09120063 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 10256 N STELLING RD CONTRACTOR:WOLFGRAM/WENDT PERMIT NO:09120063
OWNER'S NAME: WOLFGRAM/WENDT ::2600 RICARDO RD DATE ISSUED: 12/10/2009
t GR'S PHONE: 4082521133 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION 3UILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
JOB DESCRIPTION: REPLACE WINDOWS&EXTERIOR DOORS IN EXISTING
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions OPENINGS
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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$19000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:32630013.00 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 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued bp- Date:
Date:
Signature Date
L OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I 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.
1,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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I 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 I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I 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 r
Compensation laws of California. If,after making this certificate of exemption,I neo author',e agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must � Date: l1`
forthwith comply with such provisions or this permit shall be deemed revoked. J\�'(�yf /t � �i_
f ONSTRkJCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work'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 constriction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
i- nify and keep harmless the City of Cupertino against liabilities,judgments,
L and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this pen-nit.Additionally,the applicant understands and will comply
with all non-point_source regulagons per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18. 4
�( ..L�'%�✓� ` `� /tet Licensed Professional
Signator Date (J
4;1c4lax
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child) will perform:
A. All the work authodi ed by this permit
B. _ A portion of the wor<
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired i o do:
A. _ All of the work
B. _ A portion of the wor< (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) ocher than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' comFensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side). _
Property Owner's Signature:/�l - ' ✓ +�y Date: 1 1 U
j ��J,j �. Air, ( .. y /' 1�' Permit#
job Address:
Any changes to the information provided orl.tlLis form shall be submitted to the City of Cupertino Build
Department.
�:-aT�l CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
Build'T�Address:
Mailing Address if differen from bu1Iaddress):
C i
Are Hazardous Materials being used as part of this pr 'ect? Yes 0No
HOA: Exterior work only) Yes ❑ No es, provide letter from HOA
Owner's N j, )CJT4K,c",o
: Phone#:
1wimdf- NU Z�� '� � � 33
Contractor: 0 Phone:
0 l Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial
Job Description: � - j or�
S
Building Permit Info:
Bldg �'� Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B �� r'
Valuation: Square Footage:
i I l
Project Size: Ex res Standard ❑ 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:
For help, contact Build it Green at www.builditgreen.or
Revised 07/14/09
r 3" CITY OF C;UPERTINO
Urn OFI� GENERAL BUILD ING APPLICATION
CUPEt�T o FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Afplications (up to 400 sf) B
additional stucco application
1WINREP Replacem:,nt windows/sliding glass B
door (ea 8 windows)
1WINMEWSTR New Window-structural shear B
wall/mascnry(includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
I ELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK 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-st ind alone
r 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic]tesidential B
1BSEISMICO Seismic Commercial B
1TRAVDOC Travel & Documentation B
1BUSLIC Business License B
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