11050153CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10292 ORANGE AVE CONTRACTOR: D PERMIT NO: 11050153
OWNER'S NAME:
PHONE NO:
G LICENSED CONTRACTOR'S DECLARATION
T— I
ELECT PLUMB
License Class Lic. # �% Zy
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BUILDING PERMIT INFO: BLDG
MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: SFDWL DEMO (2,064SQFT)
(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.
Sq. Ft Floor Area:
Valuation: $5000
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. —T -T
APN Number: 35719030.00
Occupancy Type:
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
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 DA RMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FR A T CALLED INSPECTION.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulatirns per the Cupertino Municipal Code, Section
9.18.
Signature Date
Issued b Date:
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material berg installed. If a roof is
1 hereby affirm 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 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
1 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 & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should 1 store or handle hazardous 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 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued, I shall
Health & Safety Code, Sections 25505, 25533, and 25534.
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
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forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of wrk'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 C.)
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 and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
ARCHITECT'S DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
DEMOLITION
CITY OF CUPERTINO
FMON FEE ESTIMATOR - BUILDING DIVISION
19
ADDRESS: 10292 ORANGE AVE
DATE: 05/19/2011 7REVIEWED
BY: MENDEZ
APN:
BP#:
"VALUATION:
1$5,000
*PERMIT TYPE: Demolition Permit
K I
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 SFDWL-DEM
PERMIT TYPE:
WORK
SFDWL DEMO 2,064 SQ FT
SCOPE
FEE ID FLR AREA
(S.f.)
1DEMORES 2,064
11. Kai,
Fian
Lice. Ahvl
PEerril"!
(Vier Ueeh. lusp,
iwfech. Inv", Fe
NOTE: These fees are based on the Preliminary information available and are onlv an estimate. Contact the Dept for addn 7 info.
FEE ITEMS (Fee Resolulion 09-051 ff. 7/1110)
FEE
QTV/FEE
MISC ITEMS
1jyJL PC F'(4('
Mm
Permit Fee:
$507.00
Suppl. Insp. Fee-0 Reg. 0 OT
0.0
h,s
$0.00
Lwil
Permit
onxtructionhix
i cwwieal Review, rec:
Work FfWhout Permit�'
hawiingf`ee)--
A
71-avel DoM,wnvnrali(m Fce--t,
Strong Motion Fee: IBSEISAECR
$0.50
Select an Administrative Item
-1
Bldg; Stds Commission Fee:. IBCBSC
$1.00
SUBTOTALS:
1 $508.50
$0.001 TOTAL FEE:
1 $508.501
Revised: 04/29/2011