09120028CITY OF CUPERTIP O BUILDING PERMIT
BUILDING ADDRESS: 10415 STERN AVE
r-''NER'S NAME: ANNA Y WEI
0,vNER'S PHONE: 4087184317
❑ LICENSED CONTRACTOR'S DECLARATION
License Class
Contractor
Lic. #
Date
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 the work for which this
permit is issued.
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,
costs, and expenses which may accrue against said City in consequence of the
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.
-ature Date
r 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I 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.
1 certify that in the performance of the work for which this permit is issued, 1 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
1 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
the above mentioned property for inspection purposes. (We) agree to save
anify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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.
Date
CONTRACTOR: CALVIN & BROS PERMIT NO: 09120028
CONSTRUCTION, INC
1194 FARGATE CIR DATE ISSUED: 12/04/2009
SAN JOSE, CA 95131 PHONE NO: (408) 582-4988
BUILDING PERMIT INFO: BLDG ELECT I— PLUMB
MECH f— RESIDENTIAL I— COMMERCIAL
JOB DESCRIPTION: GAS LLINE REPLACED**SEE NOTES**
Sq. Ft Floor Area: Valuation: $550
APN Number: 37510059.00 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by,:•�' �'�
Date: / 'Z
RE -ROOFS:
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.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I 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 as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized age t
:r- �
Da e•
CONSTRUCTION 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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
at
CITY OF
CUPERTINO
CITY OF CUPERTINO
GENERAI-d BUILDING
PERMIT APPLICATION FORM
APN # �. .--�
Date:
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project?
Yes No.El
HOA: (Exterior work only) Yes ❑ No 4f yes, provide letter from HOA
Owner's Name:
Phone #:
Contractor:
Phone:
Fax:
Contractor License #: -12c-; 7=:a
Cupertino Business License #:
Contact: (� _ - --
Phone: 0 3 z u ; tf Is,
Fax:
Residential Commercial El
Job Description:
Building Permit Info:
Bldg ❑ Elect ❑ PlumbK
Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
1-A, I -B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B
Valuation: 0511,5t-1)
Square Footage:
Project Size: Ex ressStandard ❑ Large ❑ 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:
For help, contact Build it Green at www.builditgreen.or
Revised 07/14/09
sli'M CITY OF CUPERTINO
CUPEf�F GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Group
Permit Type
1GENRES or
1GENCOM
1STUCOAP
Stucco Applications (up to 400 sf)
additional stucco application
B
1 WINREP
Replacement windows/sliding glass
door (ea 8 windows)
B
1WINMEWSTR
New Window -structural shear
wall/mase (includes plan ck fee)
B
1 EPERMITFEE
Electrical Permit Fee
E
1MPERMITFEE
Mechanical Permit Fee
M
f
1 PPERMITFEE
PlumbinE Permit Fee
P
1 ELCPLNCK
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
when not over counter)
Standard Plan Check (when no E/M/P)
hourly-st�md alone
B
1BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1BSEISMICR
Seismic Presidential
B
1BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
1
1BUSLIC
Business License
B
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