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09120132 CITY OF CUPERTIPIO BUILDING PERMIT F�L'ILDING ADDKESS: 10556 LARRY WAY CONTRACTOR:TBD-TO BE PERMIT NO:09120132 DETERMINED OWNER'S NAME: VAN HOl"ROBERT A JR AND CHRIST DATE ISSUED: 12/21/2009 ;NF,R'S PHONE: 4082570397 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class I.ic.# PANEL UPGRADE TO 200 AMP Contractor Date 1 hereby aftirm that I 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. 1 hereby affirm under penalty of perjury one of the following two declarations: 1 have and will maintain a certiticate 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:$1500 1 have and will maintain Worker's Compensation lnsurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:3]602026A0 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above informa[ion is pERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relatin� wITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence ofthe '' '��-' granting of this permit. Additionally,the applicant understands and will comply Issued by: ,�.-.._1_ _�---__r..___.--1 Date: -�� r with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature___ _ Date All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. � OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby aftirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensatio�, will do[he work,a��d the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contracton to HA7,ARDOUS MA'TERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the Calitbrnia Health&Safety Code,Sections 25505,25533,and 25534. I will 1 hereby at'firm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declaratious: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous 1 have and will main[ain a Certiticate of Consent ro self-insure for Work�r's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminauts as defined by the Bay Area Air Qualit� Management District 1 performance of the work for wt�ich this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S cti ns 25505, 533,and 2553�. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent�� Dafe:�L_�_ permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ ar�}'person i�i any manner so as to become subject[o thr. Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If,afier making this certificate�:i exemption,I become subject to the Worker's Compensation provisinns of the Labor Code,I mu;t I hereby affirm that there is a construction lending agency fnr thc performance of forthwith comply with such,provisions or this permit;hall be deemed revoked. work's fur which this permit is issued(Sec.3097,Civ C) Lender's Name _ _ — APPLICANT CERTIFICATION Lender's Address - 1 certiYy[hat 1 have read this application and sta[e that the above information is correct. I agree to comply with all city and county ordinances and state laws relatir g to building construction,and hereby authorize representaUves of this city to enter �:��on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARA7'ION ,nnify and keep harmless the C�ty ofCupertino against liabilities,judgments, _.:..and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. granting of this perniit.Additionally,the applicant undertands and will comply H ith all non- oini source regulations p [he Cupertino Municipal Code,Sec[ion Licensed Protessional __—_ 9 1 A. Signatwe--- �---��_- -- Date.�?.rL l, � ��:�� „ Community Development �� , � , 10300 Tone Avenue -�' ` Cupertino CA 95014 Telephone(408)777-3228 C1TY OF Fax(408)777-3333 �UPEI�TINO Buildin De artment JOB ADDRESS: ,�� t, �� PERMIT# � 3,� ( 7 OWNER'S NAME: a A1 p � PHONE # � � 'O GENERAL CONTRACTOR-- � ' � FAX # I am not using any subcontractors: Si;nature Date Please check a licable subcontractors and com�lete the followin information: SUBCONTRACTOR BUSIl`dESS NAME SUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical �� 1= (.�� t`' �2S 7� f�p '�l� Excavation � Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 2 'Zl� o Owner/Contractor S' ature Date , ``'�`` CITY OF I�UPERTINO CITY OF CUPE�TINO GENERAI� BUILDING PERMIT APPL,ICATION FORM Oq 12 6(�3 Z-- APN# Date: I 2 �� ,bv 2 �Z� -� Building 1�dO�� U �,, pt�7,T.. C�- �'`v l l T -�•-f � Mailing Address (if different from building addre s): ___-.__ Are Hazardous Materials being used as part of th�s project? Yes No HOA: xterior work onl Yes ❑ No [�If es, rovide letter from HOA � Owner' e: � , /� Phon ^��Q . V C Contrac�.. �� Phone: ��' �- � —�Z�$ yV� Fax: Contractor License#: �r �-I (o�}� Cu ertino Business License#: Contact: Phone: Fax: Residential Commercial � Job Description: �,,�P �.� �''�i�l-��-- �� —""' ` ( � �� (=��"� 7'a �� .-��s � Building Permit Info: ' Bldg Q� Elect L�� Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ IUIIUV-A ❑ IUIII B, IV-HT, V-B 0� `�'- � - Valuatio • Square Footage: j �.:�� .�� Project Size: Express Standard ❑ Lar e ❑ Ma'or ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: ,q � For help, contact Build it Green at www.builditgreen.or �„/ Revised 07/14/09 F��;� CITY OF (:UPERTINO ��n�f GENERAL BUILDING APPLICATION CUPEI�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco A��plications (up to 400 s fl B additional stucco a lication 1WINREP Replacement windows/sliding glass B door (ea �3 windows) . 1WINMEWSTR New Winiow-structural shear B � wall/masc�nry(includes lan ck fee) . 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alc�ne Electric Pln Ck(hourly) E 1MECPLNCK Stand Alc>ne Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alc�ne Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-st�nd alone � 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES � 1BSEISMICR Seismic�Zesidential � B ' 1BSEISMICO Seismic ��ommercial B r 1 TRAVDOC Travel & Documentation B / 1BUSLIC Business License B / ; 1,6z 1-� 2 �,� s of s