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09080023 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20667 FORGE WAY CONTRACTOR:JOHN VIDOVICH PERMIT NO:09080023 OWNER'S NAME: JOHN VIDOVICH 20691 FORGE WAY DATE ISSUED: 10/01/2009 ER'S PHONE: 4087384444 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT f— PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPAIR WATER DAMAGE AND DRY ROT IN (commencing with Section 7000)of Division 3 of the Business&Professions ELEVATED Code and that my license is in full force and effect. WALKWAYS;UNITS 125,126,127,128,129,130,131,132, 133,134,135,136,225,226,227,228,229,230,23 1, 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. 1 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 Sq.Ft Floor Area: Valuation:$30000 permit is issued. APPLICANT CERTIFICATION APN Number:32336020.FRG125 Occupancy Type: I 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 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. �/�' --Y-< ,Issued by � -�'" �' DatL+.-�l "�/ Signature Date � L•, OWNER-BUILDER DECLARATION ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to anyy 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: 1,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 1 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 I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will 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,Sec' 5505,25533,and 25534. 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 Owner or,Ru1 ed a forthwith comply with such provisions or this permit shall be deemed revoked. CC � Date: X' APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I h y 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 i• nify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address acid 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,Sgction ARCHITECT'S DECLARATION 9.18• I understand my plans shall be used as public records. Signatur Date '/ "d Licensed Professional CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32336020 .FRG125 DATE ISSUED. . . . . . . : 10/01/2009 RECEIPT #. . . . . . . . . : BS000008808 REFERENCE ID # . . . 09080023 SITE ADDRESS . . . . . : 20667 FORGE WAY SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : JOHN VIDOVICH ADDRESS . . . . . . . . . . : 20691 FORGE WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CRAIG CRANDALL CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : JOHN VIDOVICH ADDRESS . . . . . . . . . . : 20691 FORGE WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 30, 000 . 00 2 . 00 0 .00 2 . 00 0 . 00 1BSEISMICR VALUATION 30, 000 . 00 3 . 00 0 .00 3 . 00 0 . 00 1FOUNDREPA EACH 1. 00 760 . 00 0 . 00 760. 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 .00 0 . 00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 807 . 00 0 . 00 807. 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 807. 00 VISA --------------- TOTAL RECEIPT 807 .00 Q� o ��� 3 CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM 4 Building Address: rt7to & Cc Mailing Address (if differwAt from buil ng address): Are Hazardous Materials being used as part of this project? Yes Ll No El HOA: (Exterior work only) Yes ❑ No ❑ If yes,provide letter from HOA Ow '©Mme: � Phone#: Contractor: Phone: Fax: - Bz Contractor License#: Cupertino Business License#: Conta Phone: (. & Fax: p j —-'Aq Residential U Commercial _ Job Description: G�� f� � � a e di/`yrd r 1 evp•T k y" Building Permit Info: Bldg Z' Elect ❑ Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B lil � Val tion: Square Footage: Project Size: Express ft�tandard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable,include in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.bufldity-reen.org Revised 07/14/09 . f CITY OF CUPERTINO CUPE(�F GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM ACOUSTICAL REVIEW IACOUSFDW SFDWL/Duplex New B IACOUSRESAD SFDWL/Duplex-Addition/Alteration B l ACOUSCOM Multi-Family/Commercial B CHIMNEY'S 1 CHIMNEY Chimney B 1 CHEANEYR Chimney Repair B FENCES 1 FENCE>6FT Non-masonry, over 6 ft in height B 1 FENCEMAS>6 Masonry, over 6 ft in height B FIREPLACES 1FIREPLMAS Fireplace Masonry B 1 FIREPLFAB Fireplace Pre-Fabricated/Metal B 1FLAGPOL>20 Flag pole(over 20 ft in height) B 1 MODUSTRU Modular Structures B FOUNDATIONS 1 FOUNDREP Foundation Repair B 1 PILECAST Pile Foundation Cast in place concrete B 1 PILEDRIV Pile Foundation Driven(steel, pre- B stressed concrete 3 of 5 CITY OF CUPERTINO C U CITY OF O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly-stand alone / 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT / TYPES / 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B / 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B 5 of 5 /pmt _ � 1�����N:t►fl"� .- -- � -- ''_Q��1Ni�L�a��` N I"�i'��,�_n `�I�^'� - _- ;�I L43, _6�I 141. 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PHONE # GENERAL CONTRACTOR: FAX # _ Z I am not using any subcontractors: Signature Date Please check applicable subcontract d complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date r c