12070258CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21971 COLUN113US AVE,
O\\'NER'S NAME: GREIF RICIIARD K
OWNE'R'S PIIONE: 4086160408
121
) LICENSED CONC
I'RAfOR'S IDFCLARATION
/Lii'cense Class —7 i g_6 Z 6 Lic. d
Contractor.7 r (!!A _��/✓ L r vrf.D'me
hereby affirm (hit Fain licensed under the pros'isio ns of hapler'J
(commencing with Section 7000) of Division 3 Of the RuSiness & Professions
Code and that Inv license is in full force and effect.
I hereby affirm under pen alt' of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 ol'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 provided for by
Section 3700 of the Labor Code, for the performance ofthe work for which this
Permit is issued.
AI'PI-ICAN'I' CI'11'1'11ICA'I'ION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all cit' and county ordinances and state laws relating
to building construction, mrd hereby authorize representatives of this city to enter
upon the above mentioned propeny for inspection purposes. (We) agree to save
indemnify and keep lu m less the City of Cupertino against liabilities, judgments,
costs, and expenses which may ac_eme against said City in consequence of the
granting of this permit. Add-' if , the applicant understands mrd will comply
ur
with all non -point soce ulatirn5 per the Cupertino Municipal Code, Section
9.18.
Signalum- Date �/ Z
❑ / OWNER -BUILDER DECLARATION
hereby affirm IhaI 1 nor exempt from the Contractor's License Loc for one of
the following two reasons:
I, as owner of the property, or my employees with wages :a their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
herebyaffirm under penalty of perjury one of the following 1111 cc
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Cade, for the
performance of the work for which this pemrit is issued.
I have and will maintain Worker's Compensation Insurance, as provided Ibr by
Section 3700 of the Labor Code, for the perfommnce of the work for which this
permit is issued.
I certify that in the performance of One 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 Califnmia. If, after making this certificate of exemption. I
become subject to the Worker's Compensation provisions of the Labor Code. I most
forthwith comply with such provisions or (his permit shall be deemed revoked.
\I'I'LIC.\N'I' CFKI'I FIC.\'PION
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 laws 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 harmless the City of Cupertino against liabilities,judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupenino Municipal Code, Section
9.18.
Date
CONTRACTOR: SIERRA STRUCTURE INC
PERMITNO: 12070258
2435 SHERWOOD WAY
DATE, ISSUED: 07/312012
MEADOW VISTA. CA 95722
PHONE NO: (916) 275.1971
BUILDING PERNI IT INFO: BLDG r
ELECT 1- PLUi111Br
MECH I' RESIDENTIAL r COMMERCIAL 1 -
JOB DESCRIPTION: RESTUCCO 276 SQEr R ELECTRICAL UPGRADE TO 200
AMPS
Sq. Ft Floor Area: I Valuation: $3000
ARN Number: 35614037.00 1 Occupant) Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued
RF --ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new, materials for
inspection.
Signature of Applicant: Date:
AL1, ROOF COVERINGS TO BE CLASS "A" OR BETTER
IL\/.AI2DOUS M,\I'IiKLU.S DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth & SnDty Code, Sections 25505. 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth &
Safely Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or dr ices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance y2 (h the Cupertino Nl ode - pal Code. Chapter 9.12 and the
Health & Safety C],iific.�Sections 25505. 25533, and 25534.
Owner or IS forized agent:
Dnlc:y
CONSTRLICI'ION LI?LADING AGENC\'
I hereby affum lhm there is a construction lending agency for the perfommace of work's
for which this permit is issued (Sec. 3097, Cir C.)
Lender'sName
Lender's Address
ARCIIITE.C`I"S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
g.lN
ADDRESS: 21971 columbus ave.
DATE: 07/31/2012
REVIEWED BY: bob s.
Aleeh. Pernnit Fee:
APN:
BP#:
`VALUATION:
$3,000
*PERMITTYPE: Building Permit
PLAN CIIECKTYPE: Alteration / Repair
PRIMARY
USE: SFD or Duplex
Elce. Insp. Fee:
PEIVTAMATION
PERMITTYPE: 1GENRE A
WORK
restucco 276 s.f., electrical upgrade to 200 amps
SCOPE
t1'OTF.: This estimate does not htchulejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the nrelintinary information available and are onh• an estimate. Contact the Dent for arlydn'I into.
FEE ITEMS (Fee Resoh ion 11-053 Elf 7/1/11)
Alech. Plan Check
Phunh. Plop Cheek
Elec. Plan Check 0.0 1 hrs $0.00
Aleeh. Pernnit Fee:
I'btmh. Permit Fee:
Elec. Permit Fee: IEPERAIIT
Other,lfech. Imp.
Other Plumb lacy.
Other Elec. Insp. 0.0 hrs $45.00
,ilech. ht y. Fee:
Phunh. bevn. Fee:
Elce. Insp. Fee:
t1'OTF.: This estimate does not htchulejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the nrelintinary information available and are onh• an estimate. Contact the Dent for arlydn'I into.
FEE ITEMS (Fee Resoh ion 11-053 Elf 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= s. f. Restucco
$467.00 ISTUCOAPP
SuppI. PC Fee: Q Reg. 0 CIT
0.0
hrs
$0.00
PMC Plan Check:
$0.00
200 amps Electrical
$45.00 IERT<200 Services
Permit Fee:
$0.00
Suppl. Insp. FeeiO Reg. 0 OT0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$45.00
Cmtsn'action Tax:
Administrative Fee: ]ADMIN
$42.00
0
E)
Work Without Permit? 0 Yes 0 No
$0.00
Advanced Plannine Fee:
$0.00
Select a Non -Residential (F)
Building or Structure 0
i
Travel Documentation Fee: ITRAVDOC
$45.00
Stt'ong Motion Fee: IBSEISABCR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$133.50
$512.001ToTAL
FEE:
$645.50
Revised: 07/01/2012
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(4018) 777-3228 • FAX (408) 777-3333 • buildinq(Dcuoertino.ora
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PROJECT ADDRESS —3
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OWNERNAME PHONE
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STREET ADDRESS CITY. STATE. ZIP
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CONTACT NAME PHONE
E-MAIL
STREET ADDRESS
CITY. STATE. ZIP
FAX
❑ OWNER ❑ OWNER.BUILDER ❑ OWN, RAGE ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARc=cT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME' LICENSE NUMBER
LICENSE TYPE
BUS.LIC�i
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COMPANY NAME /
E-MAIL
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FAX
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STREET ADDRESS
CITY. STATE. ZIP
PHONE
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ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS. LIC 3
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY. STATE, ZIP
I PHONE
DESCRIPTION OF WORK
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EXISTING USE
PROPOSED USE
CONSIR TYPE aSTORffS
USE
TYPE
OC/C(. I
SQ.FT.
VALUATION (S)
ROG
NEW FLOOR
�
TNETf AL
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEI, AREA REMODEL AREA
PORCH AREA DECK AREA
TOTAL DECKiPORCH AREA GARAGEAREA: DETACH
❑ ATTACH
I
M DWELLING UNITS:
IS A SECOND UNIT ❑YES
SECOND STORY ❑YES
BEING ADDED' ❑NO
ADDITION' ❑NO
PRE -APPLICATION OYES IF YES. PROVIDE COPY OF
PLANMNGAPPL9 ❑NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑YES'n
EICHLER ROME' ❑NO
RECEIVED RY;.,y �, R,; TOTAL VALUATION:
� � - �
�
00 0
By my signature below, 1 certify to each of the following: 1 am the prope owner or authorized agent to act on the property owner's behalf. I have read this
application and the information 1 have provid5d is correct. 1 h r tthe Description of Work and verify it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to buildi UK( rite rep xn[atives of Cupertino
to enter the above-iden[ifi d property for inspection purposes.
/ttrruction.
/
Signature ofApplicandAgenC �/-
Date:
SUPPLEMENT DIFORNMATIONREQUIRED
- n.;cuRCRTv"e` t_=+
T'trrtol-Z P.
_ New SFD or hfultifam' y dwellings: Apply for demolition permit for
'�--''
O�TECOU�TEA
gvr _2
existing building(s). Demolition permit is required prior to issuance of building
.1 t�
r •�Butt.mNcPLyN R �VTEN -a`y y.,-5
permit for new building.
❑ ENPRE35. 'x,' c �.I
I❑' F: PLA.NUIvd P"N RFVIFW.
{'r?I;a
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_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if Hazardous Materials
ii❑,JSTANDARD �' i
rj}$ o t
NQ !'UREICNV
any are being used as part of this project.
+�,,,fc r ,
:�OtLAROE-✓�.
.y^• eT. _� , y(
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Planning Approval Letter Meeting Planning
N.'-��=��11�❑O
FIRE DEPT
�W.~'F
—Copy of or with prior to
`j❑u3`"�'
r``R,.�e�..
submittal of Building Permit application.
r�F.YVIRONME.\'TAE t1EALTF7 �`:
Bldgdpp_ 011.doc revised 06/21111 -