10090039 CITY OF CUPERTINO BUILDING PERMIT
PERMIT NO: 10090039TRACTOR:
BUILDING ADDRESS: 10161 MACADAM LN CON _
OWNER'S NAME: ENGELI GAGNI T�
��1 t, Lo-&i-,s DATE ISSUED:09/07/2010
�C,}�M �•
ER'S PHONE: 4084459608 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG� ELECT� PLUMB r
License Class 2-- ( Lic.#- V Al ! 1 MECH r RESIDENTIAL r– COMMERCIAL
Contractort/���7Z��[–/t✓t0�s � Date f
4
VAL JOB DESCRIPTION:ADD DEDICATED CIRCUIT,ADD T OFF FOR GAS&ADD
I hereby affirm that I am licensed under the provisions of Chapter 9 SUMP FOR SEWER
(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 Valuation:$2500
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued.
APPLICANT CERTIFICATION APN Number:36901054.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
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
granting of this permit. Additionally,the applicant understands and will comply 180 D YS FROM LAS ALLED INSPECTION.
with all non-point source regulations per the Cuperti o Municipal Code,Section 9 �f
9.18. % Q � / ,2t.l ✓Date:
'� /'O Issued by:
Signature ' = Date r
L, OWNER-BUILDER D CLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one Of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
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
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sectio 5505,25533,and 25534.
Compensation laws of Califomia. If,after making this certificate of exemption,I O or aut rite t: q ,3
become subject to the Worker's Compensation provisions of the Labor Code,I rm st Date: ! d
forthwith comply with such provisions or this permit shall be deemed revoked.
ONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that ere is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relati�g for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
unify and keep harmless the City of Cupertino against liabilities,judgments,
,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Signature
Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR.-BUILDING DIVISION
ADDRESS: 10161 Macadam Ln DATE: 09/07/2010 REVIEWED BY: Larry S
APN: BP#: *VALUATION: $2,500
PERMIT TYPE: Building Permit PLiLN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY �l)y, [; PENTAMATION 1GENRES
USE: SFD or Duplex 1'L 0OR PERMIT TYPE:
WORK
SCOPE
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NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resohilion 09-051 Eff. 7%7./10) FE]: QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 =1 # Plumbing
Suppl. PC Fee: E) Reg. 0 OT0.0 hrs $0.00 $21.00 1PRSEWER Sewer, Sanitary
PME Plan Check: $0.00 I J # Plumbing
Permit Fee: $0.00 $63.00 1PGASRES Piping,Gas<=4 Outlets
Suppl. Insp.Fee10 Reg. 0 OT 0.0 hrs $0.00 = Electrical
PME Unit Fee: $0.00 $42.00 1BREMRECEP Recep/Switch/Outlets
PME Permit Fee: $0.00
("on it licrion T'n - r
Acoustical Fee: 0 Yes (E) No $0.00 0
Work Without Permit? 0 Yes 0 No $0.00
Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: 1 TRA VDOC $42.00
Building or Structure
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
BldgStds Commission Fee: IBCBSC 911.00
SUBTOTALS: $43.50, $126.00 TOTAL FEE: $169.50
Revised: 9/01/2010
CITY OF CUPERTINO
6 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36901054 .00
DATE ISSUED. . . . . . . : 09/07/2010
RECEIPT #. . . . . . . . . BS000011393
REFERENCE ID # 10090039
SITE ADDRESS 10161 MACADAM LN
SUBDIVISION . . . . . . .
CITY CL;PERTINO
IMPACT AREA . . . . . .
OWNER ErGELI GAGNI
ADDRESS . . . . . . . . . . : 1C161 MACADAM LN
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM PF.ESTIGE LANDSCAPE
CONTRACTOR TE-D - TO BE DETERMINED LIC # 00096
COMPANY TF;D - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . :
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ----------- -------
1BCBSC VALUATION 2, 500 .00 1.00 0.00 1. 00 0 .00
1BREMRECEP NO. OUTLETS 1. 00 42 .00 0. 00 42.00 0 .00
1BSEISMICR VALUATION 2, 500. 00 0 .50 0 .00 0.50 0 .00
1PGASRES OUTLETS 1. 00 63 .00 0 .00 63 . 00 0 . 00
1PRSEWER UNITS 1. 00 21. 00 0. 00 21.00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 .00 0 .00 -----42_00 ------0_00
---------- ----------
TOTAL PERMIT 169 .50 0.00 169.50 0 .00
= - CITY OF CUPERTINO
c1TY OF
CvFEKINo GENERAL BUILDING
PER HT APPLICATION FORM
APN Date:
Building Address: to -o
�p � �JQ�1
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: xterior work only) Yes ❑ No ❑ If yes,provide letter from HOA
Owner's Name: Phone#:
n
j d 17
Contr ctora Phone: l----
' � L Fax:
Contractor License#: i�9 a
Cupertino Business License
Contact: Ph6Tie:
Fax:
residential Commercial
Job Description: /
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14J)
Building Permit Info:
Bldg ❑ Elect Plumb Mech ❑
Type of Construction (Usage Class): Occupancy Type:
P-1-5
1-B ❑ E/UI/V-A ❑ II/III B, IV-HT,V-B
Valuation: Square Footage:
Project Size: 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.
`oints Achieved:
r`or help, contact Build it Green at www.builditgreen.or
Revised 07/14/09
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