPERTINO
ITEM 1 OF 1 I PERMIT RECEIPT OPERATOR: suew
COPY f{ 1
I .
Sec : Twp: Rng: Sub: Blk: Lot :
APN ' ' : . 34213033 . 00
DATE ISSUE 07/02/2012
07/02/2012
RECEIPT #. . . . . .1. . . : BS000017215
REFERENCE ID •# 12050003
SITE- ADDRESS% . . L . . : 22881 STONEBRIDGE ST
'SUBDIVISION . . . I. . . :
CITY . . . . . . ... . . �. . . : CUPERTINO
IMPACT AREA . . . . . . :
OWNER. . . . . . . . . '. , . . : THOMSEN HARRY A III AND MARY J
ADDRESS -.: 22881 STONEBRIDGE
CITY/STATE/ZIP CUPERTINO, CA 95014-5639
RECEIVED� FROM I . : ANDERSON CONSTRUCT
CONTRACTOR. . . .. . : ANDERSON CONSTRUCTION LIC U 33316
COMPANY '. . . . . . . .. . . : ANDERSON CONSTRUCTION
ADDRESS, . . . . . . . . . : 939 KENNARD WAY
CITY/STATE/ZIP SUNNYVALE, CA 94087
TELEPHONE ... . . . . (408) 733-8271
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
1BCBSC VALUATION 28, 00,0 . 00 2 . 00 2 . 00 0 . 00 0 . 00
1BSEISMICR VALUATION .28, 000 . 00 2 . 80 2 . 80 0,. 00 0 . 00
1REMRESKIT SQ FEET 1 . 00 588 . 00 588 . 00 0 . 00 0 . 00
1STINSP UNITS 1 . 00 133 . 00 0 . 00 133 . 00 0 . 00
TOTAL PERMIT 725 . 80 592 . 80 133 . 00 0 . 00
METHOD OF PAYMENT -- _AMOUNT, REFERENCE NUMBER
---------------- ------ ---------- ------- ---
CHECK 133 . 00 1202
----------
TOTAL
-'-------TOTAL RECEIPT 133 . 00
i
I
I