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12120022 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10187 CAMBERLEY LN CONTRACTOR:PACIFIC COAST HOME PERMIT NO: 12120022 SOLUTIONS OWNER'S NAME: CORRINE DEVINE 4155 E LA PALMA AVE STE 500 DATE ISSUED: 12/06/2012 OWNER'S PHONE: 4087770474 ANAHEIM,CA 92807 PHONE NO:(714)622-1700 ❑ LICENSED CONTRA-CTOWS DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class C( l GZ�Lic.q 1412 '(37 MECH r RESIDENTIAL r COMMERCIAL r Contract4AQ Fte COA91, Date LgZ - - l2 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE'$WINDOW AND I PATIO DOOR (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I 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. Sq.Ft Floor Area: Valuation:$8998 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 permit is issued. APN Number:34242026.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 18 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS M LAST CALLED INSPECTION. costs,and expenses which may accme against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issrfer) Date: 9.18. p, ff4�� ,�lSignature �QA4 We Date 2 RE-ROOFS: ❑ OWNER-BUILDER DECLARATION 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 1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. 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 Owne autho ' d ent: Compensation laws of California. If,after making this certificate of exemption,I R4 �� Date:t'2— C —IZ 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. CONSTRUCTION LENDING AGENCY I hereby afftrtn that there is a construction lending agency for the performance of cork's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date Co CM ��1 Ccne� i� t N 4 C ct3 LL� This ,vt ps N: snc;.,... therou'om, wl;hcvt approvaa ,r„,n the Buif��:. The st;mpinp of ff is plan anc: sc-crfications Si v be hetc io cerrni or to been e.p„roval of the vic ,'::,r of any provision, of any City Ordinance or Siaie L,�v BY V14 "3N DAI E 1 12 PERMIT No. ®12.12 ppm. �d � Z �� VEIL COPYDEC U 6 2012 .. BY:.--- CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION oO 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333•building(ftuoertino.oro ❑NEW CONSTRUCTION [-I ADDITION ❑ ALTERATION/TI ❑ REVISION/DEF E�7RRED OR/hGINA7L PERMITN PROJECT ADDRESS 1012 7 Cp MF)r KLFY LANG QAPN0 344 42- �� `-'V " /n OWNER NAME Co RRI Ne /•1nf'CVI _ ICC PHONEJ�IO O -,,,.O l-,,,.OL( E-MAIL V/ STREET ADDRESSID(e1 CAMK�-KL Y LAANC CI^,STAT�IZIP 1407 ^5U( FAX CONTACT NAMFj� ^QDD,1 RAL P f.G IrPHONE `� E-MAIL STREET ADDRESS rITY STATE, ZIP .� FAX zy>o EJASt-1(rr h'��t� AVE `TW";Z & Rf� ��CiO �-A ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR XCONTRACTORAGENT ❑ ARCHITECT Cl ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME^ /A�r 51 #T b w I LICENSE NUMBEIy? .3� LLIICECNSETYPEt C� BUS.LIC#�i' Om COMPANY NA 1Cl`. f�TC L�� rttv`^I u�rU�� E-MAIL ( rj FAX T I STREET ADDRESS �.� r LFt PALMA 7�-AVy CITY,STAT,ZIP - � 1'90 PHONE ARCHITECT/ENGINEER NAME �1• LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK Apr- gyp JLpCgj 3 WINb0VJ5 I�ob(Z EXISTING USE PROPOSED USE CONSTR.TYPE #sToms IKSS OZ- -Z_ USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR l DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTALDECK/PORCHAREA GARAGE AREA: ADETACH ATTACH #DWELLNGUNITS: IS A SECOND UNIT ❑YES SECONDSTORY L]YES BEING ADDED? eNNO ADDITION? NO PRE-APPLICATION ❑YES IF YES,PROVmE COPY OF ISTBEBLDGAN !R JYES RECEI D TOTAL VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLERHOME? NO Uq G� By my signature below,I certify to each of the following: 1 am the property owner or authorized ent to act on the prope is behalf. IVVhave readls this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I a e to comply with all applicable local ordinances and state laws relating to building consuuctio . I authorize representatives of Cupertino to enter the above-id initial property for inspection purposes. Signature of Applicant/Agent: Date: 1 1 1-2- SUPPLEMENTAL INFO TION REQUIRED PIAN CHPCICTYPE �� ROUTING SLIP OVER-THE-COUNTER _New SFD or Multifamily dwellings: Apply for demolition permit for /EJ BUILDING PLAN REVIEW ` existing building(s). Demolition permit is required prior to issuance of buildin permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 11STANDARD ElPUBUC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. El MAJOR ❑ SANITARY SEWER Dlsralcr ❑'ENVIRONMENTAL HEALTH BldgApp_I011.doc revised 06121111 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: ((J k'61 CA M BE RJ 1A NP PERMIT# OWNER'SNAME: {ZR(NC I)EV(Nk. PHONE# GENERAL CONTRACTOR: R9C11 IC: {}dME 5"11 W5 BUSINESS LICENSE# ADDRESS: LSE. LAAL -A AVE CITY/ZIPCODE: EIM 9Z�l *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL.OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. Q� I am not using any subcontractors �lSignature Date Please check applicable'subcontra06rs:andcomplete the following information: •/ SUBCONTRACTOR -' BUSINESS NAME 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 Owner/Contractor Signature Date