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10100161 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21989 MCCLELLAN RD CONTRACTOR:CONSTRUCTION PERMIT NO: 10100161 DYNAMICS 'NER'S NAME: MATTSON PHYLLIS H TRUSTEE 648 THORNTON WAY DATE ISSUED: 10/21/2010 OWNER'S PHONE: 4082520488 SAN JOSE,CA 95128 PHONE NO:4082946325 ❑ LICENSED CONTRACTOR'S DECLARATIONF_ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class ��"� Lic.# S�y �� l� MECH r RESIDENTIAL r COMMERCIAL r Contractor 'C S'f tac¢Jb,, b VN,4 tc s Date /.r I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADD 1 WINDOW&REPLACE 3 EXISTING WINDOWS (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:$3000 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 whic v s permit is issued. APN Number:35713003.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by '�7�� �--- Date:/`✓�G 9.18. Stu d Date'%C"Z�� l 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) 1,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). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE 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. I 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& ty Code, ections 25505,25533,and 25534. 1 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 O r autho d agent: Compensation laws of California. If,after making this certificate of exemption,I — Date: C" become subject to the Worker's Compensation provisions of the Labor Code,I mus forthwith comply with such provisions or this permit shall be deemed revoked. 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 the above mentioned property for inspection purposes.(We)agree to save .mify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION 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 Date CITY OF CUPERTINO FEE ESTIMATOR-- BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$3,000 R�PERMITTVPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY 1 is"1:11: PENTAMATION 1 GENRES USE: SFD or Duplex 1 I������ ;t ;�. PERMIT TYPE: WORK SCOPE 01h",P v,,b(r! P I'l-i"C' ln�, 1 _P_ F""', 1"v' NOTE. Thesefees are based on the preliminary!n formation<<vailable and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee Resolution 09-05I Eff T"I/I(Y FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 4 # Window/Sliding Glass Door Suppl. PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 $380.00 I WINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee10 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 f_`017str'1Wii017 1 trA Acoustical Fee: 0 Yes (F) No $0.00 0 Work Without Permit? Ct Yes E) No $0.00 e) Planning Fee: $0.00 Select a Non-Residential %i rizl OoE rrl�r �irt:rtif>rr I° cts: Building or Structure Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $' .00 SUBTOTALS: $' .501 $380.00 TOTAL FEE-T $381.50 Revised: 10/17/2010 CITY OF CUPERTINO 4 ITEMS OF 4 PERMI" RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bll:: Lot : APN . . . . . . . . : 35'713003 . 00 DATE ISSUED. . . . . . . : 10,'21/2010 RECEIPT #. . . . . . . . . : BS()00011808 REFERENCE ID # . . . : 10:_00161 SITE ADDRESS . . . . . : 21989 MCCLELLAN RD SUBDIVISION . . . . . . CITY CU:?E RT I NO IMPACT AREA . . . . . . OWNER MATTSON PHYLLIS H TRUSTEE ADDRESS 21989 MCCLELLAN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4007 RECEIVED FROM . . . . : C014STRUCTION DYNAMI CONTRACTOR BRIAN E ROONY LIC # 24319 COMPANY CONSTRUCTION DYNAMICS ADDRESS . . . . . . . . . . : 643 THORNTON WAY CITY/STATE/ZIP . . . : SK4 JOSE, CA 95128 TELEPHONE . . . . . . . . : 4032946325 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- - --------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 000 . 00 1 . 00 0 . 00 1 . 00 0 .00 1BSEISMICR VALUATION 3, 000 . 00 0 .50 0 . 00 0 .50 0 . 00 1BUSLIC FLAT RATE 1. 00 114 . 00 0 . 00 114 . 00 0 . 00 1WINREP EACH 8 4 . 00 380 . 00 0 . 00 380 . 00 0 . 00 - --------- ---------- ---------- ---------- TOTAL PERMIT 495 .50 0. 00 495. 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 495 .50 #584 --------------- TOTAL RECEIPT 495 .50 Building Department City Of Cupertino LM 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: e /I," Z4, PERMIT# 6�)/ OWNER'S NAME: PHONE# 1— GENERAL CONTRACTOR: Co fvs f ,c4 ju BUSINESS LICENSE # ADDRESS: .3r%2CITY/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 SUBCONTPACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. lam not using any subcontractors: Siltdature Date Please check applicable subcontractors and cor plate 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/ ntractor Signature Date MODIFICATION REQUEST FORM Association Name: Park Villas Association-Ridgecres Date: Homeowner Name: Phyllis Mattson Address: 21989 McClellan Road,Cupertino,CA 95014 Z Phone Numbers: — Desc 'ption of work propos Please attach a separate sheet with a sk itch or plains for the work you are proposi Lv�tiL �°' • 2� A licensed contractor must perform the wo k. � 1 Name: &4441 Contractor's License number,phone number acid proof of insurance must be provided. IMPORTANT,please note the following: 1. Applicant agrees&understands submit sion of this form alone does not fulfill all requirements for approval.The Board may require additional information in order to make a decision. nd]-Vau have received Wtltte a BoaM gp=yaLthe iRgp kation is considered not +Oamy' , 2. Applicant understands modifications of special conditions may be placed on completion of work at the applicant's sole expense. 3. Applicant understands all necessary pet mita must be pulled from the City at the applicant's sole expense prior to the initiation of work and after Board approval has been given. Applicant will need to call the City's Building Department to determine which permits,if any,are necessary. 4. Applicant also understands constructioi i of said project entails continued maintenance of said item for the life of the item includii ig any damage arising from installation.If the ownership of the unit is transferred,thif;responsibility must be disclosed as it does transfer to the new homeown,r: � (l�-omeowner Signature Only) Return to Affirmative Management Services,P.O.1 tox 477,Campbell,CA 95009-0477 or Fax:408-244-0090 +++++++++++.+++++++++++.......4++++.+++++++++.+++ ...........++ (For hOA Use Only) ❑ Approved ; ❑ Approved with Contingencies: ❑ Denied ❑ Denied as additional information is required(,.s highlighted): This matter was reviewed by: OL C.16 04 'O 40-2;Q 'v 1J _ art A, III ( !R tWON UKi mi io All....-�.�.�-�--�'-7[`-_ ? 1 `i r.,� ;�1�;?'rw. /�Py .•.. 1t;. Ip4s I vili'i. b 413 11P % d 'S•,'$Gy� o o fpm J' o rte to 0 fi Q 'ice rj` s uu/ � l CITY OF irL.UPERTINO lit ADDITION/REMODEL s 4a r4 `zr� C U P E RT 1 N O FEE SCHEDULE APN# -�� Date: Is a 2'dunit being added? Yes ❑ No ® If yes, please fill out the permit a -'l:tcation ar 't. Building Address: /Ve///f Mailing Address (if different from building address): Owner's NaX4e: Phone# , rkl Contractor: Phone#: e/o - 2')V 6.?L J� c/&,o i4Fax#: Cupertino Business License: State Contractor License t ontact: Phone#: �,� -, -/.3 / C_- �Eays�s Q_" Fax#: Landscape Ordinance Compliance: Landscape area in sq. ft. (includes all irrigated ari:as): �J "— If 2,500 sq. ft. or less, compliance with the Landscape Water-Efficiency Checklist is required. If more than 2,500 sq. ft., a complete Landscape Project Submittal is required. Compliance Method: ❑ Plant Type ] Water Budget Building Permit Info:, Bldg. Elect. ❑ Plumb. [ Mech. ❑ Hillside ❑ Job Description: Addition-What is being added?(Be Specific): /.- 4L5V_e.td What is being r modeled (not including addition)? Re -�2 5 ev_'.*�-, LA-i Remodel Includes Re-Roof: Yes ❑ No [] If yes list number of squares Remodel Includes Structural: Yes ❑ No [J Do you have the pre-application planning approval? Yes ❑ No ❑ If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Dther. W�,J&- Uke• ���� Type of Construction (Usage Class): Occupancy Ty3e: A-7 V— 1-A, 1-B ❑ IUIII/V-A ❑ II/VI B, IV-HT, V-B E- Valuation: > 090 Please check this box if the project is a Project Size: Express ® Standard ❑ L [a'or ❑ second-story addition ❑ Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, Green Building Points Achieved' include in plan set & the sheet index. . Revised 05/18/10