11010151 r CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22442 CARNOUSTIE CT CONTRACTOR:JM CONSTRUCTION PERMIT NO: 11010151
OWNER'S NAME: JOSEPH SEGNA 562 DIVISION ST DATE ISSUED:01/28/2011
OWNER'S PHONE: 6504946385 CAMPBELL,CA 95008 PHONE NO:(408)379-9852
LICENSED CONTRACTOR'S DECLARATIONI— r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class 2 Lic.#
/ MECH T_ RESIDENTIAL I— COMMERCIAL�
Contractor J/-,c�t' �n rI 47t)4 r Date /— 7-F—
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE DRYWALL AFFECTED BY WATER DAMAMGE,
(commencing with Section 7000)of Division 3 of the Business&Professions INCLUDING INSULATION
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 Sq.Ft Floor Area: Valuation:$15000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. 'P11?_
APN Number:35603028.00 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 7 Lr
9.18. C� Issued byDate:
Signature Date-1,a&
d
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.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I 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. I 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.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
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
Compensation laws of California. If,after making this certificate of exemption,I Owne Rued agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 1-261-11
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION 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 construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
^sts,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
sting of this permit.Additionally,the applicant understands and will comply
ah all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: TraciC
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35603028 .00
DATE ISSUED. . . . . . . : 01/28/2011
RECEIPT #. . . . . . . . . : BS000012597
REFERENCE ID # . . . : 11010151
SITE ADDRESS . . . . . : 22442 CARNOUSTIE CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JOSEPH SEGNA
ADDRESS 22442 CARNOUSTIE CT
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3949
RECEIVED FROM . . . . : JM CONSTRUCTION
CONTRACTOR . . . . . . . : EDENS, JIM LIC # 20955
COMPANY JM CONSTRUCTION
ADDRESS 562 DIVISION ST
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE . . . . . . . . : (408) 379-9852
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 15, 000. 00 1 .00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 15, 000 . 00 1 .50 0. 00 1.50 0 .00
1INSPMIS HOURS 2 . 00 252 . 00 0.00 252 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 254 .50 0 .00 254 .50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 254 .50 #47347
---------------
TOTAL RECEIPT 254 .50
Building Department
City Of Cupertino
LM 10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: 2,2- [f Z C;4 PERMIT#
OWNER'S NAME: y a —' . PHONE# 0,9
GENERAL CONTRACT R: BUSINESS LICENSE#
ADDRESS: 6 L A CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
ignature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting
Linoleum /Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF
12 CITY OF CUPERTINO S
GENERAL1 �
BUILDING
CUPERTINO
PERMIT APPLICATION FORM
APN# C) . Date:
Building Address:
ZZ�yZ � r va-�te
Mailing Address (if different from building address):
Are Hazardous Materials being used as part oft ' project? Yes No
HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA
If Residential.is house an Eichler? Yes ❑ No If es, needs planning approval.
Owner's Name: Phone #:
6 ) - 411 �,q .3P-
Contractor:' Phone: 9 o 9 q 9S e--
-J
-J -5 o rl Fax: v >' `�- �fi t✓'S
Contractor License#:
Cupertino Business License#: z U MS'S
Contact: Phone: y o - �_c!-`?
S Fax/e-mail: 9 3 q- et 9.5--7-
Residential Commercial
Job Description:
wader �r� d9c� �Y/ C./L d.<-- j n;� l f( n ')
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction(Usage Class): Occupancy Type-
1-A, 1-B ❑ IVIII/V-A ❑ II/III B, IV-HT, V-B [
Valuation: Square Footage:
Project Size: Counter G--Express ❑ 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.buildit2reep.org
Revised 12/06/10