11100141 CIT*k*' OF �-UPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21485 MILLARD LN CONTRACTOR:ANDERSON PERMIT NO: 11100141
INSTALLATION
OWNER'S NAME: SHANE&LINA MARTIN 696 AUZERAIS AVE DATE ISSUED: 10/18/2011
'NER'S PHONE: 4082451130 SAN JOSE,CA 95126 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.# S6,dd
A / � MECH F RESIDENTIAL COMMERCIAL�
Contractor Eh S? f/_(iltz-Date �a`7 �l<<
JOB DESCRIPTION:SFD,2 STORY WINDOW REPLACEMENT,29 WINDOWS,
I hereby affirm that I am licensed under the provisions of Chapter 9
NON-STRUCTURAL
(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 Sq.Ft Floor Area: Valuation:$11900
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:32644063.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
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. Issued -- Date. ��
Signature Date lU�/✓ qtr
L OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,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 and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
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
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or rized a ent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
iad—•-ify and keep harmless the City of Cupertino against liabilities,judgments,
_1d expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
gran,ag of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION-CUPERTINO
APPROVED
This set of plans and specifications MUST be kept at the -4
job site dur;
c r c^^struction. It is unlawful to make anyl V?
ar e,or alterations on same,or to deviate
there, n, v✓ithout approval from the Building(:)fficial.
The stam�-aing of th?s plan and specifications SH��L.L.NOT
be r pla to Parmi'or to be a
of any provisionn approval of the violation
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of any City Ordinance or Stare Law. ell
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CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: TraciC
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32644063 .00
DATE ISSUED. . . . . . . : 10/18/2011
RECEIPT #. . . . . . . . . BS000015085
REFERENCE ID # . . . : 11100141
SITE ADDRESS 21485 MILLARD LN
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER SHANE & LINA MARTIN
ADDRESS 21485 MILLARD LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM ANDERSON INSTALLATI
CONTRACTOR JOHN SCALMANINI LIC # 22780
COMPANY ANDERSON INSTALLATION
ADDRESS 696 AUZERAIS AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95126
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ------
1BCBSC VALUATION 11, 900 .00 1.00 0 . 00 1 . 00 0 .00
1BSEISMICR VALUATION 11, 900. 00 1 .19 0 . 00 1.19 0 .00
1WINREP EACH 8 29. 00 782 .00 0 . 00 782 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 784 .19 0 . 00 784 .19 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 784 .19 Visa 085382
---------------
TOTAL RECEIPT 784 .19
CITY OF CUPERTINO
l ) )
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21485 millard In. DATE: 10/18/2011 REVIEWED BY: bob s.
l �(, j_0 Cp2, BP#: "VALUATION: $11,900
APN: 3 `TY
'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY PENTAMATION 1 GENRES
USE: SFD or Duplex PERMIT TYPE:
wORK sfd 2 story window replacement non structural
SCOPE
Lj
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Theseees are based on the relimna information available and are onlyan estimate Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053Eff '-1.;11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 29 # Window/Sliding Glass Door
Suppl.PC Fee: (F) Reg. Q OT 0.0 hrs $0.00 $782.00 IWINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp.Fee.e Reg. Q OT ko hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? 0 Yes (j) No $0.00
Advanced Planning,Fee: $0.00 Select a Non-Residential G
Building or Structure
A
Strong Motion Fee: IBSEISMICR $1.19 Select an Administrative Item
Bldy,Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $2.191 $782.00 TOTAL FEE.- $784.19
Revised: 10/01/2011
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE -CUPERTINO, CA 95014-3255 11
(408)777-3228- FAX(408)777-3333 - building(cDcupertino.org
CUPERTINO
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS ^ ' /I d 1,4 e AFN# C)
OWNER NAME \ A�e ✓ • ( r [✓7 lit V Y PHO Yoe - ) G,
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STREET ADDRESS S' /n CITY, STATE,ZIP FAX
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CONTACT NAME0 sG n PHONE yaL,, / / ( E-MAIL
STREET ADDRESS / �v^� ILgr_J 1,STATE, ZIP
❑OWNER ❑ OWNER-BUILDER OWNER AGENT Y ONTRACTOR ❑CONTRACTOR AGENT J❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME ;JU�', LICENSE NUMBER LICENSE TYPE BUS.LIC#
hDerSo tvtn /)ac,( �- O c)I 1 11
CO ANY NAME E-MAIL FAX
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S'T'REET ADDRESS 6q(
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# 1
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK '
Rewo-e At, p TZQ 14-c C� 15-r a c)L, c)ri
EXISTING USE PROPOSED USE CONSTR TYPE #ST 5
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL ^7 +
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER V
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA DETACH
ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? []NO ADDITION! []NO
PRE-APPLICATION [IYES IF YES,PROVIDE COPY OF Is THE BLDG AN ❑YES RECEIVED BY; TOTAL VALUATION: cJ
PLANNING APPL# [:]NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO - � dj // GI 0c)
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. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildi nstruction. 1 authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: TC' —/ G -Z--I(
SUPP AL INFORMATION REQUIRED PLAN CE(ECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit forU
OVER-THE COUNTER BILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ElND
STAARD ElPUBLIC WORKS
To—rm.if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIREDPPP
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANTTARY SEWER DISTRICT
bmittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp 2011.doc revised 06/21/11