12080166 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 20657 GARDENSIDE CIR CONI'RACI'OR:BRADSHAW ROOFING PERMITNO: 12080166
INC
OWNI.R'S NAME: MINDY MING-SIIAN WENG 1821 S BASCOM AVI?PMB 160 DA'Z'E ISSUED:08117/2012
OWNER'S PHONE: 4084632432 CAMPBELL,CA 95008 P1101NE NO:(408)246-9930
❑ LICI.NSED CONI'RACI'OR'S DFCLARATION JORDF-SCRIPI'lON: RESIDENTIAL❑ COMMERCIAL.
License Class ^39 LiCA Q 3e)k//J TEAR OFF EXISTING SHAKE AND INSTALL 12 SQRS
7 CLASS
Contractor L J Date A ASPHALT COMP SHINGLES, COLOR ACED BARK
1 hereby alfirm that 1 am licensed under file provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business\ 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 mud 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 w'hichthis permit is issued. Sq.FI Floor Area: Vulmrtion:$6000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perforanmxe of due work for which this \PN Number:36232024.00 Occupancy'fype:
permit is issued.
,u'PLIc,\Nr GI•:R'ruac,crlON
I certify that 1 have read this application mid stoic that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.l agree to complywith all city and county ordinances and state laws relating WITHIN IRB DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby audmorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY FROM LAST CALLED INSP CTION.
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 conmply Issued by:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 7�I, / //2— 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.
❑ OWNER-BIIILDISR DECLARATION
Signature of Applicmt: )ate: <.
hereby affirm that 1 am exempt from the Gnvnmcmr's License Laefor one of
the following rya reasons: ALL ROOF COVERINGS 10 RE CLASS"A"Olt BE PI'Ell
1,as owner of the property,or nnv enployea with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sea7044,
Business d Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IL\'LARDOIIS dl,\'I7?RLUS DISCI.OSURF.
construct the project(Sec.7044,Business R Professions Code). 1 have read the hazardous mmnerials requirements under Chapter 6.95 of the
California IlealIll S Safely Code.Sections 25505,25533,and 25534. I will
hereby affirm under penalty of perjury one of the following three an in Win cum plia are with the Cu pertinu Municipal Code.Chapter 9.12 and the
declarations: Ilealth S Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to SCIf-lnsare for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section3700 of the Labor Code,for the air contaminants as defined M'the Bay Area Air Quality Management District I
performance of the work Im w'hichdnis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safe(N Code,Sections /05,25633,an -5"34.
Section 3700 of the Labor Code,for the performance of the work for which this --'= Ld"�"� e/ /�
Owner or authorized agrm�r//`� Ihrc:
permit is issued.
I certify thin in the performance of die work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSfRl1C1'I01N,LENDING AGENCY
become subject to the Worker's Conupensaion provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTI FICATION Lender'sAddress
I certify then I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances mid state laws relating
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property,for inspection purposes.(We)agree to save ,UtC111TFCf'S DECLARATION
and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses whidm may accrue against said City in consequence of die 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 Dae
Building Department
City Of Cupertino
10300"forre Avenue
Cupertino, CA 950143255
Telephone: 403-777=3223
CUPERTINO -.Fax- 408-777-3333
CONTRACTOR / SUBCONTRACTOR,LIST r
JOB ADDRESS: 2 (»� . �,e PERMIT# oZD D
OWNER'S NAME: mimil, PHONE # LID< - ,, L q Q 361
GENERAL CONTRACTOR: -j, BUSINESS LICENSE # 3 6
ADDRESS: I / u e CfrWZIPCODE: OWSR7S
f *Our municipal code requires all businesses working in the city to have a City of Cupertino usiness license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL 13E SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OIC CUPERTINO
BUSINESS LICENSE.
3t. I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets.& Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
1't Lathing
i Masonry
Painting/ Wallpaper
Paving
Plastering
Plumbing
` Roofing /
Septic Tank
Sheet Metal
- Sheet Rock
Tile //
luiG�
Owner/Contractor Signature Date
REROOF TEAR-OFF POLICY
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
CUPERTINO 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
(408)777-3228- FAX(408)777-3333•buildingecuoertino.org
PROJECT ADDRESS APN0 1 '
nsOD
OWNER NAME lPHONE E-MAIL
' c.le1 ' O b - 4
STREET ADDRESS CI , STATE.ZIP Sot FAX
L( t
TRACT NAIVE LICENSE NUMBE LICENSE TYP BuS.LIC.#-38 / C
1 t JJ �j
COMPANYNAME E-MAI 1-y! FAX -
Rr,
STREET ADD E55 CITY.STATE,ZIP HONE
�/ 1 C S CE
I UNDERSTAND AND AGREE TO T14E FOLLOWING:
1. The re-roof project shall comply with all applicable provisions of the 2010 California Codes.
2. An inspection request can be scheduled up to the day before the inspection date. Please call (408)777-
3228 from 7:30 - 3:30pm (Mon-Thurs) or 7:30 - 2:30pm (Friday) to schedule the next day inspection.
For Tear-Off and Nailing Inspections, you must also call on the day of the inspection only after that
phase of the work is completed. The building inspector will be available within one hour. Progress
and Final Inspections will be given a two hour window.
3. Tear-Off Inspection is required. Any and all dry-rotted wood shall be replaced prior to this inspection.
Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either
completely knocked-down or removed prior to this inspection.
4. If plywood is installed, a plywood Nailing Inspection is required.
5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the
building inspector. Any roofing which is applied without first obtaining an approved inspection will
require the removal of all new material down to the sheathing so a proper inspection can be performed.
6. Progress Inspection is required when approximately 50% of roof covering is installed.
7. A Final Inspection and approval shall be obtained from the building inspector when the re-roofing is
completed. To receive a final sign-off, the following items will be verified:
a. Flat roofs shall have a minimum of'/<" per foot of slope and demonstrate there is no ponding.
b. Listings from approved testing agencies for all pre-manufactured products used shall be
available on-site to review at the time of the inspection.
c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed.
8. NOTE: .If you call for a tear-off or plywood nailing inspection and the work is not complete, you will be
charged a re-inspection fee of$126.00. The re-inspection fee shall be paid before another inspection
can be scheduled.
By my signing below, I certify each of the following is true: I am the property owner or authorized agent to act on the
property owner's behalf. 1 understand and agree to comply with the re-roof policy stated above. 1 also understand that
smoke detectors and carbon monoxide detectors are required to be installed in accordance with Sections R314 and R315 of
the 2010 California Residential Code
Signature of Applicant/Agent: Date:
Re,oofPo1iev_2011.doc revised 02/16111
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 20657 gardenside circle DATE: 08`11412012 REVIEWED BY: bobs.
\ APN: BPH: ' /p `VALUATION: $6,000
*PERb11TTYPE: Building Permit PLAN CIIECKTYPE: Alteration I Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMiTTYPE: 1SFDWLR00
WORK remove existing shake install comp shingles. Z15 �d Q
SCOPE
Meth.Plan Check Plumb. Plan Check Flee. Plan Check
blech.Permit Fee: Plumb.Permit Fee: /.'fee. Permit Fee:
Other,tfech.Insp. Odrer Plumb Insµ Ll I Other Elce.Insp.
Ifech.Grsp,Fec: Plumb. hcrp.Fee: Flee.Gap.Fee:
NOTE: This eviinutte does not inchule fees due to other Departments(i.e. Planting, Public Works, Fire,Sanitary Server District,School
District, etc.). There feav are bused on the prelintinan information available and nre only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resohttion 11-053 Eff 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1,200 s.f.. Re roof
Suppl. PC Fee: (D Reg. Q OT 0.0 hrs $0.00 $180.00 IRER00FRES
PME Plan Check: $0.00
Permit Fee: $0.00
Supp]. Insp. Fee,.G Reg. Q OT 1 0,0 1 Ins $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consnvction Tax
Administrative Fee:
Work Without Permit? O Yes Q) No $0.00
Advanced Planning Fee: $0,00 Select Non-Residential E)
Travel Documentation Fees: Building or Structure O
A
Strong Motion Fee: IBSEISMICR $0.60 Select an Administrative Item
Blds; Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.60 $180.001 TOTAL FEE: $181.60
Revised: 07/01/2012
REROOF PERMIT APPLICATION
C .G COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION t
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (40g)7ii-3228• FAA(408)I77-3333•buildinG0cucertino.om
PROTECT ADDRESS r (1 `
Cle
DWN NAn iJ HON L ��' �1 LI�oC� E-0fA1L o�
14 Ing
STREET ADDRESS =6-DATE,ZIP A (4 -1 sot y I FAX
per C
CONTACT NAME PHONE E-NWL
STREETADDRESS CITY'.STATE.ZIP FAX
❑OWNER ❑ OWNER-0UILDER ❑ OWNER.AMW COTnA{CrOR ❑CONTRACTOR AGENT ❑ ARQ[ITECI' ❑ENCdtrEER ❑ DEVELOPER ❑TENANT
CONTRACT RNAME LICENSENUMBER LICENSE TYPE BUS.LIC.0O�/' (`^
7 V-t
COh1PANY•NAA¢ FA%
STREET ADDRESS CITY'.STATE ZIP M_ija `t..1
Ij
vezn
ARCHITEC IENG WEER NAME LICENSE NUMBER BUS,LIC.+'
CONIPANY NAME EJ TAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex ❑ Mulu-Famil V- ROOF-AREA: •}//�'�'T� VALUATION: /��� o
STRUCTURE. ❑ Commercial tt a019 \ � 066
EXISTINGROOFTYPE: ❑BUR-T-UPROOF ❑ASPHALT SHINGLES an V.'OOD SHAKES ❑WOODSHINGLES ❑OTHER(SPECIFY)
REMOVE•REPLACE E14U I IF NO. //1 PLYWOOD :5' ❑ PLYtY'D ❑OSBPRCH: (,) ROOF
❑ O S• y, S.- 13SA" TYPE' 1:1rDX
CLASS A
PROPOSEDROOF TYPE: ❑BUILT-UPROOF ASPHALTSH[NGLES C3 WOOD SHAKES ❑WOOD SHINOLES ❑OTHER [CC-ES REPORT
DESCRIPTION OF WORK: - ` G
es
By my signature below,I certify to each of the following: I am the property owner or authorized aeent to act on the property owner'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 rela t. WHY i o on. I au riz preunmtives of Cupertino to enter the aabbove-identi t d property for inspection purposes.
Signature of.4pplicarn Agenc�A/J.(/ti� � _ Date: /�a�C, ons 2—
rr
SUPPLEMENTAL WFOMATION REQUIRED OFFICE USE ONLY
_If building is associated With a Home Owners Association,provide letterrOVER-
�TYPE RQVTING SLIP
of approval from HOA. NTER BUTI.DINGPWNREVIEW
Provide Planning approval N verity'if there any restrictions. ❑ PLtNMNG PLAN REVIEW
Provide copy ofManufacnvers[ns[alla[ion Speciticauons. ❑ FERE DEPT
vide signed copy of Cupertino's Teat-Off Policy. ❑ OTHER:
Reroojrpp 2011.doc revised 03.•'/6/!1
10300 1orreAvenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228:
CP
UERTINO _ Fax: 408_777_3333
CITY OF CU11ERTIN0 BU11,1)1NC 11ERfMIT
BUILD INCA DDRESS: 101041-IIIERTY OAK LN CON'I'1(,fC101l:NUI.IGII'I'SOL(1'I'IONS,INC PER?n'r 0: 12080199
OWNER'S NAME: DANNY YU 1350 DULAVE SrE 202 DATE ISSIiED:08/1 720 1 2
iOWNER'S PI IONF.: •1087183069 C\MPBIA.L.CA 9511118 PI If IN Ii SO:(4118)3(9-74a7
Cl LICENSED CUMRACI'O2'S 1)1CCLA RKI'I ON BUILDING I'ER,MIT INFO: BLDG 1:111:0, r PLUMB
1 License Class / .1c.
r r r
Anscu Itralurlu'rlA11 COMMERCIAL
l Conlraf[ Date // 7/
/ y
I herchy affirm(hal I a it licensed to the pro%isions of Ch:,peer 9 JOB DESCItI I',ION: IN STA LLA'I'ION OP 2 S 4 SK}'I.IGI I'1 IN A-1-1 IC(VIiLIJx)
(cununenring wish Serlion 70 00)of Ili vision}of Ihr ISusincss fi I'rofessiuns
Code and that my license is in fall Force and effect.
I here[)) :dfirm trader penally of perjury(,lie of the follmring Soon declarations:
I have and will maintain a cenilicate of consent to self-insure for Worker's
Compensation,as provided lite by Section 3700 at the Labor Code,for the
performance of the stork for which this permit is issued. Sq.FI Fluor Arra: Valualiun:S500
I have and will maintain Worker's Compensation Insurance,as provided lite by
Section 3700 of the Labor Code,for the perlbrmance of the work for which this
pennil is issued AVN Number:342320'19.00 Occupanc)Type:
APPLICANT CE1t,I FICA,ION
I certify that I have read this application and stale that the name inlitnnatimn is
correct.l agree to comply with all city and county ordinances and state laws relating I'ERA9I'I' E\I'I RES I F WOIiK IS NO"I' STA It"I'F D
to building construction.and hereby authorize representatives of this city to enter
upon tile above mentioned plopem•lorinspection purposes. (We)agree to save WITHIN fall DAYS OF PI R(IMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments. 180 DAYS FROA'I LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. AOdi(ionally,t licam w cntands and will comply n/ Q
with all non-point source regulation er the Cype ino I nicipal Code,Section Issued by: ✓E.9� f t G� Date:�/•�7•�a"
9.18.
Signawr- ale 7. /Z-
Rh:ROOFS:
❑ / 0\\'\Efl-14UILDER DBCLAR:\'1'I(IN All roofs shall be inspected prior In amp roofing material being installed.If a roof is
installed without line obtaining;m inspection. I agree to remote all new materials lin
I hereby affirm than I :mh c\cmpl tram Ihr Cunlrtctur'%License Luw fur one of inspection.
the falluo.in- non reasons:
I,as owner of the property,or nay employees with wages as their sole compensation. Signature ol'Applicanl: Dale:
will do the work,and die stmclure is not intended or ollcred for sale(Sec.70J4,
Business C Professions Code)
1,as owner of the property,ani exclusively contracting with licensed contractors m ,\I,I,hour COVERINCS,O BF.CLASS 'A"014 BILI-ITH
conswct the project(Sec.704.1,Business R Prolcssions Code).
I hereby affirm under penally of perjury ane of the folloo.ine three HA%ARIMUS MATERIALS DISCLOSUREi
declannimu: I hn%e read Ibe hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Cenilicate of Consent to self-insure for Worker's Califurnia llealth&Safro Code.Seeliuns 25505,25533,and 25534. 1 will maintain
Compensation.as provided for by Section 3700 of the Labor Code,for the connplimwe will,[tnr Cupertino Municipal Cudv.Chaplcr.9.12 and Ihv Ile:dth S
performance or the work for%%]rich this permit is issued. Safety Code.Section 25532(a)should I sure ur handle hazardous material.
I have and will maintain Worker's Compensation Insurance.as provided lir by Additionally should 1 use equipment or deniers which emit hazardous air
Section 3700 oflhc Labor Code,for the performance oflhe work lbr which this cunl:unillanis as defiued by the Ion, Area Air Quality?Lmagrmenl Distrirl I will
xnttit is issued. maintain compliance 11111,the Cuperli�ya Municipal Code.Chapter 9.12 and the
p I Icallh X Safety Cudv,Srcti nr25S S.'�>JJ,and25534.
I certify that in(he performance of the work for which this pennil is issued,I shall
not employ any person in any manner s0 as to become subject to the Worker's (hrn r rha d.
Compensation laws of California. If.atter making this certificate o'e\emption-I _ Ifane: ] � '
become subject la the Worker's Compensation provisions 01'the Labor Codc.I nasi
fonhwith comply with such provisions or this permit shall be deemed revoked, CUNSI'III,('I'ION I.P:Nu1m;ACF.NC 1'
I hereby affirm that[here is it construction lending agency lot the perlimnance of work's
APPLICANT CER I'11'ICA 1'ION 1'orvhich Ellis permit is issued(Sec.3097,Cie C.)
I certify that I have read this application and stale that the above inlorreation is Lender's Fame
correct. I agree to comply with all city and county ordinances and state laws relutin_e
to building construction,and hereby authorize representatives 01 dais city to enter Lender's Address
upon the above mentioned property far inspection purposes.(We)agree Rt save
indemnile and keep harmless the City of Cupenino against Iiabilities.judgme Els.
coils,and expenses which man
y ace ,c against said City in consequence 01'the ARCH ITEM"S UICCLAIt,VI'10\'
granting of this permit.Additionally,the applicant understands and will comply I understand nay plans shrill be used as public records.
with all non-point source regulations per the Cupenino Municipal Code.Section
9.18. Licensed I'rufessiivaal
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10104 Liberty Oak Ln DATE: 08/17/2012 REVIEWED BY: Sean
\ APN: BP#: SO/ -VALUATION: $500
*PERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY Buildina is PEN7•Ab1ATION
Multi-Family Dwelling 1GENRES
USE: ,3Stories C) Yes E) No PERMIT T\'PE:
WORK Installation of 2X4 skylight Velux .
SCOPE
Xtech. Plan Check Plumb.Plan Check F.lec.Plan Check
r tech. Permit rew: Plumb. Permit Fee: Flee. Permit Fee:
Odrer Mech,lnsp. Other Plumb Insp. Other Flee.In
.Ned,. /asp.Fee: Plumb. brcp.ree: Mee.Insp. Few:
NOTE: This artinmte does not includejees due ra other Departments(i.e. Planning, Public Works. Fire,Sanitary Server District,School
District,etc.). These feav are hued an the prelintinan information available and are only an estimate. Contact the De t or ttthln7 into.
FEE ITEMS (Fce Resolution 11-053 F_/L 7/I/1 U FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Skylight
Suppl. PC Fee: r) Reg. Q OTE-61hrs $0.00 $400.00 FISKYL110SF <= 10 s.f.
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee0 Reg. Q OT F0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consimciion Tax:
Administrative Fee: O
Work Without Permit? O Yes Q No $0.00 E)
Advanced Plannine Fee: $0.00 Select a Nan-Residential E)
Trove/Documentation Fees: Building or Structure Q
A
Stone Motion Fee: IBSEISHICR $0.50 Select an Administrative Item
Blde Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $400.00 TOTAL FEE: $401.50
Revised: 07/01/2012
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildina(ftuoertino.ora /� Uh/CT�J
CUPERTINO
❑NEW CONSTRUCTION ❑ ADDITION LTJ mJERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT M
PROJECT ADDRESS /0
1 /-J / /y �� / `'- APNh 3y�
OWNER NAME (J(/{ ('('� (^'/PHONE 71,F-9a,"'?
1,F_ ^/\/ ' E-MAIL
STftEEf ADDRESS/O /0 ( ,,/ / CITY, STATE,ZI fVJ(/l„(r,0 FAX
CONTACT NAME / K C PHONE
STREET ADDRESS RST
,,// CY. ATE,ZIP FAX
OWNER ❑ OWNER-BUILDER 11OWNERAGE.NT ELI CUM1TRACTOR ❑COYIAACIORAGEM ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONIRACrORNAME LICENSE NUMBER /� LICENSE'IYPE //J BUS.LICd
COMPANY NAME r .) ! ccc111 O EA ^^ //fn / I- /(1^/, , FA. �//,0 /x0
STREET ADDRESS/ ` \I� CIT\',STATE/%// `VC/,A�(� "W� (/� P!{OIN.I((W
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC b
COMPANY NAMEE-MAIL FAS
STREET ADDRESS CTT\',STATE,ZIP PHONE
DESCRIPTION OF WORK
//✓STA« — 'n/
h
1.
EXXPTJING USE PROPOSE USE CONsTR.T'PE asTORIFs h
Ve USE TYPE OCC. SQ.FT. VALUATION(5)
EXISTG NEW FLOOR DEMO TOTAL
ARG AREA AREA NET AREA II
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECJGPORCH AREA GARAGE AREA: DETACH
❑ATTACH
i DWELLING UNITS: ISASl:CONp IINfT ❑YES SECOND STORY ❑t'E$
BEINC dDDEU! 2'!tO ADDHIONP '2
PRE-APPLICATION AYES M YES.PROVIDE COPYOF IS"IHEBLDCAN ❑YES RECEIVEUB\': ^/ TOTAI,VALUATION:
PGNNINGAPPLN r.J'X.`0 PIANNINGAPPROVALLETTER CICHLF.ROOME] 350 �11 `^^ I
By my signature below,I cenifv to each of the following: I am the o rty owrJl or authorize age'}to act on the property owner's behalf..II havereadthis
application and the infprmatio (have provide is earrect. I ev, a pJ
pp sJ- p y �12�Descr tion of Worn a vert fy it is accurate. I agree to comply with all applicable local
ordinances and state laws reletin_ g to byi di �t'ructio uut die represenatives ol'Cupertm -mer the aabove-idened prope y for inspection purposes.
Signature ofApplicant/Agen(._ 1 Date: X 9 �7 Ia
SUPPLEMENTAL INi ORN•IATiONRTUCIRED PI.ANCHECKTYPF ROUTINGSLIP
New SPD or Multifamily dwellings: Apply for demolition permit for }� A
eX15lln bUlId10 S . Demolition OYER.ruE.COUNTER Cp�-�i BUILDING PLAN REVIEW
g gO permit is required prior to issuance of building
permit for new building. ❑ EXPRESS PI.AN.N NG PLAN REVIEW
r
_Commercial Bldgs: Provide a completed I lazardous Materials Disclosure ❑ STANDARD ElPua,icw'oRKs
form ifany Hazardous Materials are being used as pan ofthis project.
/ ❑ LARGE ❑ FIRE DEY I'
✓ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR ❑ $dSITAR\'SEN't;H D15THICT
submittal o(13uilding Permit application.Arrij�U�EIJ P/L.
❑ EN\'IRO\'\IEXT,\I.IEE\I.T'll
R1dgA1)p_201 I.doc revised 06/21/11
0