12100051 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 6115 SHADYGROVE DR CONI'RACI'OR: f t 'ERMITNO: 12100051
OWNER'SNANE: ROBINSONIOELA LQa..�g_C Tft_.0-C.I SI a rJ DATE ISSUE-I1: 10l09R012
OWNER'S PHONE: 4082579457 t E�� PHONE.NO:
❑ LICENSED CON fRACTOR'S DECLARATION r_ r_ELECT PLUr
BUILDING PERMIT INFO: BLDG MB
License Class Lic.tl -70705)
/� �� NECFI r RESIDENTIAL r COp1i\IERCIAL r�
Contractor✓v' IS n,JY anCA Date
hereby affirm that 1 ain licensed ander the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE WOOD SIDING TO MATCH
(cum meneing with Section 7000)of Division 3 of the Business& Professions EXISTING
Code and that my license is in full force and effect. WI'fI1 VERTICAL GROOVES UP TO6INCHES APART(1320
SQ Mn UPGRADE MAIN ELECTRICAL PANEL TO 200 AMP
1 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 the work for which this
permit is issued Sq.Ft Floor Area: Valuation:$16000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APNi Number:37540010.00 Occupancy Type:
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 CityofCupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may acerae 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-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18. q I - / / /},
Signa Vgr iC.� Date / Id �Z Issued by: �E�/y T�l�/�/� Date:AO•
❑ OWNEIR-RUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law fur one of Rh:ROOFS:
the following Iwo reasons: All roofs shall be inspected prior to any roofing material being installed If a roof is
I,as owner of the properly,runty 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&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business& Professions Code).
I hereby affirm under penally of perjury one of the fallowing three AL1.ROOF COVERINGS T'O BE CLASS"A"OR BE'FITR
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS\IATERIAI S DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this pemnit 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 I lealth&Safety Code,Sections 25505,25533.and'5534. I will maintain
Section 3700 critic Labor Code,for die performance of the work for which this compliance with the Cupertino Municipal Code.Chapter 9.1_and the Ilealth&
F Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of die work for which this permit is issued,I shall contaminants as defined by the Ray Area Air Quality Management District I 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. If,a0er making this cenificate of exemption,I Health&Safety Code.Sections 25505,25533.and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I rats,
forthwith comply with such provisions or this permit shall be deemed revoked r or authorized
Datc:
AI'I'LIC,\N'1'CER'TIFICAT'ION CONSTROC'VION LENDING AGENCI'
I certify that I have read this application and stale that the above information is
cored.I agree to comply with all city and county ordinances and suite laws relating I hereby aflirm that 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 liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Leader's Address
graving of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
121 --�) 00 �s )
CONSTRUCTION PERMIT APPLICATION
IN TA
G COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
C U P ERTI N O (408) 777-3228• FAX(408) 777-3333• buildinorcDcuoertino.oro
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DDE///FERRED ORIGINAL PERMIT#
\� PROJECT ADDRES ` 1 ` C\ \ �VVV� APNN
OWNER NAI �1 PHONE / E-MAIL
o "7 CH 577 1
STREETADDRESS CITY, STATE,ZIP FAX
CONTACT NAME �= / PHONE E-MAIL
STREET ADDRESS �j CITY,STATE, ZIP FAX '
11 OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT CONTRACTOR ❑CON'TRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CON/T�R OA NAM LICENSE NUMBER —T LIC STYPE BUS,LIC9
rj f
70-7251
1
OMPANYNAME E-MAIL FAX
l.�r j Lp i
STREET ADDRES CITY,STATE,ZIP PHONE
t tZ e �e1 . tio $IirQ , zc.A9y 55 "70-7- - 9
ARCHITECT/ENGINEER NAME LICENSE NUMBE I BUS.LIC 0
COMPANY NAME E-MAIL FAX
STREETADDRESS c 2 CITY,STATE,ZIP11�� PHONE
ES
DCRIPTION OF WORK KcA�cm✓a.� O\ 33 o -'S Y�O✓ 5'4
'ZC0 Ke r Y1-(u\' 21 k-r •co. �m-•e. I
EXIS USE PROPOSEDUSE CONSTRWE NST
_G `�J{ USE TYPE OCC. SQ.FT. l'ALUATION(S)
or
EXISTG N FLOOR DEMO TOTAL
AREA AREA AREA NETAREA
BATFDt00%1 I CHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCHAREA DECK AREA TOTALDECK/PORCHAREA GARAGEAREA: UDETACH
❑ATTACH
P DWELLING UNITS: ISASECONDUNIT DYES SECONDSTORYYES
DELN'G ADDED! MNO ADDITION? ' 0
PRE-APPLICATION�1'FS IF YES.PROVIDE COPY OF IS THE BLDG AN AYES ;REGEIVE Y: TOTAL VALUATION:
PLANNNDNGAPPLq NO PLANNING APPROVAL LETTER EICDE LERHOMNO T '.•k '`�
t 6 oCr
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on theproperty ow'ner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and veriJV it is accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/AgenE 7
Date: - 101 / /2_ Z
SUPPLEMENTAL INFORMATION REQUIRED Nom, _P�INtCHETEcC i 1 e
New SFD or Multifamily dwellings: Apply for demolition permit for rF"e �"�TS+` uh' -r ✓ �. :"q£W � ""
I-
THE COUNTER BUILDING ILA,\REV TEN A_
existing building(s). Demolition permit is required prior to issuance of building I-F% ✓°" tJ _ :'I`: >a
^ ,�tI� ti
permit for new building. ❑% E\PRess$ + • §ILA\U\GPLA\REr7 J '
�i � ^ r ,fru
_Commercial Btdgs: Protide a completed Hazardous h�la[erials Disclosure ❑D STANDARD - c lows',
u I UBLIG\YORRS 'Y^. ` 3
form if any Hazardous Materials are being used as part of this project. ,,NN s r` P� �`-%] �'-�' y'
❑Ry WRGC ` „ 37 '+ DEPT <
_Copy of Planning Approval Letter or Meeting with Planning prior toi j WJOR AMTARYSEN ER DISTRICsubmitral of$vilding Permit application a jt -# i ,
� al )jO�y F.\'\'IRO\MENTAL IiE.aLT'H�:.,
BldgApp_1011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRF,SS: 6115 Shady Grove DATE: 10/09/2012 REVIEWED Bl': Sean
APN: BP#: *VALUATION: $16,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
(YORK Remove and replace wood sidingto match existingwith vertical rooves u to 6 inches apart 1320 s
SCOPE ft); upgrade main electrical panel to 200 amp.
Alech. Plan Check Plumb. Plan Check Elec. Plan Check 0.0 hrs $0.00
Sfech. Permit Fee: Plumb.Permit Fec: Elec. Permit Fee: IEPERAHT
Othe•Afech.Insp. Other Plumb 1nsp, Ll I Other Elec. Insp. 0.0 hrs $45.00
,bfech.Insp. Fee: Plumb. hecp. Fee: Elec.insp.Fac:
NOTE: This evintate does not incluelefeev due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School
District,etc.). These feev are hared on the prelinjinan information aroilable and are only an estimale. Contact the Det for uhh;'I info.
FEE ITEMS (Fee Resolution 11-053 E/T 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 400 s.f. Siding
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $400.00 ISIDEOTHER I All Other
PME Plan Check: $0.00 F2007 amps Electrical
Permit Fee: $0.00 $45.00 IERT<200 Services
Suppl. Insp. Fee-.0 Reg. Q OT F0,0Thrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $45.00
Conswuction Toe:
Administrative Fee: 1ADAHN $42.00 O
Work Without Permit? O Yes (j) No $0.00 0
A6anced Planning Fee: $0.00 Select a Non-Residential (7
Travel Documentation Fee: 1TRAvDOC $45.00 Building or Structure 0
Strong Motion Fee: IBSEISAHCR $1.60 Select an Administrative Item
Bldg Stds Commission Fce: IHCHSC $1.00
SUBTOTALS: 1 $134.60 $445.001 TOTAL FEE: 1 $579.60
Revised: 10/01/2012