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09120058 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10916 NORTHRIDGE SQ CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09120058 OWNER'S NAME: MASSIMO LANFRANCONI DATE ISSUED: 12/10/2009 ER'S PHONE: 4088738167 PHONE NO: I LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT f— PLUMB License Class 636 Li,.# '76970-7 MECH RESIDENTIAL COMMERCIAL Contractor e I.?—/( ' I hereby affi th7Sti.. sed u der the provisions of Chapter 9 JOB DESCRIPTION: INSTALL ART TUB(STANDARD SIZE ACRYLIC, INSULATED (commencin with7000)of Division 3 of the Business&Professions REPLACEMENT TUB);NO SHEETROCK,NO TILE;PLUMBING Code and that my license is in full force and effect. ONLY 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 permit is issued. Sq.Ft Floor Area: Valuation:$3000 APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is APN Number:31636021.00 Occupancy Type: 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 ate r 2 �' D c� Issued byre Date: rC / `'I CI OWN -BUILD CLARATION 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 roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,1 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) I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: constrict 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 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. 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. Ow tho ' gent: Date r 2-1to APPLICANT CERTIFICATION STRUCTION LENDING AGENCY I certify that 1 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 a rm 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 nify and keep harmless the City of Cupertino against liabilities,judgments, L ,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 CITY OF `..:i CITY OF CUPERTINO GENERAL BUILDING C U P E RT I N O PERMIT APPLICATION FORM APN # � Date: 10 Building Address: 10916 North Ridge Square Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes ❑ No E HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA Owner's Name: Phone#: Massimo Lanfranconi 408-873-8167 or 408-505-1020 Contractor: Phone: 510-887-0300 US Remodelers, Inc. Fax: 510-887-1610 Contractor License #: 768707 Cupertino Business License #: Contact: Laura Phone: 510-887-0300 Fax: Residential Q Commercial ❑ Job Description: install Art Tub (standard size acrylic, insulated replacement tub) . -7, I �1 Lim 3i n. 1. I Building Permit Info: Bldg ❑ Elect ❑ Plumb E Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Valuation: Square Footage: NA $3,000 Project Size: Express ❑ Standard E Large ] Major ❑ 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: I For help, contact Build it Green at www.builditgr-,en.or Revised 07/14/09 CITY OF CUPERTINO C U CITY OF O GENERAL BUILDING APPLICATION FEE S(�HEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B addition<<1 stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) 1EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechaniml Permit Fee M 1 PPERMITFEE Plumbin.;Permit Fee P IELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check(when no E/M/P) B when not over counter) hourly-s,.and alone 1BCBSC Cal Bld€, Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &;Documentation B 1BUSLIC Business. License B 5 of 5 Community Development 10300 Torre Avenue 'A ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 XPEkTINO Building Department JOB ADDRESS: PERMIT ��l�USS6F,-- OWNER'S NAME: PHONE # og S 05 -10 L o GENERAL CONTRACTOR' C)5 12,CkA v a C / -V-!; FAX # I am not using any subcontractors: ` 12--110107_ Zl►o1o7 i gnature Date Please check applicable subcontractors and om lete the following information: 60 SUBCONTRACTOR BUSI14ESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical 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 iv o ,r ' ature Date