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11100081CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10873 W ESTATES DR OWNER'S NAME: MORRIS DAVID W AND BARBARA S ("VNER'S PHONE: 4084831469 LICENSED CONTRACTOR'S DECLARATION CONTRACTOR: T' 'ERMIT NO: 11100081 DATE ISSUED: 10/11/2011 PHONE NO: BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class i6 Lic. # % % 92 61 I MECH RESIDENTIAL COMMERCIAL F Contract Date �O�//�// I hereby affirm tha am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 1 WINDOW LIKE FOR LIKE (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 regulations per the Cupertino Municipal Code, Section 9.18. SignatureDatemol- OWNER-BUILDER DECLARATION I :rereby 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) 1, 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. 11 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, coy+s, and expenses which may accrue against said City in consequence of the ig of this permit. Additionally, the applicant understands and will comply Al non -point source regulations per the Cupertino Municipal Code, Section 9.16. Signature Date Sq. Ft Floor Area: I Valuation: $350 APN Number: 36923042.00 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: Date: 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 Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or uffig;iz!ed�ag�ent� ��- Date• � %//// .r 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 3 ITEMS OF 4 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36923042.00 DATE ISSUED.......: 10/11/2011 RECEIPT #......... BS000015017 REFERENCE ID # ...: 11100081 SITE ADDRESS 10873 W ESTATES DR SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OPERATOR: patg COPY # : 1 OWNER MORRIS DAVID W AND BARBARA S ADDRESS 10873 W ESTATES DR CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: GERALD J BRAGER CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096 COMPANY ..........: TBD - TO BE DETERMINED ADDRESS ........... CITY/STATE/ZIP ...: , TELEPHONE ......... FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ---------- NEW BAL --------- ----------------------- 1BCBSC VALUATION ---------- 350.00 -------------------- 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 350.00 0.50 0.00 0.50 0.00 1WINREP EACH 8 1.00 392.00 0.00 392.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- ---------- 393.50 0.00 393.50 0.00 METHOD OF PAYMENT AMOUNT REFERENCE -------------------- NUMBER ----------------- --------------- CREDIT CARD 508.50 VISA --------------- TOTAL RECEIPT 508.50 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(3cupertino.org F-1 VMu rnN.RTRTTC7n0N n ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS -- - - (7 77 7 "7' C78" 7 OWNER NAME /.rJ022/.s�le PHONEE-MAIL STREET ADDRESS CITY, STATE, ZIP FAX PHONE E-MAIL CONTACT NAME�C2' i o- ..3141 ,j CITY, STATE, ZIP FAX c ❑ OWNER ❑ OWNER-Bun.DER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT COINMAUOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIPS! PHONE ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE. ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQFI. VALUATION (S) EXISTG AREA I NEW FLOOR AREA DEMO AREA TOTAL NET•4,REA ` BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH AREA I DECK AREA TOTAL DECK/PORCHAREAEGLARAGE AREA DETACH []ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES TORY ❑ YESBEING ADDED? ❑NO ? ❑NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF APPL # NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO EI Y: RECEIVED BY- TOTAL ALUATION: PLANNING ❑ By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the prrperty owner's behalf. 1 have read this application and the information I have provided is correct. I have read le Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relaying to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signalise of Applicant(Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER -nM -COUNTER ER ❑ IlUUMING PLAN REVIEW _ existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING Plant REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElSTANDARD ❑ PUBLIC WORKS _ form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ i;nmEnEpr _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ gANTTARY SEYVER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 1. doc revised 06/21/11 ��,�,.t�� CITY OF CUPERTINO 11 ! 1PUIP r crrnvr A rrnID — RITIT .TIINf D1V1CI0N LaiADDRESS: 10873 WESTESTATES DATE: REVIEWED BY: APN: BP#: *VALUATION: $350 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex p Suppl. PC Fee: Q Reg. () OT PENTAMATION 1GENRES PERMIT TYPE: USE: Li 2=d 14 $0.00 WORK 1 WINDOW REPLACED LIKE 4 LIKE MEET EGRESS Permit Fee: SCOPE Suppl. Insp. Feer Reg. Q OT NOTE: This estimate does not inetude fees due to otner veparrments (t.e. rtunntng, ruuuc ..vrna, ..•c, __a __.. --I.. __ d m�f N.o [)ant fnr nddn't info_ Ulstrtet, etc.. [ neae ee3 urc uuacu — anc FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/11) FEE - QTY/FEE --- i -- - -- MISC ITEMS Plan Check Fee: $0.00 1 # $392.00 Window / Sliding Glass Door 1 WINREP Replacement Suppl. PC Fee: Q Reg. () OT 0.0 hrs Li 2=d PME Plan Check: $0.00 Li NOTE: This estimate does not inetude fees due to otner veparrments (t.e. rtunntng, ruuuc ..vrna, ..•c, __a __.. --I.. __ d m�f N.o [)ant fnr nddn't info_ Ulstrtet, etc.. [ neae ee3 urc uuacu — anc FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/11) FEE - QTY/FEE --- i -- - -- MISC ITEMS Plan Check Fee: $0.00 1 # $392.00 Window / Sliding Glass Door 1 WINREP Replacement Suppl. PC Fee: Q Reg. () OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. Q OT 0.01 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 F 0 E) Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning_Fee: $0.00 Select a Non -Residential Building or Structure Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $392.00 TOTAL FEE: $393.50 meviseu. i u/v ucv 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: 104 -7 PERMIT # OWNER'S NAME: IT, ar_r`/ S i,411, !7) PHONE # GENERAL CONTRACTOR: 6- 7% BUSINESS LICENSE # ADDRESS: Cement Finishing CITY/ZIPCODE: *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 SUBCONT TORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature - ate Please check applicable subcontractors and complete the following information: Date 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 Date