The URL can be used to link to this page

13010136 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18751 PENDERGAST AVE CONTRACTOR:JIGSAW DESIGN BUILD PERMIT NO: 13010136 INC OWNER'S NAME: HAR-EL OPHER Y AND NAOMI 101 IST ST APT S39 DATE ISSUED:01/28/2013 OWNER'S PHONE: 4082574125 LOS ALTOS,CA 94022 PHONE NO:(650)305-1103 00 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class n / Lic.d �'/7 �Z(/ L'. TEMPORARY POWER POLE Contraclorc,�, I hereby affirm that I am licensed under the 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. 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:$300 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 APN Number:37527033.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FRO�4 LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenseswhich ey accme against said City in consequence of the granting of this permit. ditionally,the applicant understands and will comply Issued by: Date: with all non-point sou gulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.Ue roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION �+ Signature of Applicant: i' "r Date: I hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(See.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter-6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminantsas defined by the Bal' e Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the C rtino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Section 05,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Da J / permit is issued. I 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 Compensation laws of California. If,after making this certificate of exemption,I CO RU ION LENDIN A ENCY become subject to the Worker's Compensation 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.l Lender's Name APPLICANT CERTIFICATION Lender's Address 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 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the 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 Date GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O� 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 G \(G M I SC CUPERTINO (408)777-3228•FAX(408)777-3333•buildinGcuoertino.orG `/1J(_) PLUMBING MECHANICAL DELECTRICAL MISCELLANEOUS PROJECT ADDRESS � I % APN It OWNER NAME /07 / /,zV(J e,C PHONE STREET ADDRESS Oj1.� _�/��tj^C j, CITY, STATE,`ZIPW/'�.L/ XCI � FAX CONTACT NAME �A_ .r—P PHONE STREETADDRESS /a/ CITY,STATE, ZIP �J//J I /-.t FAX rC ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT IrCONTRACIOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME �I7.� I f1•}�7//' LICENSE NUMBERLICENSE TYPE BUS.LICA COMPANY NAME ll i Il ,L1 (9 E-MAIL ( FAX STREEFADDRESS CITY.STATE,ZIP PHONE ARCHITEC VENGINEER NAME LICENSE NUMBER BUS.UC M COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFDor DUPLEX ❑ MULTI-FAMILY PROJECT IN WI.DIAND ❑ YES PROJECT IN ❑YES ISTHEBLDGAN ❑YES BUILDNG: ❑COMMERCW URBAN INTERFACE AREA [3 NO FLOOD ZONE El No EICHLER HOME? El NO DESCRIPTION OF WORK TOTAL VALUATION: 3 OO RECEIVED BY: By my signature below,I certify to each of the following: the property owner or authorized agent to acton the property owner's behalf I have read this application and the information I have provided is correct. ave read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction orize representatives of Cupertino to enter the above-iidrdentiffiedTprp�-perty for inspection puooses. Signature of Applicant(Agent Date: .7-/T '" /S SUPPLEMENTAL TION REQUIRED OFFICE USE ONLY m OVER-THE-COUNTER ❑ EXPRESS Y u ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPM=App_2011.doc revised 06121/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 18751 Pendergast DATE: 0112812013 REVIEWED BY: RDW APN: BP#: 'VALUATION: $300 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1REAP14 USE: PERMIT TYPE: WORK TeMD Power Pole SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $45 TOTALS: $45.00 Much. Plan Check Plumb.Plan Check Elec.Plan Check 0.0 1 hrs $0.00 ,Meeh. Perntil Fee: Plumb. Permit Fee: Elec.Permit Fee: IEPERMIT Other Hech. Insp. Other Plumb Insp. Li I Other Elea Insp. 0.0 hrS $45.00 A-Lech. hap. Fee: Plumb. hisp.Fee: Ele.c.Insp. Fec: NOTE:This estimate does not include fees due to other Departmentss(ice Planning,Public Works,Fire,Sanitary Sewer District'School District etc). These ees are based on the relimin in ormadon available and are only an estimate Contact the Dept for addn'l info. FEE ITEMS(Fee Resolution 11-053 Efl 7/1/122 FEE QTY/FEE MISC ITEMS Plan Check lice: Suppl.PC Fee PME Plan Check: $0.00 Permit Fee: Suppl. lnsp Fee PME Unit Fee: $45.00 PME Permit Fee: $45.00 Construction Tac. Administrative Fee: IADMIN $42.00 Work Without Permit? O Yes Q No $0.00 Advanced Planning Fees: Travel Documentation Fee: I MVDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: . IBCBSC $1.00 $178.50 $0.00TOTALFEE4 $178.50 Revised: 10/01/2012 r Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: 4Q57 PERMIT# OWNER'S NAME: �i9,Q, PHONE# 4,V4 :Re9,E- 11dZ GENERAL CONT CTOR:T/ ,-*/ v 13USINESS LICENSE# ADDRESS: p/ Co CITY/ZIPCODE: 4Z 2 *Our municipal code requires all busines king in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OC ANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND CONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: - Signature Date Please check applicable subcon ctors 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 Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal ' Sheet Rock Tile ner/Contractor Signature Date