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10100199CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10450 ANN ARBOR AVE OWNER'S NAME: ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Lsa-LAn I Contractor to 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 (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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of die work for which this permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above infor ati 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses whi ma accrue against said City in consequence of the granting of this permit. i ' ally, the applicant understands and will comply with all non -point sourc egul ion er the Cupertino Municipal Code Section 9.18. Signature ate C. OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 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 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 permit is issued. I certify that in the performance of the work for which this permit is issued, I shall 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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 upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, cc nd expenses which may accrue against said City in consequence of the p g of this permit. Additionally, the applicant understands and will comply Al non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date CONTRACTOR (n 1 ;..A ERMIT NO: 10100199 DATE ISSUED: 03/21/2011 1 PHONE NO: BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH F RESIDENTIAL r- COMMERCIAL F JOB DESCRIPTION: CONSTRUCT I STORY 3,121 SQ FT W/ ATTACHED GARAGE 472.5 SQ FT Sq. Ft Floor Area: I Valuation: $500000 APN Number: 32628017.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued b Date: 7 2 /- V( 1 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety', Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants s defined by the Bay Area Air Quality Management District I will maintain col ith the Cupertino Municipal Code, Chapter 9.12 and the Health & Sa y C de, ctions 25505, 25533, and 25534. Owner or, LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Add ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10450 ANN ARBOR AVE CONTRACTOR: MASUDA SERVICES INC PERMIT NO: 10100199 OWNER'S NAME: CAMPBELL, CA 95008 PHONE NO: (408) 691-9408 ❑ LICENSED CONTRACTOR'S DECLARATIONr- r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# r MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: CONSTRUCT I STORY 3,121 SQ FT W/ ATTACHED (commencing with Section 7000) of Division 3 of the Business & Professions GARAGE Code and that my license is in full force and effect. 472.5 SQ FT I hereby affirm under penalty of perjury one of the following two declarations: 5/15/12 REVISION # I -CONSTRUCT 204 L.F. OF FENCE T TALL -ISSUED 5/15/12 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. 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: $500000 permit is issued. APPLICANT CERTIFICATION APN Number: 32628017.00 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non -point source regulations per the Cupertino Municipal Code, Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued by: Date: IV OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE -ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a rool' is I, as owner of the property, or my employees with wages as their sole compensation, installed without first obtaining an inspection, I agree to remove all new materials for will do the work, and the structure is not intended or offered for sale (Sec.7044, inspection. Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 performance of the work for which this permit is issued. 1 have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain Section 3700 of the Labor Code, for the performance of the work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 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 I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Compensation laws of California. If, after making this certificate of exemption, I Health & Safety Code, Sections 25505, 25533, and 25534. become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or 5,, ,r ' i Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction, and hereby authorize representatives of this city to enter for which this permit is issued (Sec. 3097, Civ C.) upon the above mentioned property for inspection purposes. (We) agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Lender's Address 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. Signature Date Licensed Professional FM_7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: DATE: REVIEWED BY: PC FEE ID APN: BP#: "VALUATION: 1$500,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex USE: 7'017,41, 1'1 UUI� ibl_ 1. PENTAMATION 1 R3SFDW PERMIT TYPE: WORK Permit Fee: SCOPE Suppl. Insp. Fee.0 Reg. © OT OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 3,594 $2,823.64 1R3PLNCK $2,918.76 1R31NSP Permit Fee: $2,918.76 Suppl. Insp. Fee.0 Reg. © OT 0.0 firs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr. Tax: IBCONSTAXR 1 bld s $558.42 Acoustical Fee: © Yes 0 No $0.00 0 0 Work Without Permit? 0 Yes 0 No $0.00 TOTALS: 3,594 $2,823.64 Travel Documentation Fee: ITRA VDOCS $2,918.76 Strong Motion Fee: IBSEISMICR NOTE. These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn 7 info. FEE ITEMS (Fee Resolution 09-051 Eff. 7/1'10) Xfech. Plun Ojc ck i'hu umh Nor C,Sr ;� r[ [:. N(V7 ('hrck Fecii Permit Fee. 1'lumh. 17" , ;' Fcc: dClrr. Prrmir V0. �77/rc�r 11c•S•%, h-ity,. 0(hcr f'lriir� 0;11,-,r Js1,.( hiv:1Li :1 Foch. In.�p. /'�e: Phtiarfs. hasp. led: l:ier. In.�1,. 1.,.e: NOTE. These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn 7 info. FEE ITEMS (Fee Resolution 09-051 Eff. 7/1'10) FEE TY/FEE MISC ITEMS Plan Check Fee: $2,823.64 2 a Electrical S %7ofC 1ERT1200 Services Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $2,918.76 Suppl. Insp. Fee.0 Reg. © OT 0.0 firs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr. Tax: IBCONSTAXR 1 bld s $558.42 Acoustical Fee: © Yes 0 No $0.00 0 0 Work Without Permit? 0 Yes 0 No $0.00 Planning Fee: PLLONGRNGR $467.22 Select a Non -Residential 0 Building or Structure i Travel Documentation Fee: ITRA VDOCS Strong Motion Fee: IBSEISMICR $50.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $20.00 SUBTOTALS; 1 $6,880.04 0 TOTAL FEE: �.04 Revised: 10/17/2010 IM -1 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) ADDRESS: 10450 Ann Arbor Ave DATE: 05/15/2012 REVIEWED BY: Sean EMN APN: BP#: 0100/ 'VALUATION: 1$7,512 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: ad h /tisp. PENTAMATION 1GENRES I PERMIT TYPE: WORK Construct 204 L.F offence 7' tall. �rion#l: SCOPE NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) FEE 1,1t�ch. /Tart C'h, c(APlrrmb. Plan C bccti P.�lec'..Plan C'hcck 110(:11, Pl'J a;! f'(':': F'�lllti7 b. Permil rce: $0.00 O;hr.r Afec;h. Mv, 0111er NuM6 Irer:p_ Odwr Elco- 1c,1: Ll I ad h /tisp. Phtt,rl'. risp. [cc Flec. Insp. Fcc: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F-2047 l.f. $522.00 Fence ]FENCE>6FT Fence, Non -Masonry >6' Suppl. PC Fee: Q Reg. 0 OT0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee.S Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 ("onsloiction lax. "I (Yin in is"rativef ue. E) Work Without Permit? 0 Yes No $0.00 Advanced PlanninL Fee: $0.00 Select a Non -Residential Building or Structure Q Ti <n l l�Oc7utICY1.U7it)Y/ 1 'rc a: Strong Motion Fee: .BSEISMICR $0.75 Select an Administrative Item Bldg Stds Commission Fee: .BCBSC $1.00 SUBTOTALS: $1.75 $522.00 TOTAL FEE: $523.75 Revised: 04/01/2012