11060231CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 19975 PRICE AVE
OWNER'S NAME:
IT-- LICENSED CONTRACTOR'S DECLARATION
License Class /, Lic. # 5_t/ 3 3 Z-6>
Contractor Date
I 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
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
eranting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
•1ature ""' Date
❑ 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
CONTRACTOR: S.EA. PERMIT NO: 1 106023 1
CONSTRUCTION
1941 O'FARRELL ST DATE ISSUED: 08/23/2011
SAN MATEO, CA 94403 PHONE NO: (650) 2874202
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: REPLACE 3,454 SIDING, REMOVE EXTERIOR DECK
ABOVE
ENTRY REPLACE WITH NEW GABLE ROOF 68 SQ FT AND 17
WINDOWS AND DOOR
Sq. Ft Floor Area: I Valuation: $31250
APN Number: 36905040.00 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. 1 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 authorized agent: ' Date:
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I mustI 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
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
building construction, and hereby authorize representatives of this city to enter
i the above mentioned property for inspection purposes. (We) agree to save
emnify 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
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
_._ CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
19ADDRESS: 19975 price ave.
FEE
DATE: 06/30/2011
REVIEWED BY: bobs.
--11 APN:
BP#:
"VALUATION: 1$31,250
rPERMIT TYPE: Building Permit
Roof Structure Replacement
IROFSTRREP
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE: p
0.0
hrs
PENTAMATION 1GENRES
PERMIT TYPE:
WORK
sfd add new able roof 68 sq. ft., replace
3454 sq. ft. siding, and 17 windows and doors except for
SCOPE
I entry and garage doors.
Permit Fee:
NnTF. Thorn esare haved on the nrvliminary inMrination availahle and are only an estimate. Contact the Dept for addn'l into.
FEE ITEMS (Fee Resohrtfori 09-031 Eff. 7/1110)
FEE
1>(Y";
MISC ITEMS
Fun'), ...1. e ;, i<,
$0.00
F__6_8__j s.£
$633.00
Roof Structure Replacement
IROFSTRREP
Suppl. PC Fee: G Reg. 0 OT
0.0
NnTF. Thorn esare haved on the nrvliminary inMrination availahle and are only an estimate. Contact the Dept for addn'l into.
FEE ITEMS (Fee Resohrtfori 09-031 Eff. 7/1110)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
F__6_8__j s.£
$633.00
Roof Structure Replacement
IROFSTRREP
Suppl. PC Fee: G Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
3,454 s.£ Siding
$1,900.00 ISIDEOTHER All Other
Permit Fee:
$0.00
Suppl. Insp. Fee:O Reg. 0
OT
0.0
hrs
$0.00
= # Window / Sliding Glass Door
$632.00 1WINREP Replacement
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
t','f.}JL'!t'71i.'Ii£13t DC7?,
Acoustical Fee:
0 Yes 0 No
$0.00
0
G)
Work Without Permit? 0 Yes E) No
$0.00
Plannir Fee:
$0.00
Select a Non -Residential
Building or Structure
77 i
Strong Motion Fee:
IBSEISMICR
$3.13
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$2.00
SUBTOTALS:
$5.131$3,165.00
TOTAL FEE:
F$3,170.13
Revised: 04/29/2011