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11080132CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10382 PALO VISTA RD CONTRACTOR: J D HAALAND PERMIT NO: 11080132 CONSTRUCTION INC OWNER'S NAME: CARMEL, CA 93923 PHONE NO: (831)726-1577 ❑ LICENSED CONTRACTOR'S DECLARAATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lic. # �� l CONSTRUCT 2 STORY SFDWL 3,763 LIVING, 500 SQ FT Jam� � �� c.� Contractor_ ) I a- Date /J f 6 12-- ATTACHED GARAGE, 527 SQ FT TO DECK/ PORCH L 1 hereby affirm that 1 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 Sq. Ft Floor Area: Valuation: $480000 performance of the work for whichthis 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 APN Number: 35702050.00 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 0 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 DAY OM LAST CALLED INSPE IO . 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 p it. Additionally the applicant understands and will comply Issued by: Date: with all Z 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. ❑ OWNER DECLARATION -BUILDER Signature of Applicant: Date: 1 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 1, 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will 1 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 1 use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the y Area Air Quality Management District I performance of the work for which this permit is issued. tino Mu 'ci al Code, Chapter 9.12 and will maintain is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person inany manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, 1 CLENDING AGENCY 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.) 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10382 PALO VISTA RD CONTRACTOR '� .f Kt1 ar, PERMIT NO: 11080I32 OWNER'S NAME: wp PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # I- t MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: CONSTRUCT 2 STORY SFDWL 3,763 LIVING, 500 SQ FT (commencing with Section 7000) of Division 3 of the Business & Professions ATTACKED GARAGE, 527 SQ FT TO DECK/ PORCH 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: $480000 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 35702050.00 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 upon the above mentioned property for inspection purposes. (We) agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18.��� j Issued Signature Date OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: Date: I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain I have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should I store or handle hazardous material. permit is issued. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued, I shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. Compensation laws of California. If, aftgr making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must Oor : 6 APPLICANT CERTIFICATION CON RUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. I understand my plans shall be used as public records. Signature Date 6 t Licensed Professional FM_7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: "VALUATION: 1$480,000 %PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex USE: 2nd Unit? Yes • No PENTAMATION 1R3SFDW PERMIT TYPE: WORK SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,III-B,IV,V-B 4,790 $3,040.40 1R3PLNCK $3,625.40 1R31NSP TOTALS: 4,790 $3,040.40 $3,625.40 _L_ Li NOTE: These fees are based on the vreliminary information available and are onlv an estimate. Contact the Dent for addn 7 info. FEE ITEMS flee Resolution 11-053 E'. 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $3,040.40 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. © OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,625.40 Suppl. Insp. Fee4@ Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr. Tax: 1BCONSTA 1 $579.61 Acoustical Fee: 0 Yes (D No $0.00 0 0 Work Without Permit? 0 Yes 0 No $0.00 Planning Fee: PLLONGRNGR $622.70 Select a Non -Residential Building or Structure 0 Strong Motion Fee: 1BSEISMICR $48.00 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $20.00 SUBTOTALS: $7,936.11 $0.00 TOTAL FEE: 1 $7,936.11 Revised: 07/04/2011