12100112CITY OF CUPGRTINO BUILDING PERNI T
BUILDINCADDRESS: 21810S'1'1 -.VLNSCI2BGKBIVD
CON 'TlLWfOR: -1'DD- TO 1312 DETERMINED
PERMITNO: 12100112
0W.NEI('S :NAME: "rAl PING -1IUPI AND CI IOU SU -LING
I A j I m c-s-- H (-,c I W 5 � L {
CA LL— . — N [S —
IDATE ISSUED: 10/152012
OWNER'S PAIN E: 4088630956
PuDNIC N'(a:
❑ LICENSED CON T'RACTOR'S DECI, :AR :V'IION
r r r
l3UILDLNC PERMIT LNFO: BLDG ELF,Cr PLUMB
License Class Lic. H
r r r
AIIiCIi 12 ESIDIi1 \ "1'L \L COMMERCIAL
Contractor Dale
I hereby affirm that I am licensed under the provision. of Chapter9
•1013 DESCRIPTION: S'I'UCCOON 4 SIDES 017 I IOUSHANDGARAG13
(Conn lencinL with Section 7000( of Division 3 of the business S Professions
Code and (flat Inv license is in full force and effect.
I herchy affirm under penally of perjury one Ill'Ihe following Iwo declaralions:
I have and will maintain a certificate ofconsent to self - insure ]or 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.
&1. PI Floor Area:
Valuation: 52000
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Lather Code, Ibr the performance of the work for which this
AI'N Number: 35716010.00
Occup :mcy Type:
permit is i55ucd.
APPLICANT CERTIFICATION
I certify that I have read tints application and state (fat (he above nd(1rnialion Is
correct. I agree to comply with all city and county ordinances ;aid state laws relating
P1�j \`'�j•l• L`jll ) \1�5 ". "IO'�L '` \t ^' p I'„�( (i(`
„ O `I S /
I(, building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property (br inspection purposes. (We) agree to Save
NVI T HIN 18(( DAYS OF PEAZIMI T ISSUANCE OR
indemnify and keep harmless tine City of Cupertino against liabilities , judgments,
1$0 DAYS 'RONI LAS( CALL.LD INSPECTION.
costs. and expanses which may accrue against said City in consequence of the
granting of this pencil. Additionally, the applicant understands and will comply
�`
V(
w'ilh all non -point Source regulations per the Cuperflno Municipal Code, Section
(�
Issrc(1 by: Dale: 1
Signature Dale
RI': ROOFS:
❑ (MINER- IMILDER DECLARATION
All roofs shall be inspected prior to any roofing material being installed. [fa nulf is
installed without first obtaining an inspection. I agree to renmve all new materials lilt
I her infirm than I arm esempl Irom the Contractor's License Lase for one of
inspection.
Illy nulluwine Iwo lea sons:
I. as owner of the property. or my employees with wages as their sole compensation.
Signature of Applicant: Date:
trill do the work. and the structure is not intended or offered for sale (Sec.704.1,
BLlSiIICSS C PT0lVSSi0aS Code)
1, as 0% %Illr 01'01C property. :1111 CSCIIIsively contracting Milt licensed contractors to
ALI. I30017 COPERINGS'10 BE CLASS "e\" OR fir I -IT;I(
construct tine project (Sec.7044, Business R Professions Code).
I hereby' affirm under penally of perjut y one of the following three
HAZARDOUS MA ITRTALS DISCLOSURE
decfaraliuns:
1 [talc read the hazardous lluneriale requirements under Chapter 6.95 oflhe
I have and will maintain a CertifiC :nc of Consent tO SCll'- insure lot Worker's
("alilbrnia Ilealth & Safely Code, Seeliu:n'_55115, 25533, and 25534. 1 will maintain
Compensation, as provided for by Section 3700 of the Labor Code, fix the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the I Iealnh R
performance of the work for which this permit is issued.
Safety Code, Section 25532(a) should I %lure or handle hazardous material.
I have and will maintain Worker's Compensation Insurance as provided for by
Additionally, should I use equipment or drvices which calif hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
conf:nnin:rl Ls as def led by the flay Area Air Quality Manamenenl District 1 will
P Until is issued,
maintain compliance ,ilh the Collection Municipal Code, Chapter 9.12 :old the
health & Sale[%, Code Sections 25505, 25533. and '_5534.
1 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
t -c •lac //
Compensation lmvs of California. If, after making this certificate tin exemption,)
J
become subject to the Worker's Compensation provisions of the Lahor Code, I nun s�,
brilovilh Comply with such provisions or this permit shall be deemed rooked,
CONSTRUCTION RD(.I Il1N I,ILN'III : \(r AGES( Y
I hereby allirm that there is It construction lending agency for the performance of work's
APPLICANT CERTI FI CATI ON
for which this permit is issued (Sec. 3097. Cie C.)
I Certify that I Inee read this application and stall' that Ilse above information Is
Lender*, Sainc
Correct. I agree In comply with all city and county ladlonaCCS and State laws relating
to budding construction, and hereby authorize representatives oflhis city to enter
Lender's Address
upon the above mentioned property for inspection purposes. (WC) agree to save
indemnify and keep harmless tine City of Cupertino against liabilities, judgments.
costs, and expenses which any accrue against said City in consequence of the
AltClll'I'ICCI "5 UICCL:UtA'I'I(IN'
grading_ oflhls permit. Additionally, the appllCanl Understands and %% ill comply
I IlndCr$I :alld Ills' plans shell be used 112 public records.
with all noel -point SOIIrCC regulations per lire Cupertino Municipal Code, Section
9.18,
Licensed Professional
��%
'
Sign' r. Date
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT' BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255
(408) 777 -3228' FAX (408) 777 -3333' building8cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION VI ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
// 0/0
PROTECT ADDRESS 416IV 1XVIMS W U/(v(�11 Ip ApP�r'u((
//
OIVNER NAME v I IN~r, TQ� Cl( Ot/I SU -LI/i PHONE (408)810 J • 0'15 E -MAIL p�nc�9 �01y� veal i. caM
('
STREETADDRESS 21�o SiCV'6YlS 13IUd
rA
CITY, STATE, ZIP
Ca I,1
`(
I FAX N/e .
VTai rJ
V(u,
E -MAIL ��ya ,y P/l q&6- "IV?
CONTACT NAME PIN (`ka
PHONE��081�B1oS olsis
ADDRESS Z(OlO SktVenS (31Vd
CITY, STA ZIP,:1V 960(4
FAX WA
,,STTREET
Ly OWWER 11 OWNER-BUILDER ❑ OWNER AGENT ❑ CON - TRACTOR 11 CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME I, C�( � UQS LICENSE NUMBER 1, �I
LICETSE TYPE
BUS. LIC M
COMPANYNAME S. y.��CCO 1. E -MAIL ShACCO
JtUI IL O ro ck aol•�wt
FAX
STREET ADDRESS CITY, STATE, ZIP f
`
PHONE I,IOg� 2Dq.- 2055
ARCHITECTIENGINEER NAME
LICENSENUMBER
BUS. LIC#
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
stLkCC,o inn L1 Std2s of house awd 0.nA e
EXISTING USE PROPOSED USE
CONSTR.TITE
ksTORJE5
I
USE
TYPE
OCC.
SQ.FT.
VALUATION (f)
EXISTG
N'EW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
N•ET AREA
BATHROOM KITCHEN OT}RR
REMODEL AREA REfODELAREA REMODEL AREA
PORCH AREA DECK AREA
TOTAL DECKMORCH AREA
GARAGE AREA: UDETACH
❑ATTACH
k DWELLING UNITS:
IS A SECOND UNIT ❑YFS
SECONDSTORY ❑Yi
BEIN'OADDED? ❑NO
ADDITION? ❑NO
PRE - APPLICATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AF ❑YES
RECEIVED'BY•��X
TOTAL VALUATIIOON:
PLANNINGAPPLY ❑NO PLANNING APPROVAL LETTER
EICHLER HO]t£? IQ'INO
a
By my signature below, 1 certifv to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have readthis
application and the information I have provided is correct. I have read the Description of Mork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relaun in c traction. 1 autho a representatives of Cupertino to enter the above - identified property for inspection purposes.
Signature of Applicam /A nr Date: I B �1 ro
- - SUPPLEMENTAL fNFORIIIATION RE OIRED
�`MAl 9c ce `iiN"�'
M0
r1N-C SLIP _
New SFD or A1ultifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
elmal
O \ER TFIL COUNTER.-
Y - r ' �'
.rte'- tr ".rdm"�n rTa`•
�B ILnING'PLA N RE�TE \l
2c
/G'j
permit for new building.
Commercial Bldgs: Provide Hazardous Materials Disclosure
EvNAess a -
���+srnnnARD N
�R'�.`,i`
ru�Nl W\ RE \'IE\ 1
�F-F
_ a completed
To-"- if anv Hazardous A4aterials are being used as part of this project.
w - N
Copy of Planning Approval Letter or Meeting With Planning prior to
§'" F ' '
❑^ 4'i
submittal of Building Permit application.
SANITAp YSE\\ ER DD�I.STg:R�I,CT
ENV1RO N.NLE',TA" E' TtH
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
NOTE: This ertitnate does not includejeev due to other Departments (i.e. Planning, Public (Yorks, Fire, Sanitary Server District, School
District. etc.). These fees are based an die arelintinan• information available and are only rut estimate. Contact the Dent for addn'I info.
FEE ITEMS (Fee Resolution 11 -053 EIL 7 11117)
ADDRESS: 21810 St Crk Blvd
DATE: 10/15/2012
REVIEWED BY: jsg
`
APN:
Dec. Permit Fee:
'VALUATION:
$2,000
*PERMITTYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
Elec. Insp. Fec:
PENI'AMATION 1GENRES
PERMIT TYPE:
WORE;
stucco 4 sides of house
SCOPE
$0.00
NOTE: This ertitnate does not includejeev due to other Departments (i.e. Planning, Public (Yorks, Fire, Sanitary Server District, School
District. etc.). These fees are based an die arelintinan• information available and are only rut estimate. Contact the Dent for addn'I info.
FEE ITEMS (Fee Resolution 11 -053 EIL 7 11117)
blech. Plan Check
Plumb. Plan Check
Flee. Plan Check
Mech. Permit Fee:
Phtmh. Permit Fee:
Dec. Permit Fee:
Other,llech. Insp.
Other Plnmh Insp.
Other Elce. Insp.
dlech. Insp. Fec:
Plumb. hep. ree:
Elec. Insp. Fec:
NOTE: This ertitnate does not includejeev due to other Departments (i.e. Planning, Public (Yorks, Fire, Sanitary Server District, School
District. etc.). These fees are based an die arelintinan• information available and are only rut estimate. Contact the Dent for addn'I info.
FEE ITEMS (Fee Resolution 11 -053 EIL 7 11117)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0.00
400 s. f.
$400.00
Siding
ISIDEOTHER All Other
Suppl. PC Fee: Q Reg. Q OT
O.Q
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee0 Reg. Q OT
F0 ,O
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tar:
Adininictratire Fee:
Q
E)
Work Without Permit? O Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select Non - Residential
Building or Stntcture
Q
0
Tracer Docannentorion Fees:
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$400.001
TOTAL FEE:
$401.50
Revised: 10/01/2012