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09100066 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7573 ORANGE BLOSSOM DR CONTRACTOR:DEVERA CONSTRUCTION PERMIT NO:09100066 INC. OWNER'S NAME: JOE&EDGAR MASRI&ANN PETERSON MASR 941 D BERRYESSA RD DATE ISSUED: 10/09/2009 ER'S PHONE: 4088731831 SAN JOSE,CA 95133 PHONE NO:(408)441-9598 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT f— PLUMB License Class Lic.# F MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:KITCHEN REMODEL,CHANGE FLOOR TO TILE, (commencing with Section 7000)of Division 3 of the Business&Professions CHANGE Code and that my license is in full force and effect. CABINETS,APPLIANCES,LIGHTING,NO CHANGE TO FLOOR PLAN&EXTEND GAS LINE 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 Sq.Ft Floor Area: Valuation:$20000 permit is issued. APPLICANT CERTIFICATION APN Number:36611056.00 Occupancy Type: 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. Signature Date Issued by: Date: OWNER-BUILDER DECLARATION RE-ROOFS: 1 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: 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 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 1 will 1 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,after making this certificate of exemption,1 become subject to the Worker's Compensation provisions of the Labor Code,I must Ow or au ri�d age Date- forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION 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 up--the above mentioned property for inspection purposes.(We)agree to save i iffy and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address cc,--..,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 ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Y Signature Date ,o' —0 Licensed Professional CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36611056 .00 DATE ISSUED. . . . . . . : 10/09/2009 RECEIPT #. . . . . . . . . BS000008875 REFERENCE ID # • • . : 09100066 SITE ADDRESS . . . . . : 7573 ORANGE BLOSSOM DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER JOE &EDGAR MASRI& ANN PETERSON ADDRESS 7573 ORANGE BLOSSOM DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JOSEPH ELIAS MASRI CONTRACTOR HENRY DEVERA LIC # 24605 COMPANY DEVERA CONSTRUCTION INC. ADDRESS 941 D BERRYESSA RD CITY/STATE/ZIP . . . : SAN JOSE, CA 95133 TELEPHONE . . . . . . . . : (408) 441-9598 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 20, 000. 00 1 . 00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 20, 000 . 00 2 . 00 0.00 2 . 00 0 .00 1REMRESKIT SQ FEET 256 . 00 570 .00 0. 00 570 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 573 . 00 0 . 00 573 . 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 573 .00 #418 --------------- TOTAL RECEIPT 573 . 00 0 ��zro CITY OF CUPERTINO =' ADDITION/REMODEL CITY OF + CUPEkTINO PERMIT APPLICATION FORM APN "3 I ("PI 10�r d V Date: /o/0 q lo I Is a 2 nd unit being added? Yes ❑ No to If yes, please fill out the permit application for 2"d unit. Building Address: 757-1) 0("Ioe N o ss c►v ' �r Mailing Address (if different from building address): Owner's Name: S oc,. uvId C-_J a/, gk4 C4,M-k` Phone# : 7' Ain yt��.�- asp-� Contractor: Phone#: 41676- 31(o -(;3,?O f��G1V �dvc> Fax #: Contractor License#: t{0 D IS' Cupertino Business License#: 06- Contact: Phone#: YO?- t F 3-t 3 A Fax #: Building Permit Info: Bldg. ❑ Elect. ❑ Plumb. ❑ Mech. ❑ Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? IGiciaA - c1�c�� -�'iOa r +0+1(y-/ NL' CVC--1')X- -tv lF ioo.r- Remodel Includes Re-Roof. Yes ❑ No 0 If yes list number of squ98a"LcX 0"9- Remodel Includes Structural: Yes ❑ No Do you have the pre-application planning approval? Yes ❑ No ❑ If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction(Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT,V-B ❑ Valuation: Please check this box if the project is a a c1> o Z second-story addition ❑ Project Size: Express ❑ Standard ❑ Large ❑ Major❑ Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, Green Building Points Achieved: include in plan set& the sheet index. ***For Office Use Only*** Over-the-Counter ❑ Revised 07/06/09 CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft DECKS 1R3SFDADD OR 1R3SFDREM 1 DECKWOOD Deck (Wood)-Each B (Each) 1 DECKRAIL Deck Railing-Each B (Each) GARAGES 1R3SFDADD OR DETACHED 1R3SFDREM 1 GARDTW<=1 K Wood Frame up to B 1,000 SF (each) 1 GARDTM<=1 K Masonry up to 1,000 SF B (each) 1BCONSTAXR Construction Tax Res (new detached garage) PATIO'S OPEN 1R3SFDADD OR 1R3SFDREM 1 PATIOWOOD Wood Frame up to 300 B SF 1 PATIOMETAL Metal Frame up to 300 B SF 1PATIOOTHER Other Frame up to 300 SF B PATIO'S CLOSED 1R3SFDADD OR & SUN ROOMS 1R3SFDREM 1PATIOENCLW Enclosed Wood up to 300 B SF 1PATIOENCLM Enclosed Metal up to 300 B SF 1PATIOENCLO Other Enclosed Patio up B to 300 SF 1 COVPORCH Porch Covered-Each B (Each) REMODELS 1R3SFDREM / 1REMRESKIT Kitchen Remodel up to B (Deduct "$"for ea plan 300 SF check 1REMRESBAT Bath Remodel up to 300 B 64 SF 1REMREOTH Other Remodel up to 300 B 66 SF CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1 MECPLNCK Stand Alone Mechanical M Pln Ck(hourly 1 PLMPLNCK Stand Alone Plumbing P Pln Ck(hourly) / 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B