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12120076CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 19161 ANNE LN I IM M OR: BROTHERS HOME I PERMIT NO: 12120076 I OWNER'S NAME: RANCHES FEDERICO D AND CARMEN M 2510 DOUGLAS BLVD I DATE ISSUED: 12/14/2012 OWNER'S PHONE: 4083165441 1 ROSEVILLE, CA 95661 I PHONE NO: (408)295 -0680 I ❑ LICENSED CONTRACTOR'S DECLARATION License Class L I Lic. # Contractor Date 12, Y 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. I 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. APPLICANT CERTIFICATION 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 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 comply with all non -point source regulat' s per the Cupertino Municipal Code, Section 9.18. Signature / / Date Z- ❑ OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 (Sec.7044, Business & Professions Code) I, as owner ofthe property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. I 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. 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 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. APPLICANT CERTIFICATION 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 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 comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date BUILDING PERMIT INFO: BLDG I- ELECT r- PLUMB f- MECH r- RESIDENTIAL COMMERCIAL r- JOB DESCRIPTION: INSTALLING 1 BAY WINDOW LIKE FOR LIKE Sq. Ft Floor Area: I Valuation: $4390 APN Number: 37507011.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: � it f� Date: /p9 /.( /, RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the ertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Se s 25505, 25533, and 25534. Owner or auth i l Date: Z CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 (408) 777 -3228 - FAX (408) 777 -3333 - buildina(c1cupertino.orq 7 PLUMBING 7 MECHANICAL ❑ELECTRICAL MISCELLANEOUS I2I -z,_>--I MEP MISC PROJECT ADDRESS A` N "% -- l0 1 7 C ' 1 OWNER NAME ., PHONE ` .. E -MAIL STREET ADDRESS 1110 CITY, STATE, ZIP FAX CONTACT NAME PH NE r A r �I E -MAIL STREET ADDRESS CITY, STATE, ZIP FAX OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CO CTOR N LIC SE NUMBER SE TYPE G—Jl BUS. LIC # COMPANY NAME E -MAIL FAX S ET D S IV 401A vt CITY, STATE, ZIP 9S- 1 I r —sa ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME ' E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or DUPLEX ❑ MULTI - FAMILY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA ❑ NO PROJECT IN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK iNr 0 I r C 1 TOTAL VALUATION: iO �� RECEIVED BY By my signature below, I certify to each of the followin I am the grope owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is ct. I have read escription of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building truction. I autho ' representatives of Cupertino to enter the above - identified rope; y for inspection p400ses. Signature of Applicant/Agent: Date: Tr SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY v E' k ❑ OVER - THE - COUNTER ❑ EXPRESS U U ❑ STANDARD a ❑ LARGE ❑ MAJOR 1EPMrscAPP_2011.doc revised 06121111 � �'► l,� ��L.; L1��t � ��i�1 ✓V J L7c "�� qv\, t?� ctc,IV15 1 Ayw CUPERTINC} ��%IlJPERTiNO ..d. ^g Department �uldin� Department ' f -�ttio `�� 1012 - ? �. 012 REVIEWED FOR CODE COMPL! NCE REVIEWED FOR CODE CIO MPL IANCE I. Reviewed E3y: Reviewed By 0 *%OPv FIR'ICE Lk; o 7�. :5rjW1P opfA`t Scze P-0 c �1 e Lot l �� -� -� I Ic-t CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 Fax: 408 - 777 -3333 JOB ADDRESS: PERMIT # OWNER'S NAME: PHONE # ® - - GENERAL CONTRACTOR: 13nAea h6ptq- KN BUSINESS LICENSE # ADDRESS: CITY /ZIPCODE: SG *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 SUBCON CTORS E OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Z1 i 2" If Z Signa ure Date Please check applicable subcontractors and complete the following information: r/ 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 110, i Owner / Contractor Signature i Date