12100086 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10139 BYRNE AVE CONTRACFOR:ZICOVICI I BUILDERS INC PERMIT NO: 12100086
OWNER'SNAIHF: SMITH ROGER C AND GAIDIES-SMITH BRE 17510 FARLEYRD WEST' DA'Z'E ISSUED: 10/102012
OWNER'S PHONE: 4088020721 LOS GATOS.CA 95030 PHONE NO:(408)399-0606
❑ LICENSED CON'PRACI'OR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT r__1 PLUMB r
IC
License Class 7!"' Lick r r Fj
MECH RESIDENTIALCOMMERCIAL
Contactor 2X0-0UvQ '�JASDate O ( ,
herebv affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:200 AMI'T17NIPORARY POWER POLE FOR
(commencing with Section 7000)of Division 3 of the Business& Professions CONSTRUCTION OP
Code and that my license is in full force and effect. RESIDENCE
hereby affirm under penalty of perjury one of the following fwo 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.
1 have and will maintain Worker's Compensation Insurance,as provided(or by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$500
APPLICANT'CF.R'I'IPICA'I'ION
I certify that I have read this application and state that the above information is APN Number:35711009.00 Occupancy'rype:
correct.I agree to comply with all city and county ordinances mid 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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against aid City in consequence of the
granting of this/rehinit. Additi nal ,thea cant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-p rut or reg ati sper Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date 1 �Z Issued by: �E�/✓ RZz;i Date: AD 'Iq
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to mmv rooting material berg installed.If a roof is
1,as owner of the property,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&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contactors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code),
I hereby affirm under penalty of perjury one of the following three ALI,ROOF COVERINGS T'O BE CLASS"A"OR BETIT.R
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS 1LtTERIAI 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 hare read the hazardous materials requirements tinder Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code.Sections 25505.25533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the IluJth&
Section 3700 of the Labor Code,for the per(onnance of the work for which this Safety Code.Section 25532(1)should I store or handle hazardous material.
permit is issued. Additionalh.,should I use equipment or devices which emit hazardous air
I certify that in the perfomtance of the work forobich this permit is issued,I shall contaminam.s as define hp the Ihq•Arca Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's main aim rnm fiance t tth the operon.Jluniripal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,1
Berth_
lya th `Sa ry•C Jc Sectio s 255115,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code.I must
forthwith comply with such provisions or this permit shall be deemed revoked. Own r u hori eu •-y
Darr: V
APPLICANTCERTIFICATION CONSTRUCTION LENDING AGENCY
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 Imus relating I hereby affirm that there is a construction lending agency for the performance of swrk'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 Lender's Address
gruntingofthis permit.Additionally,the applicant understands and will comply
with all non-point source regulation;per the Cupertino Municipal Code,Section ARCIIIT'F.CI"S DECLARATION
9.18.
1 understand my plans shall be used tats public records.
Signature Date
Licensed Professional
! 21 vv � 8�n
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
mi
COPE RTI NO (408)777-3228 • FAX(408)777-3333• bui�lddirn.ing cuoerino.ora v\
❑?LUMBING ❑,MECNI
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CONTRACTOR NAME) yDV� D LICENSE NUM9E �[D�� uC ; �E� 9US.IJC."q�J
COMPANY NAME U(, r(..fi[Ju•�G/%s-St/LC... I `- (Z��
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COMPANY NAME' TwI �J�� E.MAM FAX
STREET'ADDRESS /B i�'(1/XI Al4/llV4gj' CITY.STA`�� ♦,y�xrLPG /b � PHONE
USE OF �SFD wOUP1FX ❑ MULTI.F (AMIL'vYYY PROTECT W WE ❑ = 1•QPRROO (IEC/rINJ ❑ /YES 115 THE BLDG AN ❑ YFS
BUILDING: []GONAD ctkt. URBAN INTERFACE AREA NO Fl D ZONE ❑NO E1L'HI.E.R HOME? ❑NO
DESCRtFnON OF WOR%
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����✓TOTAL VALUATION: �"' RECEIVED BY:
By nny signave below,I certify to eacb of the olloviing: I am the Perry owner or xuLSorized agent to act on the proper-,y owner's behalf. I have read this
application and the info, 4 ha e p vided'is correbL [have yy a e Ileseiption of Work and verity it is accua[a I xg:.a,[o comply wish all applicable local
ordinances and I, laws relating' buil n�consS�ttiOa I auth6'i :epresentadves of Cupenino to enter the abov-- end5edpmpee:r+"er inspecdon pulposes.
Signamn:of Applicar.JAgcnt: / T " l / Date:
I G ��yl 7i
SUNLENENTAL INFORMATION REQUIRED ' OFFICE use ONLY
OYER-THE-COUNTER
_ — ❑ EXPRESS
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❑ STANDARD
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❑ LARGE
❑ MAJOR
ME'P:ifucApp_ 011.doc revised 06/21/11
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255'
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333 ,
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: Q PERMIT#
OWNER'S NAME: {LMi}l PHONE ft
GENERAL CONTRACT : Zip c-�1JZV ' Jil wS Z.LC- BUSINESS LICENSE#
ADDRESS: 510 -( Q 4 Las&44 CITY/ZIPCODE: S a
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCC 1NCl' INSPE TION ) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL S BC N AC Sr E OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
1 am not using any subcontractors: . 0
Sign ure I Date
Please check applicable subcontractors an complete the following information:
SUBCONTRACTOR BUSINESS NAtYIE BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/ Wood
Glass-/ Glazing
Heating
Insulation -
Landscaping
Lathing
Masonry
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
caner/Contractor Signature D• to
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10139 Byrne Ave DATE: 10110/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP14
USE: PERMIT TYPE:
WORK 200 amp temporary ower pole for construction of residence.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 200 Amps $45
TOTALS: $45.00
Mech. Plan Check Plumb.Plan Check Elec. Plan Check 0.0 1 hrs $0.00
Alech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERAHT
Other,llerh.Insp. Other Plumb Insp. Other Flee. Insp. hrs $45.00
0.0
Mech.Insp.Fre: Plumb. bup. Fee: Eler.Insp. Fee:
NOTE: This estimate does not include jeer due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District, etc). These eev are Faced on the prefintinarl information available and are only an estimate. Contact the De t. or addn'I info.
FEE ITEMS (Fee Resolution 11-053 E/7 7/1/12) FEE QTY/FEE MISC ITEMS
Plan check ree:
Stippl. PC vee.
PME Plan Check: $0.00
Permit vee:
Suppl. Msp vee
PME Unit Fee: $45.00
PME Permit Fee: $45.00
Construction Tal:
Administrative Fee: 1ADMIN $42.00
Work Without Permit? Yes (E) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA I DOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
13Idg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $178.50 $0.001 TOTAL FEF.: $178.50
Revised: 10/01/2012