12110025 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20990 VALLEY GREEN DR CON'TRACT'OR:KORET FOUNDATION PERMIT NO: 12110025
OWNERS NANIF,: KOREf FOUNDATION 1050 RAISfON RD DATE ISSUED: 111052012
OWNER'S PIIONE: 4082530200 BELMONI'.CA 9400:2243 PIIONE NO:
❑ LICENSED CON TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT 17 PLUMB r
License Class Lic.N r r' F]
NI F,CFI RESIDENTLU, COMMERCIAL
Contractor Date
hereby affirm that 1 am licensed under the provisions of Chu pter 9 JOB DESCRIPTION:APT 603-INSTALLATION OF WASHER&DRY HOOKUPS
(commencing with Section 7000)of Di%ision 3 of the Business S Professions
Code and that my license is in full force and effect.
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
pert'onnance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$500
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
permit is issued: APS Number:32609053.00 Occupancy Type:
APPLIC\N'r CFRTIFICATION
I certify that I have read this application and store that the above information is
correct,l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes, (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the �^—
granting of this permit. Additionally,the applicant understands and will comply —{/��J /` /1 J - Z
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: V � 6 Date:
9.18.
Signature Date
RF.-ROOFS:
Q(f OWNER-RUl.LDER DECLARA'T'ION All roofs shall be inspected prior many roofing material being installed.If a roof is
installed without first obtaining at inspection,I agree to remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation. Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business R Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BE'I-I'ER
construct the project(Sec.7044,Business Q Professions Code).
hereby affirm under penally of perjury one of the following three HAZARDOUS MATERIALS IIISCLOSIIRF
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilealth S Safety Cade.Sections 2.5505,25533,and 25534. 1 wfll maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the Compliance N'tth the CupertinoMunicipal Code.Chapter 9.12 and the Ilealth d
performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material.
I have and will mainmin Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices whie h emit hazardous air
Section 3700 of the Labor Code,for the performance of the work far which this contaminants as defined by the Briv Area Air Quality Management District I will
permit i5 issued. p maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
P Ilealth S Safety Code.Sections 25505.25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner sons to become subject to the Worker's Own r or auryforizedft ent:
Compensation laws of California. If,after making this certificate of exemption,I a Date[_
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall he deemed revoked. CONS'TRUC1'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICAN I'CERTI FICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
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 nceme against said City in consequence of the .V2CII1'I'F:C"t"S DELL,\KATION
graining of this permit Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records.
with all non-point source regulations perthe Cupertino Municipal Code,Section
9.18. lJ // Licensed Professional
Signmu :c�G� A Date '
C)
'aFT I COIN'STRUCTION PERMIT ,'SPP-ICATION
4� )
♦. /� COii;ia U.I: :��/°LCFi:i r i DF =. Ti : u t =UPD! C
i0300 TORRE AVENUE • CUPERTINO, CA.c ,A- 25'•
CUPERTINO (--08)777-3228 - FAX(=08) rrra 3 •G :h'ic0cuoertinoac
❑t,'.w CONSTRUOTION ❑ ADDITION ❑ .A_LT.-R-e.TiON/TI ❑ RE`i3SION/DEF°_ ED OU=.A.L?ER IIT
PRoB>crADDREsr
. .. 3/� —'hi,"e•�`•-`o_n � .# X03 � 9' S3
OR'NE2NAME .r 1 PHOhc E. M
STt_—I'A➢DRE55 CTC, STAR'
Z � �r. I / ✓�if20 �/� I _
COhZACr NA.M'c 1 PHONE _ E-MAR
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SIRc'E'r ADDRESS STATE 2 FAX
OWNER ❑ oW .B=ur ❑ OwtF AGBNT 11 coN crOR DcoN crORAGE ❑, ARCHr U 0INGB. ❑ DEYFT.OPEIL ❑TINANL
CONTR =RNAME" LtCHNSENOMBER.- I 'I,=SETYPE �O HUS.LICk -
COMPANY NAME _ E-MAB. FAX
61Z IZA 11
IIRF—cr ADDRESS 1 CrrY,SIA'fE ZIP ONE p
AAn P4
ARCHR'ECTE GNEERNAME LICFNIE NUNMER BUS.LIC#
COMPANYNAME E-MAIL FAX
v s=r ADDRESS CnY,STATE,ZIP PHONE
DFSCRB OON/OF WORK
IV
EXSIINGILSE .� _ PROPOSED iSE CONSRL TYPE isrotus - • 'SVI N ii}'S 1Ni44ui:: '•x"+'-:r ^u.
'Ea2src tiSR'FlDlat ' =AL Duo- magr��^1. ^F'�-�'"'��
AREA ARFa . AREA t�raREn ,r.
HAZHROOM KfrCHEN - OnIDtS�fh ' {y �v
REMODEL AREA. REMODEL AUX— .REMODEL/
PORLHAREA ➢ECKAREA TOTAL I)ECPJPOAUTAAEA GARAGE ARF.1 El DETACH
❑ATTACH
tnwDLavrmux - ansernwm�is pm3 sReorm rroar ❑i•Ey - - + ,./ e' �-,p�"r�` �`'t.:, 'tit,,: .
�.i.' a@LAn�•. - prro•. Annrriq+i.: L]No �'� _;� ear ��"'Af,'4s, .'.lr-�"
rxs.T,ePcrAt[ar ❑ Y&� ffYSS.tatnt'D7E COPYOF; •PWMFA'9 NAME. GF1Yr3 -+uv `
'PV3IIIIIlG APPLI Q SC' PUNNLb APPAOVALLtTtEQ -ti+ YSF -rM1-.
13y my sigoatroe below,I certify to each of the following:.,I am the property owner or authorised agent to act on t}ie propertyner
ows behalf, _a
I baveu
application and the mformauon I have provided is coaect I have adihe Des<rrpoon of Work and verify it,i'accurate I agree to comply wrdrall'apphcable Ideal v
ordinances and state law'telaDng to - ding co snort I nuth representanvas ofCupcmno to enter the above[deotifiod property for mspectton proposes'
F Sigaatroe of ! ' _ t'{At ��{,�_ 1 �./ 4 -L1V �t "r p4}'�.�t.n r. y .'.�f*„.
�r UP�PI!2�=ALINFORMAIIONRE,Q
New S�FD or M D�fam�tly dw�ellm�gsApply:f➢r demohnoB pe-mrt ror t ,��• cow ry D "'' y y,x"'-e
exisTmg ouIldmg(s) DemoltnoD`perml u required prior to.tssuHnce ofbuudiDg
permit for new building.,-g:, .;x-1 .• >;.Fo�'- s
CDmmercta]Bldgs Pt�'ovtde a completedHaztHrdous Materials Duciosuro r•.yyvARm: � ,� IBc+�o ,
•tom if any Hazardous Matena]s ue ti mg used'as part of tliis'prolect': -
Copy of Plaauing-Approval'Le.er or-Nteeting with Planning paor to E
submittal if Builduig Penmtapphcatioti. r." a ' rc
rr�£- `t "Av$. r E.ZTti Pa;.tE.`�T `r'
' BId,�Ipp 7011 dos re rsed 03/1Q/11r
- I
0"INER"BUILDER DISCLOSURE FORM
COMMUNITY D `!=LO?L4ENT'EE?.=RTI✓iEIdT• BUILDING DI';'IEIGN
- 10300 TORRE AVENUE • CUPER T INO, CA 95014-3255
CUPERTINO (408)777-3223• .-?X.(403)777-3333buiidinc�y��o=_'i�a:aa
Dear Property Owner(s):
An application for a building permit has been submitted in your harre listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN -3d-609105^, I BPm
OWNER NAME — - OWNER ADDRESSVC C
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment and Information Verincation Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
5�(l ,. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder"building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowners insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
2]Z2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
� b. 1 understand.as an "Owner-Builder" I am the responsible party,of'record on the pennit.•1 understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead'of my-own.
S -i/4. I understand Contractors are required by to be licensed and bonded in California and to list their license
numbers on permits and contracts.
S/5. 1 understand if I employ or otherwise engage any persons, other than California_licensed Contractors;and the
total-value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer under state and federal law:
S6 I understand yf I am considered an employer under state and federal lausf reglsterwlth the state and
federal government,w thhold payroll taxes, provide workers compensation disability Insurance a d eii. to
' unemployment compensation oceach employee 1 also undersfaFnd Amy allure to abide by these,}ws may sub)ect = , ' }
-�-=me to seriousnna`ncial risk — •—•r�-s — - >r �� - '+ r = --='—�--
V 7. I uride`�stand under Califomia Contrac.ors'State License Law'an 6r-"builder who builds single_family
.residential structures cannot legally build them v✓5th the intent to oder diem for saleunless a//vi'ork is performed by
licensed subcontractor and'tfia numtie�of structures does not"ercead'four v✓itfiin-any'calendar year,-orall'of the 'work
is 'performed under contract with a licensed general building Contractor.
Sl/ 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any,financial or personal injuries'sustained by any subsequent owners)tfiat result from any latent construction t 1
cdefects,In the workmanship or materials
_
;,ter-rOA+nerBuilderFor nr 1010 doc revised 0411,/10 '-
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9. I understand I may obtain more information regarding my obligations as an "employer' from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board(CSLB)at 1-800-321-CSLB (2752)or wAw.cslb.ca.gov for more information about licensed
contractors.
L110. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
5_Y_1 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
J V12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
r information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
:you contract with someone who does riot have a license, the Contractors' State License Board may be unable to
-assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
:employee of that individual or firm is injured %vhile working on your property, you may be held liable for damages. If
you obtain a permit as Owrier-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
..i Lender Name: - Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and.
returned to the agency responsible for issuing the permit. Note:A copy of the properly owner's drivers license,
forin.notarization, or other verification acceptabie to the city may be required to be presented'when the permit is issued
to verify the property owner's sign
PCyper.tyOwner's Signature: Date: .
,r - .- '. . - . .
(NOTE--The.followingAuthorization Form is required to be completed by the property owrier only when designating an '
agent otthe property owner to appy for a"construction permit for the Ov✓ner-Builder). '
a AUTHORIZATION OF AGENT TO ACT-ON PROPERTY OWNER'S BEHALF
-'',"!:Ezoludiiigae Notice to Property,Owner, the execution of which Gunderstand is my personal responsibility, [ hereby -
'author ze the following persons)to act as,my'.agent(s)to apply for, sign, and file the documents necessary to obtain an
. -x.•..,.,-B-
Owner, uilder Permit for my project.
- r;Scope of,Construction'Project(or Descr pt on of,Work):
..
f . .
Pro)ectLocation or Address: I a
,i`t• 'Name of -• a, �„ W 5
» Address ofAuthonzed Agenf = r:{E �_ r ,
'�-
J declare under penalty o: per)ury that I am the property ov ner.for fhe address listed above and I personally lled out the
above information and'-c_erhy its:Accuracy;-Note-A copy.ofthe grope tyof✓nets drivers license;form notanzaG'on or other
t venfrcation accepta(ile to the city maybe required to be presented v✓hen the permi(is issued to ve ty the grope i}'owne'rs
_signature.
Property Owner's Signature: Date:
� " �'Y' 4.
- ,�.—rr OiSnerBuilderForn� 1010.doc revised 04/14/10,ii �--
Y 1 . —
F { �f '
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20990 valley green DATE: REVIEWED BY: '
APN: BP#: VALUATION: $500
"PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION 1RMAP1
USE: SFD or Duplex PERMIT TYPE:
(YORK I Apt 603- installation of washer& dry hookups
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTl' UNITS BP FEES
Other Appliance/Equip 1BAPPLOT 2 # $134
TOTALS: $134.00
Mech.Plan Check 0.0 hrs $0.00 Plumb. Plan Cbta:k Eler,Phar Clack
Mech. Permit Fee: IAIPERMIT Plu A pepma Fee: E/ee. Pernrir Fee:
Other Mech. Insp. 1 0.0 hrs $45.00 ether Plumb hasp. other Elec. n,cP. '
day/r.Imp. Fee: Plumb.IneP.Fee: filet.lnvp. Pee:
NOTE: This eabnate doev not include fees clue to other Departments(i.e. Planning,Public (forks, Fire,Sanitary Sewer District,School
.District,etc. . These feev rare braved on the prefininan in ortnation avrdlnble and are otdr an estimate. Contact the Dept for acicln'I info-
FEE
n o.FEE ITEMS (Fee Resolution 11-053 Eff 7/1/121 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
SBPPI.PC Fee
PME Plan Check: $0.00
Pcrmit Fee:
Suppl. /Itsp,Fee
PME Unit Fee: $134.00
PME Permit Fee: $45.00
Constructilnt Tac:
Administrative Fee: (ADMIN $42.00
Work Without Permit? () Yes (F) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA I DOC $45.00
Strong Motion Fee: IBSEISAf1CR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $267.50 $0.00 TOTAL FEE: $267.50
Revised: 10/01/2012
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: 9 C .0 rl� PERMIT# U -Z1 t L ZS
OWNER'S NAM& - t:jf-U—(-Lt ter^ PHONE #
GENERAL CONTRACTOR: BUSINESS LICENSE #
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires.all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND'ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
13USINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and 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
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
CITY OF CUPERTINO BUILDING PERMIT
RUILDINGADDRESS: 7513I1EATIIERWOODDR CONTRACTOR:GT BUILDERS 1'F,RMITNO: 12110033
OWNER'S NAME: GARUD VIVEK P AND DESAI NERA K 15405 WINCIIES'T'ER R XD MATE ISSUED: 11/0612012
OWNER'S PHONE.: 4089739117 MONTE SERENO•CA 95030 PRONE NO:(408)390-5670
❑- LICENSED CON'TRAC`T'OR'S DECLARATIONBUILDING PERMIT INFO: BLDG r ELECT r 1-1
PLUMB
License Class c.#
3M� pI F,CII r RESIDENTIAL Cl COMMERCIAL rl
Contractor Date
1 hereby a1Ti n thatI R used under the provisions of( meter 9 JOB DESCRIPTION: INSTALLA'T'ION OF 171XED SKYLIGHT IN KITCHEN
(commencin with Section 7000)of Division 3 of the Business S Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury nue of the following two declarations;
1 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 Sq.Ft Floor Arca: Valuation:$2000
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued.
APN Number:35926052.00 Occupancy Type:
APPLICANT CFRTIFIC\TION
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 stale Imes relating
in building construction,and hereby authorize representatives of this city to carr 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 pe iuonally,t e applicant rs ds and will comply
with all non- nt source re lalim er the Cu ino nicipal Code,Section
9.18. Issued by: Date. (y
Signature
❑ O\VNER-BUILDER DE LARATION RF.-ROOFS:
All roofs shall be inspected prior to any roofing material being installed If a roof is
I hereby affiA 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
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS'T'O BE CLASS"A"OR REEFER
1 hereby affirm under penaltyof perjury one of the following three
declarations: DA'LARDOUS MATERIA S DISCLOSURE
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 S Safety Code,Sections 25505,25533,and 25534. 1 will maintain-
perfomnance of the work for which this permit is issued. - compliance wish the Cupertino Municipal Cade,Chapter 9.12 and the Ifeallh S
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should [store or handle hw/Ardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally.should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
maima���iinn compliance with the Cupertino Municipal Code.Chapter 9.1_and the
I certify that in the performance of date work for which this permit is issued,I shall hafety ections 25505,25513,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Califomia. If,after making this certificate ofexemption,I Owner o au or'. d n 1: I
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.
Cfb\S'I'RUM'ION LE\I11NG ACENC\'
Al'1'1-IC\N'f CIiRlIFICA'1'10N hereby aft mn 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 Q
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
indemnify andkep Tess the Cul• pert ino against liabilities,judgments,
costs,and penscs whic may rue ago
'
Isoid Cit}'in consequence o(thc AKCII I'I'ECf'S DECL,\R,\'PION
granting o this permit.A ilio IW,the a licam understands and will comply
with all no -point source egulatims enino Municipal Code,Sectim I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature / to
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
® 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
GUPERTINO (408) 777-3228• FAX (408) 777-3333• buildinq(@cul3ertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED �I ORIGINAL PERMITN
PROJECT ADDRES J O-Q-e� Q APNM �T � _ '10
OWNER NAME "/I PHO �'CA /' E-MAIL
STREET ADORE551tTC
CITY, sTr4Fe.ZIP ��—C�
FA
XCONTACT NAME l.•V PHONE , E-A1AIL
STREET ADDRESS CITY.STATE, ZIP FAX
❑OWNER ❑ OWNER.BUILDER ❑ OWNERAGENT A,CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCIff1ECE ❑ENGINEER ❑ DEVELOPER ID TENANT
CONTRACTOR E LICEN 'IMH93 LICENSETYPE BUS.LIC9
COMPANY NAME E-MAIL FAX
STREET ADiRES 0 CITY,STATE.ZIP PHO ' D
ARCHITECT/ENGINEER NAME I LICSENUMBER BUS.LiCP
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE,ZIP PHONE
DESCRIPTION OF WORE: til—
a( �(
EXIST 'G USE PROPOS USE CONSTR E sSTORIES
USE TYPE OCC. SQ.FT. VALUATION(s)
EXISTG (/ NEW FLOOR DEMO TOTAL I�
AREA AREA AREA NTT AREA
BATHROOM KITCHEN OTHER
REMODEL.AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECR/PORCH AREA GARAGE AREA: DETACH
ATTACH
M DWELLING UNITS: ISASECONDUSIT ❑YES SECOND STORY ❑YES
BELNCADDED' [3NO ADDITION' ElNO
PRE-APPLICATION ❑1TS IF YES.PRO\'IDE COPY OF IS Tiif DLDC AB ❑YES SRECEIVEDYc1T^—„Y- `T'•"Y TOTAL-V(yt]ATION:�_
PLAi,N'INGAPPL9 nNO PI ANNIKG APPROVAL LETTER EICHLER IIOJIE! (]NO pc ,4, j. S, -
By my signature below,1 certify to each of the following: I am the pr perry owner or authorized aeent to act on the property owner's behalf. 1 have read this
application and the infonna[ion I have eject")is correc(/II haver the Description of Work and verify'it is accurate. 1 agree to comply with all applicable local
ordinances and sit laws relatine_to t1`ld.,g c¢nstructid ize representatives of Cupertino to enter the above enti d property for inspection purposes.
Signature of Applicant/AeenE / Date: ZQ
SUPPLEMENTAL[ORJIAVC�R QUIRED p� A`New SFD or Dlultifamily d\ves: .Apply demolition permit for .O\FIi=TILL COUN711UILDINGPLA1 RE\1E\V
existing building(s). Demolition pit is required prior to issuance of building Lr•is`* ytik"-r'� - , aW ( -
permit for new building. l uUY TRFs [p[�yp tvW\UNc ruN RE\Te\v
�i-2JmEA Y�A O- L. •--Y .
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sT\NnauDN t runuc�egRRs
form if any Hazardous Materials are being used as part of this project. ON
�s `❑ �IRE�D`e:. r �i 3 t
1ON[LkkGE t +k y +,` fi •e . - Viz:;
_Copy of Planning Approval Letter or Meeting with Planning prior to !f 1 1
LR❑ NITARI'�SE\\FR DIS7 RIOT r
submitral of Building Permit,application. , •c'p�
�L�r+ Lt-- �' Ai fillti: �1❑a(F-NvIRo.mFNTAL'i1EA1.TH?
BldgApp_2-011.doc revised 06/21/1/
Building Department
City Of Cupertino .
10300'Torre Avenue
Cupertino, CA 95014-3255
Telephone: 40&777-3228
C U P E RT I N O Fax: 408-777-3333 .
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: -75-Q2 gL p PERMIT# -
OWNER'S NAME: nmr #
GENERAL CONTRACTOR: BUSINESS LICENSE #
ADDRESS: ,� CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL ON"f RA TO HAVE OBTAINED A CITY O . CU ERTINO
BUSINESS LICENSE.
I am not using any Subcontractors:
Nnatre etcPlease check applicable subcontracts and co he 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
Painting/•Wallpaper.
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal -
Sheet Rock
Tile
Owner/Contractor Signature Date
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