12080150 CITY OF CUPFRTINO BUILDING PERMIT
BUILDLNGADDRIiSS: 10654NBLANEI'AVE CONTRAC'MR: PERMITNO: 12080150
OWNER'S NAME: NIHAR&VAIDEHI GOKHLE DATE ISSUED:08114/2012
OWNER'S PHONE: 4084170536 Jti . 1 t 1'IIONRs;o:
❑ LICENSE'D CONTRACT'OR'S DECLARATION BUILDING PERIMIT INFO: BLDG r ELECT r PLUMB r'
License Class- 6 Lic.9 7 7 l f.' 6 r r r
h11CC11 RESIDENTIAL COMMERCIALContractor AoAe/>x1/1 61-W" J Date '2? 2
I herebr:dTinn that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE WATER DAMAGED SHEETROCK
(commencing with Section 7000)of Division 3 of the Business J Professions AND
Code and that my license is in full force and effect. INSULATION ON FIRST FLOORANY OTHER MECHANICAU
ELECTRICAUPLUMBING PERFORMED SHALL BE UNDER A
hereby affirm under penalty of perjury one of(lie following two declarations:
1 have and will maintain a cenificate of consent to self-insure for w'orker's
Compensation,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 provided for by
Section 3700 of the Labor Code,for the performance 01'IIw work I'oryvhich this
permit is issued Sq.Ft Floor Area: Vuluatiun:$4370
.U'1'I.IGAN'1'CliR'TIFICA'I'RIN
I certify that I have read this application and state that the above information is APN.Number:31043021.00 Occupancy Type:
correct. I agree to comply with all city and county ordinarces and state laws relating
to building construction,and hereby authorize representatives of this city m enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemni1v and keep harmless tire City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-pointsource regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature / Date Issued by: l/ Date:
❑ /OWNER-R111LDER DECLARATION
I hereby affirm that I run exempt Iron the Contractor's License Um for one of RE-ROOFS:
the following Ino reasons: All roofs shall be inspected prior to any roofing material being installed If a roof is
I,as owner of the properly,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business 3 Professions Code)
I,as owner of the properly,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business R Professions Code),
hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BE ITER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS S DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Ilcallb S Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Section 3700 of the Labor Code,Ibr the performance of the work for which this compliance with'(lie Cupertino Municipal Code.Chapter 9.12 and the I lealth&
Safety Code.Section_553_(x)should I store or handle hazardous material.
permit is issued Additionally,should Fuse equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued I shall contaminants as defined by the Bay Arca Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. IL after making this certificate of exemption,I Health S Safety Code, coons 25505.25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must -
f arthwith comply with such provisions or this permit shall be deemed revoked. Own ( r amhoriorrfC
[)are:
APPLICANT'CERTI FICATION / CONSTRUCTION LENDING AGENCY '
I cenify that I have read this application and state that the above information is /
correct.I agree to comply with all city and county ordinances ad slate laws relating I hereby affirm thin there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liahilities,judgments,
costs,and expenses which may acerae against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section AI4CI IFTECI"S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10654 N Blaney Ave DATE: REVIEWED BY:
1-21 APN: BP#: `VALUATION: $4,370
"PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY Multi-Family Dwelling Buildino is PENTAMATION
USE: >3 Stories Q Yes Q No PERMITTYPE: 1R2REM�
WORK Remove and replace water damaged sheetrock and insulation on first floor. An other MEP performed
SCOPE shall be under a separate permit.
TYPEOF
OCCUPANCY TYPE: CONSTR.. FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSs.f.)
R-2 (Apartment) II-B,111-B,IV,V-B 0 $0.00 $0.00
TOTALS: 0 $0.00 $0.00
i\9ECH, HOURLY C) Yes (j) No PLUMB, HOURLY Q Yes 0 No ELEC, HOURLY Q Yes (D No
Much. Plan Check Phunh.Plan Check Flee. Plan Check
meth. Permit Fee: Plumb. Permit Fec: T:Iec. Permit Fee:
OtherMuch. Insp. Other Plumb/nsp. L1 I Other Elec./tap.
Mech.hup. Fec: Plumb. bu7p.Fee: Dec.Insp.Fee:
A'OTF: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,SunitarySesrer District,School
District,etc.). These feev are ha.sed on the prelintinan in ornmtion(mailable and are onh,an estimate. Contact the De ! or oddn'I info.
FEE ITEMS (Fee Resolution 11-053 F_/I7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Supp[. PC Fee: Q) Reg. Q OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly Only? O Yes Q No $0.00
Suppl. Insp. Fee0 Reg. Q OT 0.0 1 [its $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consnttction Tar:
Administrative Fee: Q
Work Without Permit? O Yes Q) No $0.00 G
Advanced Planning; Fee: $0.00 0 hours Inspections E)
Travel Documentation Fees: $266.00 ISTINSP Inspection, Hourly
Shona Nlotion Fee: IBSEISAIICB $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.501 $266.001 TOTAL FEE: $267.50
Revised: 07101/2012
12�g 01 �
CONSTRUCTION PERMIT APPLICATION
Im COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION IftaM 112111
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228• FAX (408) 777-3333• building cuoertino.oro
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS D/ S n / AIN tl� (0 [J. — O
v OWNER NAME ('r D I` u 1 /( PHOONSAO2 4/ 17
- �S/ I E-MAIL
STREETADDRESS I l CIT', Sy^T �PI_ VL t1J ib FAX
CONTACT NAME PHONE T1 E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNTRAGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT O ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME ,Ioq I LICENSE NUMBER LICENSETYPE BUS.LICK
14
COMPANYNAME /� E-MAIL FAX
N.r'`-Fi�S�JN /J
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC 9
COMPANY ME crg��t E-MAIL-MFAX
- Grv�
'- Sa . ! ' i 3 PHONESTREET ADSSTA� ZIP
'
DESCRIPTION OF WORK �-
C (-V"t l! n , / t0 '? C OoAI J °
ln-1rn�P (' du.v.a �
EXISTING USE/J PROPOSED E L CONS-p-PE x STORIES
/U(i/✓n/_I✓/�C .4�J4 VvK USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AAEA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTALDECKO'ORCH AAFJ. I GARAGEAREA: DETACH
E]ATTACH
N DWELLING UNITS: IS A SECOND UNIT E]YES SF.CONDSTORY AYES
OEINGADDE.D° ONO ADDI'1'ION'i [JNO
IBE-APPLICATION ❑YES IFYES,PROVIDECOPYOF I IS-1'IIEIn.UGAN ❑YES 'RECEIVED - TOTAI VALUATION: '^�
PLANNINGAPPLk []NO PLANNING APPROVAL LETTER FACHLERHOMIE. []NO `_ _ /'_ C .aj 7c),U
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 hav read this
application and the information 1 have provided�I'Tect. 1 have rea Description of Work and verify it is accurate 1 agree to comply with all applicable local
ordinances and state laws relating to Ilding c swction. l aay/I�horde presentatives of Cupertino to enter the a�F(�ove-identified property for inspection purposes.
Signature of ApplicantlAgcnl: /\ J /// / Date: /V.
SUPPLEMENTAL(FFORNLATION REQUIRED _ PI.AN CH ECi.TYPE � HOLDINcSlll-
New SFD or Multifamily dW2i 49s: Apply for demolition permit for �`v�. -
y� 'k)\FR/IID COUNTER UII i1NG PLAN RF\It\\'•
existing building(s). Demolition permit is required prior to issuance of building � 1/-��,
permit for new building. LJ I\PRESS - I ❑ I LANNINc PLAN RLN'16V -
r
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El;NTANDARO -. ElPiB LIC WORKS, -
fonn if any I lazardous Materials are being used as part of this project. I -
❑� LAIicF: - ❑ FIREDEPT ..
_Copy of Planning Approval Letter or Meeting with Planning prior to p'NIA�OR ❑ SASITARvSK%VTR DIS'1'RICr
submittal of Building Permit application.
,❑ .EN\'IROSAIE�"1'AL1I F.ALTIL_ __
BldgApp_2011.doc revised 0601/11
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10654N BLANEY AVE CONTRACTOR:ANDERSON GROUP PERMIT NO: 12080150
INTERNATIONAL
OWNER'S NAME: Nil IAR d VAIDEI If GOKIiLE 2285 PARAGON DR DATE ISSUED:08/142012
ON'NFR'S PHONE: 4084170536 SAN JOSE,CA 95131 PHONE NO:(408)954-1400
❑ LICENSED CONTRACT'OR'S DECLARATION JOB DESCRIPTION: RF,SIDINTIAL COMMERCIAL
n per/ i
License Class Lic.# / o OCN� 9/11/2012- REVISION #1 ADD 5 LIGHTS,
^ -^ p REMOVE/REPLACE KITCHEN SINK FILL IN OPENING IN
Contractor /tel Gf�SCJ/f riCy�t Date. cl-7 �4 Z KITCHEN
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business S Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to stir-insure for Worker's
Compensation,as provided for by Section 3700 of Labor Code,for the
performance of the work for which this permit is issued Sq. Ft Floor Area: Valuation:54370
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:3164302 L00 Occupancy"Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state tint the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws 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 harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the _ N G
granting of Otis permit. Additionally,the applicant understands and will comply Issued by: J�/7 l/ Date:
with all non-points t cc regulations p5Edic Cupertino Municipal Code,Section
9.18.
G� _ RE-ROOFS:
Signature Date / (—( 2 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ // ownb:R-BUDDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License haw for one of
the following two reasons: ALL ROOF COVERINGS TO RE CLASS"A"OR BETTER
I,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&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ILA""LARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code,Sections 25505,25533,and 25534. I will
hereby affirm under penalty of perjury ane of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth 3 Safety Code.Section 25532(1)should 1 store or handle hazardous
I have and willmaintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,m provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Qual' v Management District 1
pedbrmmtce of the work for which this permit is issued. will maintain compliance with t upertino pl ni p Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect'on 25505,255 nd 5534.
Section 3700 of the Labor Code,for the perfornwnce of the work for which this
permit is issued. Owner or authorized agent: Date:
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 Worker's
Compensation laws ofCalifomia. If,after making this certificate of exemption,1 C (RUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must 1 hereby aDlrn that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION 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 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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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
/aoba/.So
GENERAL PERMIT APPLICATION E P
EM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014.3255
CUPERTINO T/7-3333 raI
(408)777-3228 • FAX(408) •building0ruoeno.orc
SC
%
PLLrhffiQNG ❑ C^L�?7iCAL LE=E -CAL. ❑1USCELLANEEpO//USS.``,pp yp�� 9gypspp�
?AOlto DAFS( /7� L/C' I .A.°NY RP. MSION # l _
OWZ' ,'' '.fE R G- . �T PHONE E-MAIL1 O�Sl7— D��6
57REETADDRESS I CITY, STATE ZIP FAX
CONTACT NAME PHONE I E-MAIL
iYJE � -i civ z
STREFTADORESS Ci Y.STAT'E. ZZ? I FAX
❑OWNER ❑ OWNER.BUBDER ❑ OWNER AGr_Yi ❑'coNT.IACTOR ❑CON, ACNRAOE+i ❑ A mu=z_Cr ❑E"cmzx ❑ DEVELOPER Cl -,VANr
GDNiAA .OR NAME L:CLNSE NUMBER I WL VSE TYPE BUS.LIC4
O C= fl
cowNAW¢ E- FAX
STREFi ADDRESS C rY.STATE ZIP I PHONE
ARCHrrECTUENGINEEi NAME LICENSE NUMBER_ ,0 O I BUS.LIC a
COMPANY NAME' I E-MAIL FAX
STREET ADDRESS I CYFY,STAi<ZIP I PHONE
USE OF 1&sFD w DUPLE)( ❑ MULTI.FAMMY I PROJERN WB LAND ❑ ITS I PROTECTN ❑YES I IS THE SLOG AN ❑ YE5
HIM-DING; commEPC [Ti(E.W N riZi FACE ARES O FLOOD ZONE NO ECHL✓Z HOME? NO
DESCRIPTION OF WORX
TOTAL VALUATION: I RECEIVED BY: A/
By my sign==below,I certiy m each o: e' Ilcr 'ing: I am the property owner or authorizcd agent to act on dye property owncr's behalf. I have nerd this
application and the ivfprmatipn 1 have p 'de is corecL 1 have:rad the Description of Wcric and verifyi:is accaate. I agree m comply writ[all applicable Total
ordinances and state laws relating m buil ingc�nsrccti an- m representatives of Cwerivc:c enter the above-identified pmpe.—/for inspection puii cses.
Sigvamte ofApplicavJAgenc / an. Date: Y% — ( — 12—
$L]pP t NTAL..TIFDR.VIATION REQUIRED OFFICEUSEONLY
v OVER-THE-COUNTER
t
EXPRESS
U
❑ STANDARD
U
a ❑ LARGE
❑ MAJOR
iV P,Vacdpp_2011.doc revised 0601111 -
CiTY OF CUPERTiNO
FEE ESTIMATOR — BUILDING DIVISION
172 ADDRESS: 10654 N. Blaney Ave DATE: 09/11/2012 REVIEWED BY: Sean
APN: BPH: 12080150 'VALUATION: $1,600
•PERp11T TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIDIARY SFD or Duplex PENTAMATION 1REAP11
USE: PERMIT TYPE:
WORK Revision #1: Remove and replace kitchen sink add 5 lights in living area and fill in opening to kichen
SCOPE from living room.
Alech. Plan Check Plumb. Plan Check 0.0 hrs $0.00 Elec. Plan Check 1 0.0 1 hrs $0.00
Alech.Permit Fee: Plumb.Permit Fee: /PPERM/T Elec. Permit Fee: IEPERAUT
Orher,Vech. Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Elec,Insp. 0.0 hrs $45.00
le.ch.limp.Fee: Plumb. besp. Fee: Flee.Insp.Fee:
NOTE: This estinate floes not includejees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,eye.). Thesefees are based on lire prelinunan information available and are only an estimate. Contact the De 1 or addn'I info.
FEE ITEMS (Fee Resolmion 11-053 Elf 7/11111 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F-5-1 # Electrical
Suppl. PC Fee: Q Reg. Q OT 0.0 1 hrs $0.00 $67.00 IBREAIFIXT I Fixtures, Lighting
PME Plan Check: $0.00 1 # Plumbing
Permit Fee: Hourly Only? O Yes Q No $0.00 $10.00 IBPFIXTURE I Kitchen Type System
Suppl. Insp. Fee0 Reg. Q OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $90.00
Construction Tax:
Administrative Fee: IADAIIN $42.00 O
Work Without Permit? Yes Q No $0.00 E)
Advanced Plannine Fee: $0.00 = hours Inspections 0
Travel Documentation Pee: ITRAVDOC $45.00 $133.00 1STINSP Inspection, Hourly 0
Strontt Motion Fee: IBSEISAIICR $ 0 Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC 0 7
SUBTOTALS: $178.50 $210.00 TOTAL FEE: FPW-50
Revised: 07/01/2012
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CITY OF CUPERTINO BUILDING PERi11�PON 2---
BUILDING
IlIlI1,DING.\IIURFSS: 10654 N BLANEY AVE CO\"I'&\CI'OR:ANDERSCINIWUP�— PERMITNO: 12080150
INTERNATIONAL
OWNER'S NAME: NIHAR&VAIDEf11 GOKIiLE 2285 PARAGON DR DA'Z'E ISSUED:08/142012
OWNER'S PHONE: 4084170536 SAN JOSE,CA 95131 PHONE.NO:(408)954-1400
❑ LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: BLDG (- ELECT r PLUMB[�
License Class_ T? Lie.4 1:0 06 O r__ [f 1—,
/ C•'�/-t� MECH RESIDENTRESIDENTIALCO\IM ERCIAL
Contmetor 4)dl-6�/l fNP Date ,�
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE WATER DAMAGED SHEETROCA AND
(commencing with Section 7000)of Division 3 of the Business\ Professions INSULATION ON FIRST FLOOR.ANY OTHER MECHANICAL/
ELECTRICAUPLU\IBING PERFORMED SHALL BE UNDER A SEPARATE PERMIT 10/108012.
Code and that my license is In full farce and effect. REV42.REAIOVEAND REPLACE(I)KITCHEN WINDOW-REV421SS'D 10/108012
hereby affirm under penalty 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 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 provided for by
Section 3700 of the Labor Code,for the performance of die work for which this Sq.Ft Floor Area: Valuation:$4970
permit is issued,
APPLICA\1'CERTIFICATION APN Number:31643021.00 Occupancy Type:
I certify that I have read this application mid state that the above information is
correct.1 agree to comply with all city and county ordinances and stale laws relating
to building construction,mid hereby authorize representatives oflhis city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES iF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands mid will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section G�
9.18. ) Issued by:e�G-,�1� Awl 1, �1 Dale: /� '/,0
Signature Uate
�DP 2
❑ OWNER-BUILDER DIECLARATION RE-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beiig installed.If a roof is
the following two reasons: installed without first obtaining an inspection,1 agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business R Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business X Professions Code). ALI,ROOF COVERINGS TO BE CLASS"A"OIC BE ITER
1 hereby affirm under penalty of perjury one of the following three
declarations: IIA7.ARDOIIS MATERIALS DISCLOSURE
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 Code,for the 1 have real the hazardous Codc. istionrequirements555.2 533, Chapter 6.95 of the
California Ilealth&Safery'CnJe.Sections 25505,_5533,and 25534. 1 will mai ninin
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth S
I have and will maintain Worker's Compensation Insurance,as provided Ibr by Safety Code,Section 25532(a)should 1 snare or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the stork for which this Additionally,should I use equipment or devices which emit hazardous air
peril is issued. contaminants as defined by the Bay Area,tie Quality Management District I will
I certify that in the perfomtance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ my person in any manner so as to become subject to the Worker's Health A Safety Code.Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,L
Owueppf authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I muse / � Date:
Forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUMAON LENDING AGENCY
APPLICANT CFRTI FICATION I hereby affirm Had there is a construction lending agency for the performance of ssork's
I cenify that 1 have read this application mid state that the above information is for which this peri'is issued(Sec.3097,Civ C,)
correct.I agree to comply with all city and county ordinances and state Imus relating Lender's Name
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes,(We)agree to save Lender's Address
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 ARCHITEC—1"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
' C
CONSTRUCTION PERMIT APPLICA rLE�NSIoIV # a
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255 ts
C U P ERTI N O (408) 777-3228• FAX (408)777-3333• building0cuoertino.orct l p
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI 'N REVISION/DEFERRED ORIGINALPERMITH 4� 2651JD
PROJECT ADDRESS/�/' APN a
/0(SZ N (7 NE r /!V�
OWNER NAME PHONE E-MAIL
F1
i A � t eH GG�uc�
STREET ADDRESS r CITY, STATE,ZIP FAX
CONTACT NAME Wt[M '^ PHONE ( _ O 1( E-MAIL
u l l
STREET ADDRESS CITY,STATE, ZIP FAX
❑Ow•NER ❑ OWN•ER-BUB.DER ❑ OWNER AGMT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGLNEER ❑ DEVELOPER ❑ TENANT
CONTRA ORN ME LIC SE NUMBER LICENSE TYPE BUS.LICA
�<r 'o LJ
COMPAN NAME �7 I E-MAIL FAX
c� r or\ C.. 0 L'
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC a
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK ,,��!!
Evil/oma �-ra•' �iyli ✓� a
El 'liI :5l j PROP-SNlq t CONSTR.TYPE aSTORIES
`TD( os /�,'/^ USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG N•EW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATFIROOM KITCHEN OTHER
REAIODELAREA RFAtODEL AREA REMODEL AREA
PORCH AREA DECKAREA TOTAL DECK/PORCH AAFA GARAGE AREA: DETACH
❑ATTACH
N DWELLNG UMTS: ISASECONDUN'IT ❑YES I SECOND STORI' ❑YE$
BELCGADDED` []NO ADDITIOS' ❑NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDC AN E]YES RECEIVEDBYt+P'.. 7r"- TOTAL VALUATION:
PLANNING APPL p ❑NO PLMNU�G APP0.0\'AL LE7 TER EINLER UOAKE' ❑NO `?"A4,. , �/ �� v� 1006
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property om ner's behalf. I have read 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 relating to buildin onstruction. 1 authoriiz-e representatives of Cupertino to enter the ab/ove-identifiedd grope/rty for inspection purposes.
Signature of ApplicanJAgenC -12Y-kyVh -- r9y :71 Date: X /a // //2
SUPPLEMENTAL INFORI`1ATION REQUIRED "7'"' "r"'•='•¢'"�•'1S;'R 'g*4`�= -,.�'rA
�.,y' I 1'L4T,CHEC6;TY'1'Ee ROUTINC',SCIP �. _
1°tISSf. `�e,C�+A11!ITSTilV.H:1"`�`.'ys.., av _
New SFD or Multifamily dwellings: Apply for demolition permit for k� T \:RE Y ^L .. x
SOY ER THF�COUNTER
existing building(s). Demolition permit is required prior to issuance of building y{' v '-, •` ,BUILDING M"" -ts
permit for new building. PLAN JUtVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure �❑❑�sTA�[KAKtn Y.' - F � �-_ .......r~onLIC YY oRRs�'
form if any Hazardous Materials are being used as pan of this project. ';
❑R _W 1201 /�trA da ❑'^ FIREOLIT y •r
_Copy of Planning Approval Letter or Meeting with Planning prior to
❑ \UJOR r ❑D SANITARY SE YY ER DISI RICT '�`
submittal of Building Permit application. '�, � P
PP � wry}
s,❑e❑CENYIRO\MENTAL HEALTH -
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
172 ADDRESS: 10654 N Blaney Ave DATE: 10/10/2012 REVIEWED BY: Sean
A PN: BP#: `VALUATION: $600
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMITTYPE: 1GENRE i
WORK Revision #2: Remove and replace 1 kitchen window.
SCOPE
Meeh. PlanCheck Plumb. Plan Cheek Flee. Plan Check
bled'. Permit Fee: Plumb.Permit Fec: Vec. Permit ree:
Othcr Hech. Imp. Odea'Plumb Insp. Other Elec.Imp. Ll I
Ilech.Insp. Fec: Plumb. Insp. ree: rlec.hup.ree:
NOTE: This ewin tte does not include jeer due to other Departments(i.e. Planning. Public IVorks, Fire,Sanitary Server District,School
Disirict.'etc. . Thesefees are bused on lite prelinjinan information available and are onle an estinmte. Contact the Dept for addn7 info.
FEE ITEMS (Fee Resolution 11-053 EPL 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Window/Sliding Glass Door
Supp/. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 $0.00 Replacement
PME Plan Check: $0.00
Permit Fee: Hourly Only? ()Yes G No $0.00
Supp]. Insp. Fee:Q Reg. Q OT 1 0,0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consn-uction Tac:
Administrative Fee: O
Work Without Permit? O Yes 1) No $0.00 0
Advanced Planning Fee: $0.00 0 hours Inspections 0
Travel Docrimentation Fees: $133.00 ISThvSP Inspection, Hourly 0
Strong Motion Fee: 18SFISMICR .50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $000
SUBTOTALS: $1.50 $133.00 TOTAL FEE: $134.50
Revised: 10/01/2012