11010128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22840 STONEBRIDGE ST CONTRACTOR:PERRY IRMA TRUSTEE PERMIT NO: 11010128
OWNER'S NAME: PERRY IRMA TRUSTEE 22840 STONEBRIDGE DATE ISSUED:01/24/2011
O R'S PHONE: 4084464525 CUPERTINO,CA 95014-5643 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
License Class Lic.# MECH r RESIDENTIAL F COMMERCIAL r
Contractor Date
JOB DESCRIPTION:ADDING 5 RECESSED LIGHTS AT BEDROOM LOCATION
I hereby affirm that I 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. Sq.Ft Floor Area: Valuation:$200
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 anc T Occupancy APN Number:34213040.00 P Y YPe.
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accnue 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 Issued b Dat .r
9.18.
Signature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). P
HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner r authorize gent:
Compensation laws of California. If,after making this certificate of exemption,I
Date:
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 revoke`d..p CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
.,and expenses which may accnre against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature 1 rYL k -t-•
Date 1—2/—/
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34213040 .00
DATE ISSUED. . . . . . . : 01/25/2011
RECEIPT #. . . • • . . . . : BS000012559
REFERENCE ID # . . . : 11010128
SITE ADDRESS . . . . . : 22840 STONEBRIDGE ST
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PERRY IRMA TRUSTEE
ADDRESS . : 22840 STONEBRIDGE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5643
RECEIVED FROM . . . . : MS IRMA PERRY RN
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : PERRY IRMA TRUSTEE
ADDRESS : 22840 STONEBRIDGE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5643
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL-
---------- ----------
----
1BCBSC VALUATION 200 . 00 1 .00 0 .00 1. 00 0 .0
1BREMFIXT NO. FIXTURES 5. 00 63 .00 0.00 63 . 00 0 .00
1BREMRECEP NO. OUTLETS 1.00 42 . 00 0 .00 42 . 00 0 .00
1BSEISMICR VALUATION 200. 00 0 .50 0 .00 0 .50 0 .00
1EPERMITFE FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 .00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 ------0_00
---------- ---------- ----------
TOTAL PERMIT 190 .50 0 .00 190 . 50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-----------------
--------------- -----------------
CREDIT CARD 190 .50 VISA
---------------
TOTAL RECEIPT 190 .50
�-- CITY OF CUPERTINO
'car aF .
cUFE TING GENERAL BUILDING
PER UT APPLICATION FORM
APN# � � ,� Date:
Building Address:
aa840 S�oneY�r�d � s Cu e�TLi1C, , (°� q Svt �
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes ❑ No ® If yes, provide letter from HOA
Owner's Name: Phone*
arm c� Iffier '�rV.s�2� 40 (o .4,5.-S
Contractor: - Phone:
t :;,��r nuc leief Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
.esidential Commercial
Job Description:
{�dd.�rroom -
.
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ E/D-/V-A ❑ II/III B, IV-HT,V-B
Valuation: o� Square Footage:
Project Size: Express [g--Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LE M Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
Points Achieved:
L ,r help, contact Build it Green at www.bullditgreen.org '
Revised 07/14/09