11050010 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1361 S DE ANZA BLVD CONTRACTOR:T PERMIT NO: 11050010
OWNER'S NAME: YAMAGAMI TRUST , G DATE ISSUED:05/02/2011
(1' `ER'S PHONE: 6503783714 PHONE NO:
1.1 LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
r MECH F RESIDENTIAL COMMERCIAL
Contractor /Oate
I hereby affirm that I am licensed under the provisi ns of Chapter 9 JOB DESCRIPTION:REPAIR BATON BOARD,10 2X4 STUDS,DRYWALL,
(commencing with Section 7000)of Division 3 of the Business&Professions OREINRNEERR OF O ,PAINT INTERIOR&EXTERIOR,FRONT
C
Code and that my license is in full force and effect. CORNER BUILDING
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:$12017
permit is issued.
APPLICANT CERTIFICATION APN Number:36619047.00 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 regulationsper the CupeftirUQ'Ivlunicipal Code Section
9.18.
Issued b `'� -''`r-�--�7s��ate:SO-2 �L
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
I,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: HAZARDOUS MATERIALS DISCLOSURE
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 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.
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
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,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized.genu
forthwith comply with such provisions or this permit shall be deemed revoked. 9Date:S /J
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
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
C and expenses which may accrue against said City in consequence of the
ig 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 Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36619047. 00
DATE ISSUED. . . . . . . : 05/02/2011
RECEIPT #. . . . . . . . . : BS000013351
REFERENCE ID # . . . : 11050010
SITE ADDRESS . . . . . : 1361 S DE ANZA BLVD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : YAMAGAMI TRUST
ADDRESS . . . . . . . . . . : 1361 S DE ANZA BLVD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : GIULIANI CONST INC
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 12, 017. 00 1. 00 0. 00 1 .00 0. 00
1BSEISMICO VALUATION 12, 017. 00 2. 52 0. 00 2 .52 0. 00
1FOUNDREPA EACH 1. 00 760. 00 0. 00 760.00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 763 .52 0 . 00 763 .52 0. 00
iI o C) c)
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT' BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUP> 1N4 (408)777-3228 • FAX(408)777-3333•building cupertino.org
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS '! APN#
�Z t /
OWNER NAME PHO E-MAIL
STREET ADDRESS CITY STATE,ZIPr, F
4J3-a —3-;�,a
CONTACT NAME �41 PH E-MAI
STREET ADDRESS CITY,STATE, ZIP /� F
OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACLOR 13CONTRACrOR/AGENT ❑ ARCHITECT ❑ENGIIIEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE LICENSE� TYPE/� BUS.LIC.V
COMPANYNAME //, E-M�AA / FAX
STREET ADDRESSO CITY,STATE ZIP�� PHONE��//
CZ I
ARCHITECT/ENGINEER NAME LICENSE NUMBER /// BUS.LIC#
COMPANY NAME E-MAIL / FAX
STREET ADDRESS CITY,STATE,ZIP JJ PHONE
DESCRIPTION OF WORK G` �/ / /� Jx�
�] �
4 G✓ T /-�/°-, r " 1,
EXISTINGUSE PROPOSED LSE CONSTR.TYPE I #STORIES _ a"
a
EXLSTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA w.
PORCH AREA DECK AREA TOTAL DECK/PORCHAREA GARAGE AREA:❑ DETACH
❑ ATTACH
N DWELLING UNITS: IS A SECOM UNTr ❑YES SECOND STORY ❑YES
BEING ADDED? ❑NO ADDITION? ❑NO
PRE-APPLICATION ❑ YES IF YES,PROVIDE COPY OF PLANNER'S NAME: F L [
RE€EJtI 1f
PLANNING ADPL N ❑NO PLANNING APPROVAL LET=
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building con I authorize representatives of Cupertino to enter the above �n led property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
_New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure s1=�rFp r� a
form if any Hazardous Materials are being used as part of this project.
RG> s
_Copy of Planning Approval Letter or Meeting with Planning prior to s
submittal of Building Permit application.
B1dgApp 2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1361 de anza blvd. TDATE: 05/02/2011 REVIEWED BY: bobs.
APN: BP#: ``VALUATION: 1$12,017
°PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY Commercial Building PENTAMATION 1 BOFF
USE: PERMIT TYPE:
WORK repair baton board 10 2x4 studs drywall, reinsulatepaint interior and exterior, front corner of building.
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
B (Offices) II-B,111-B,IV,V-B 0 $0.00 $0.00
TOTALS: 0 $0.00 $0.00
MECH,HOURLY0 Yes 0'No PLUMB,HOURLY Yes Q No ELEC,HOURLY Q Yes Q No
Li I
NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info,
FEE ITEMS (P'ee.Resolution 09-051 I ff.7/1.-"10) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 0 # Foundation Repair
Suppl.PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $760.00 IFOUNDREPA
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp. Fee-E) Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: Q Yes 0 No $0.00 0
Work Without Permit? Q Yes E) No $0.00 0
Planning Hee: $0.00 Select a Non-Residential Q
Building or Structure
i
Strong Motion Fee: IBSEISNIICO $2.52 Select an Administrative Item
Bld 7 Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $3.52L $760.00 TOTAL FEE: $763.52
Revised: 04/29/2011