13030136CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21801 STEVENS CREEK BLVD
OWNER'S NAME: DOTY - NELSEN JOINT VENTURE PART
OWNER'S PHONE: 4086716576
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lie.#
Contracto Date
I hereby a rim ha 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
1 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
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 pe 't. Additionally, the applicant understands and will comply
with all non -poi ourc egulVions per the Cupertino Municipal Code, Section
Signature Dat T/(S
❑ 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 of the 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-
Signature Date
CONTRACTOR: THRASHER TERMITE & PERMIT NO: 13030136
PEST CONTROL
17427 FARLEY RD W DATE ISSUED: 03/26/2013
LOS GATOS, CA 95030 PHONE NO: (408)354 -9944
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
REPAIR & REPLACE (E) SIDING, PLY & FRAME AS
NEEDED
TO REPAIR TERMITE & FUNGUS DAMAGE, LIKE FOR
LIKE
Sq. Ft Floor Area: Valuation: $14695
APN Number: 32619119.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DA T ISSUANCE OR
180 DAYS L CALLED INSPECTION.
by;
Date: 26
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 Cu ertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 5, 533, and 25534.
Owner or authorized agent: D a t e t111
C 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
CONSTRUCTION PERMIT APPLICATION �\
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (� _
(408) 777 -3228 - FAX (408) 777 -3333 • building(ftupertino.org �" I
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI I—I RFVTS10N / DF.FF.RRFD 0RlGTNAT. PFRMTT #
PROJECT ADDRESS
APN # z-6 1 9 /
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OWNER NAME /�/
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CONTACT NAME
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OWNER-BUILDER ❑(OWNE/AG�G
❑ OWNER ❑ OWNER B/ R CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER DEVELOPER ❑ TENANT
CONTRACTOR NA
LICENSE NUMBER
LICENSE TYP ,
✓/al�
BUS. LIC # C�
COMPANY NAME r _m
E -MAIL
�{�'�
FAX
STREET ADDRESS
/NAME (
CITY. STATE, ZIP
ARCHITECTIENGINEER
LICENSENUMBER
BUS. LICU #J
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
r r- w/
EXISTING USE
PROPOSED USE CONSTR
=RMS
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODELAREA
REMODELAREA
PORCH AREA
DECK AREA
TOTAL DECK /PORCH AREA
GARAGE AREA: U DETACH
❑ ATTACH
I
# DWELLING UNITS:
IS A SECOND UNrr YES
SECOND STORY YES
BEING ADDED? []NO
ADDITION? []NO
PRE - APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
OTA.L VALUATION:
PLANNING APPL # [] NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
/ �
By my signature below, I certify to eac of ollowing: I am the property r or authoriz en ac on perty owner's behalf. I have read this
application and the information I ba pro ded is correct. I have read the Description of Work and ve ' s accurate. I agree to comply with all applicable local
ordinances and state laws relatin b 'c on. I authorize presentatives of Cupertino to enter the abo a - 'fied property for inspection purposes.
/ide
Signature of Applican Date:
SUPPLEMEN L O ATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
OVER- THE - COUNTER
BUILDING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
'ff PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC 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
❑ MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06121111
I_
CITY OF CUPERTINO
FT'F F.CTTMATn'P — RITTI.DIN DIVT .SION
JWch. Plan Check FT. Plumb. Plan Check Elec. flan Check
11ech. Permit Fee: Plumb. Permit Fee: flee. Permit Fee.:
Other 7ulech. Rap. Other- Plumb Insp. Other Elee. Insp.
Alech: Insp, ,Fee: Plumb. hrsp. Fee: Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other uepartments (t.e. running, rnotic rrurns, moire, auntiury . Cwv, �susi su, .tea •svv.
District, etc). These ftes are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info.
ADDRESS: 21801 STEVENS CREEK BLVD
DATE: 03/26/2013
REVIEWED BY: MELISSA
QTY/FEE
APN: 32619119
BP #:
"VALUATION: $14,695
*PERMIT TYPE: Building Permit
F320
PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY Commercial Buildin g
PENTAMATION 1GENC0M
PERMIT TYPE:
USE:
hrs
$0.00
$400.00
WORK
REPAIR & REPLACE E SIDING
PLY & FRAME AS NEEDED TO REPAIR TERMITE & FUNGUS
SCOPE
DAMAGE, LIKE FOR LIKE
JWch. Plan Check FT. Plumb. Plan Check Elec. flan Check
11ech. Permit Fee: Plumb. Permit Fee: flee. Permit Fee.:
Other 7ulech. Rap. Other- Plumb Insp. Other Elee. Insp.
Alech: Insp, ,Fee: Plumb. hrsp. Fee: Elec. Insp. Fee:
NOTE: This estimate does not include fees due to other uepartments (t.e. running, rnotic rrurns, moire, auntiury . Cwv, �susi su, .tea •svv.
District, etc). These ftes are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info.
FEE.ITEMS (Fee Resolution 11 -053 E . 7ff 11112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00.
F320
s.f.
Siding
Suppl. PC Fee: Q Reg. 0 OT
0.0
hrs
$0.00
$400.00
1SIDEOTHER
All Other
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:g Reg. ® OT
0.0
hrs
$0.00
PME Unit Fee:-
$0.00
PME Permit Fee:
$0.00
Constrliction Tax:
Administrative .Fee:
Work Without Permit? ® Yes (j) No
$0.00
Advanced Planning; Fee:
$0.00
Select a Non - Residential
Building or Structure
Travel Documentation Fees:
i
Strong Motion Fee: IBSEISMICO
$3.09
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
$4.09
$400.00
$404.09
�. Revised: 01/01/2013
2nd
21801
PAGE OF STANDARD INSPECTION REPORT ON PROPERTY AT:
Stevens Creek Blvd., Cupertino CA 95014
BUILDING NO. STREET, CITY, STATE, ZIP
04VIOV A'4rZXWL-� beerW7WIZO
�JFFICE COPS' ,
DIAGRAM NDTM SCALE
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of this plan and specifications T
be an approval OttV eJi
id
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BY 3 26 13
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3/14/2013 6736
INSPECTION DATE REPORT NO.
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THRASHER TERMITE & PEST CONTROL, INC. -- License No. PR 5009
6 2013
*Our municipal code requires/all businesses working in the city.to hav e a City of "Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUP INSPEGT,ION(S) WILL BE {SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND AL UB NT CTORS HAVE �OBTAI E, -," =:CITY OF UPERTINO
BUSINESS LICENSE. 2 I
I am not using any subcontracto
Signature Date
Please check applicable subcontractor and complete the following- .mformat on�4
r
JOB ADDRESS: 2
PERMIT "#
SUBCONTRACTOR
BUSINESS NAME
OWNER'S NAME: N
HONE
Cabinets & Millwork`�,�
GENERAL CONTRACTO : 71 G,re�
Bl 7SINESS: L�,CEJ�,;
ADDRESS:
CITY /ZIPGODE { k
*Our municipal code requires/all businesses working in the city.to hav e a City of "Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUP INSPEGT,ION(S) WILL BE {SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND AL UB NT CTORS HAVE �OBTAI E, -," =:CITY OF UPERTINO
BUSINESS LICENSE. 2 I
I am not using any subcontracto
Signature Date
Please check applicable subcontractor and complete the following- .mformat on�4
r
SUBCONTRACTOR
BUSINESS NAME
TTSINESS LICENSE #
Cabinets & Millwork`�,�
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing,
RoofingY'
Septic Tank
Sheet Metal
Sheet Rock
Tile
z,
4w or
/Contractor Signature Date