11010040 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10380 SCENIC BLVD CONTRACTOR: - PERMIT NO: 1 1010040
OWNER'S NAME: TOM TARSHISH DATE ISSUED:01/06/201 1
VER'S PHONE: 4084972249 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class L_ / Lic.#
MECH r RESIDENTIAL COMMERCIAL
Contractor Date ( ��
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 9 WINDOWS&3 DOORS LIKE FOR LIKE
(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. Sq.Ft Floor Area: Valuation:$10130
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 APN Number:35708005.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 1 F 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 FR LLED INSPECTION.
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 Issued by: Date: 1421,
with all non-point�nree regu ons p the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 4e?// 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.
LJ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker'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 contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with,the-Cdoifrtino Mumc al Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code cions 25505,25533 d 25534.
Section 3700 of the Labor Code,for the performance of the work for which this >
permit is issued. Owner or authorized agent: Date:
I certify that in the performance of the work for which this permit is issued,I 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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
anon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
unify and keep harmless the City of Cupertino against liabilities,judgments,
_s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10380 Scenic Blvd DATE: 01/06/2011 REVIEWED BY: RDW
APN: BP#: "VALUATION: $10,130
R
TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: P PERMIT TYPE:
WORK
SCOPE
l,fe ch. f'!an ChE'ck 11honh. Plan ChcccT, F/eta_ Plan Chcck
Ltc'c r'7. 11ernt t Fee: 1Phowb, f't'i"rP i( e c Flt!(. Perini[
t)thcr lfc'ch. fn,=p, C)Il'tc'7 Phord)la"". Oth'rliler_Inn, Li
lkch.Inn. PlamIj. Ii slr. 1'['d: 111ec Itrst. 1"'e:
NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 09-05I Eff. 7/1,'10) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Window/Sliding Glass Door
Suppl.PC Fee: E) Reg. 0 OT0.0 hs $0.00 $506.00 1 WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee.0 Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
(','onsfrtiction 7'a
Acoustical Fee: 0 Yes G No $0.00 0
Work Without Permit? 0 Yes 0 No $0.00 E)
Planning Nee: $0.00 0
7'1-avc-4 l�oczrlrrc�ntutiorr l�'€rc's.
Strong Motion Fee: IBSEISMICR $1.01 Select an Administrative Item
I
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $2.01 $506.00 TOTAL FEE: $508.01
Revised: 12/07/2010
tz
-1-4
T4
I®r-
..............
ri
(41
CITY OF
CITY OF CUPERTINO
GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part f this project? Yes No
HOA: (Exterior work only) Yes El No
If yes, provide letter from HOA
If Residential,is house an Eichler? Yes ❑ No,ff If yes, needs planning approval.
Owner's Name: Phone #:
0,'y o,�V-- 7
Contractor: Phone:
C-L--�,Npe-"J `� cc� Fax: Ob `/0P
Contractor License#: /7�Z
Cupertino Business License#:
Contact: ) Phone: 9O —JA/ —
'7Tcx-rid ' '✓ Fax/e-mail:
Residential Commercial
Job Description:
BuildingInfo:
BldgPe it Elect ❑ Plumb ❑ Mech ❑
Type o Construction(Usage Class): Occupancy Type: _
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B 'e—e51
Valuation: Square Footage:
Project Size: Counter ❑ 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.buildit reen.or
Revised 12/06/10