12070183 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21762 LINDY LN CONTRACFOR:SEAN WEIBY 1'ER\IITNO: 12070183
OWNER'S NAME: DAHM PHILIP L AND BRENDA L 12277 S SARATOGA-SUNNYVALE RD STE C DA'Z'E ISSUED:07P4n012
OWNER'S PHONE: 4088912322 SARATOGA,CA 95070 PHONE NO:(408)460-6251
❑ LICENSED CONT'RACTOR'S DECLARATION •JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class_ Lica J REPLACE WINDOWS LIKE-FOR-LIKE
coal nctor ?a,_ LI P', �>TDale
_��'�5�/2C��
1 hereby affirm([nil I am licensed under the provisions of Chapter 9
(Coil]ncacing with Section 7000)of Division 3 of the Business& Profexsiuns
Code still]that my license is in full force and effect.
hereby affirm under.penalty of perjureone of(he fallowing two declarations:
I have and will maintain a ccr ificmc of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued Sq.Ft Floor Area: Valuation:$3000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35624026.00 OccupancyType:
ype:
permit is issued.
A I'I'LIC.\NI'CFR'1'I F'IC.\'PION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state Imes relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter '
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep hamiless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting ofthis permit, Additionally,the applicant understands mid will comply Issued by: �C19/✓ ArG/-t Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RF:ROOFS:
Signature Se, Datej� All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining mm inspection,I agree to remove all new materialsfor
inspection.
❑ OWNER-BUILDER DECLARATION
herchy affirm that 1 all,exempt from the Contractor's License Low florally of Signature of Applicant: Date:
the fallowing two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) '
1,as owner of the property,am exclusively contracting with licensed contractors to IIA%ARDOUS MA'1 ERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Cade). I have read the hazardous materials requirements under Chapter 6.95 of the
California llealth&Safety Code.Sections 25505,25533,and 25534. 1 rill
1 hereby affirm under penalty of perjury one of the following Three maintain compliance with the Cupertino Municipal Code.Chapter 9.1'-and the
declarations: Health&Safety Code.Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bar Area Air Quality Management District
performance of the work for which this permit is issued will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by (Ile Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this r _ /
Owner orau(horized ager(: `�..i._ (r� , ,,w Date:
pcnnit is issued _ 't" 'tet+—gs r
1 ecnily 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 Worker's
Compensation laws of California. IL alter making this cerificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
AI'1'LIC,\N I'CI?R'I'II%G\'1TON Lender's Address
I 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 Imes relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harndess the City of Cupertino against liabilities,judgnients, ARCIIITECI"S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
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CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION 070/63
ADDRESS: 21762 Lindy In DA'Z'E: 07/24/2012 REVIEWED BY: Sean
MAPN: 356-24-026 BP#: 'VALUATION: $3,000
*PERMIT TYPE: Building Permit PLAN CIIECIC Tl'PE: Alteration / Repair
PRIMARY NI
USE: SFD Or Duplex PFRMITTYPE: 1GENRE
WORK re lace 6 windows like for like
SCOPE
Xlech. Plan Check Phonb. Plan Check F-lec. Plan Check
bfech. Permit Fee: Phunh. Permit Foe: Flec. Permit Fee:
Other,ifech. Imp. Other Plumb Insp. Other Elec.Imp.
,i e.&hup.Fec: Phunb, hnp.Fee: Elce.Insp.Fec:
A'OTE: This eslintale does not include jeer due ro other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District, etc.). Thesefees are baser/on the prelintinan•information available and are only rut estimate Contact the De I or addis7 info.
FEE ITEMS (Fee Resolution 11-053 F_R 71111 1) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 EEI # Window/Sliding Glass Door
Suppl. PC Fee: Q Reg. O OT 0.0 hrs $0.00 $400.00 Ilt'INRFP Replacement
PME Plan Check: $0.00 F-0-1 # Window/Sliding Glass Door
Permit Fee: $0.00 $0.00 I New(Non-Structural)
SuppI. Insp. Fee Q Reg. Q OT 0.0 1 hrs $0.00 = # Window/Sliding Glass Door
PME Unit Fee: $0.00 $0.00 1 New (Shearwall/Masonry)
PME Permit Fee: $0.00
Conviiiction Tac:
Administrative Fee: O
Work Without Permit? Q Yes (2) No $0.00 E)
Advanced Planning-Fee. $0.00 Select a Non-Residential G
Travel Documentation Fees•: Building or Structure 0
A
Stone Motion Fee: IBSFISMICR $0.50 Select an Administrative Item
Blda Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.501 $400.00 TOTAL FEE: $401.50
Revised: 07/01/2012
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildinoe-cuoertino.ora
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMITd
PROJECT ADDRESS [�
8 L u o APNa � ��7 0,
OIVNAM PHON E-MAIL
( J - �-
S REEF ADDRESS
I CITY, STATE,ZIP FAX
,✓ �lt- I t ! rt V I
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT (B CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
C CTOR NAME L ff BE LICENSE TYPE BUS.LIC N
M2
C IPANY NAh1E E-NAIL 11 FAX v /
ja
). r ., _e a Go y9 - ✓
STREET ADDRESS{ I fffY,SATE,ZIP N �/
ARCHITECLENGINEER NAME LICSENBUS.LIC d
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRI TION OF WORK
MSTRIG USE PROPOSED USE CONSFRTYPE aSTORM
USE TYPE OCC, SQFf. VALUATION(S)
E%ISTG NEW FLOOR✓ C/ DEMO TOTAL
AREA AREA ARFA NETARE\
BATHROOM KITCHEN OTHER
RFiMODELAREA REMODELAREA REMODEL AREA
PORCHAREA DECK AREA TOTALDECKIPORCHAREA GARAGE AREA: r DETACH
❑ATTACH
B DWELLING UNITS: IS A SECOND UNIT ❑YES SECONDS
FORY YES
BEING ADDED', �pI NO ADDI'TIOV' NO
PRE-APPLICATION YES IF YES,PROVIDE COPY OF is Fit E BLDGA9 ❑YES RECEIVED -- TOT VALUATION:
PLANNMGAPPLa NO PLANNING APPROVAL LETTER EICHLERHOME7 ANO ' �� _ J �DDO
By my Signature below,I certify to each of the following: I am the property owner or authorized agent to act ontheproperty owner's behalf. I have read this
application and the information I have provided is correct. 1 have read the Description of Work and verify it is accurate. [agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-Ice TI filed property for inspection purposes.
Signature ol'ApplicandAgenC c Date: ZS r�—nf7
SUPPLEMENTAL INFORMATION REQUIRW ..PLAN CIIECKTVPE ROUTING SIJY
New SFD or Multifamily dwellings: Apply for demolition permit for 1�i1 OVER-THE-COUNTER 'BUILDING rLAn'REVIEW
existing building(s). Demolition permit is required prior to issuance of building j-
permit.for new building. '❑ ESPRESS ❑- PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD _❑.FUBLICWORKS
Term if any Hazardous,btaterials are being used as pan of this project. ❑ LARGE ❑ .FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to -❑. ,MAJOR ❑ saNITARV SEaERm51'RICI'
submittal of Building Permit application.
❑ ENVIRONMENTALHEALTH, .
BldgApp_20/1.doc revised 06/21/11