10070025 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20174 NORTHGLEN SQ CONTRACTOR: D PERMIT NO: 10070025
OWNER'S NAME: SUSAN M TACKE '' DATE ISSUED:07/02/2010
VER'S PHONE: 4082577847 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE EXISTING SHOWER VALVE(MOEN)&INSTALL
(commencing With Section 7000)of Division 3 of the Business&Professions LINER/WALL SYSTEM OVER EXISTING BATH/SHOW
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
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$4459
permit is issued.
APPLICANT CERTIFICATION APN Number:31641058.00 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,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Dater
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that 1 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(See.7044,
Business&Professions Code) Signature of Applicant: Date:
1,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
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
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,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner oo uthorized agen` t
forthwith comply with such provisions or this permit shall be deemed revoked --�, tea' / -�' Date: 2
,ems"
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there 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 relating 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
- mify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
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
9.18. I understand my plans shall be used as public records.
Signature Date �/ b Licensed Professional
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31641058 . 00
DATE ISSUED. . . . . . . : 07/02/2010
RECEIPT #. . . . . . . . . : BS000010771
REFERENCE ID # . . . : 10070025
SITE ADDRESS . . . . . : 20174 NORTHGLEN SQ
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : SUSAN M TACKE
ADDRESS . . . . . . . . . . : 20174 NORTHGLEN SQ
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SUSAN M TACKE
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
----------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 4, 459. 00 2 . 00 0 .00 2 . 00 0 . 00
1BPFIXTURE NO OF FIXTURE 1. 00 16 . 00 0 .00 16 . 00 0 . 00
1PPERMITFE FLAT RATE 1. 00 84 .00 0 . 00 84 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 84 .00 0 . 00 84 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 186 .00 0. 00 186. 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
------------------ --------------- --------------------
CHECK 186 .00 #4525
---------------
TOTAL RECEIPT 186 .00
CITY OF (.-.'UPERTINO
CUPEI,TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN#� �.� Date:
Building Address:
S
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of thi,; project? Yes El No
HOA: (Exterior work only) Yes ❑ No [K If yes, provide letter from HOA
Owner's Name: Phone#: atol�)
Contractor: Phone: 4 e$) 3Z74
Fax: o
Contractor License#: (2 S Z_B # c03_57 3
Cupertino Business License#:
Contact: -7— Phone:
,I Lt-S )0 Sia r 111) 112 v Fax:
Residential Commercial El
Job Description:
•fin_54-r4It 6 A e-r a.I �c �z-e�►^ �`s�i�� /�� 1X, o r
Building Permit Info:
Bldg ❑ Elect ❑ Plumb 12 Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-3 Qom" V,__J .,
Valuation: . Square Footage: ll I
Project Size: Express [3---Sff ndard ❑ 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.builditer�.en.or
Revised 07/14/09
CITY OF CUPERTINO
CU
CITY
OF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
ACOUSTICAL
REVIEW
IACOUSFDW SFDWL/l)uplex New B
IACOUSRESAD SFDWL/]duplex-Addition/Alteration B
l ACOUSCOM Multi-Family/Commercial B
CHIMNEY'S
1 CHIMNEY Chimney B
1 CHIMNEYR Chimney Repair B
FENCES
1 FENCE>6FT Non-masonry, over 6 ft in height B
1 FENCEMAS>6 Masonry, over 6 ft in height B
FIREPLACES
1FIREPLMAS Fireplace Masonry B
1FIREPLFAB Fireplace Pre-Fabricated/Metal B
1 FLAGPOL>20 Flag pole (over 20 ft in height) B
1 MODUSTRU Modular Structures B
FOUNDATIONS
1 FOUNDREP Foundation Repair B
1PILECAST Pile Foundation Cast in place concrete B
1PILEDRIV Pile Foundation Driven (steel,pre- B
stressed concrete)
f_1 F�"/� T--c.t?
/ 3 of 5
CITY OF C.'UPERTINO
Cin of GENERAL BUILDING APPLICATION
CUPEI�TINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea ,3 windows)
1 WINMEWSTR New Win low-structural shear B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit Fee P
l ELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1 PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-st�md alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
/ 1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1BUSLIC Business License B
5 of 5
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: P,017�4 PERMIT# r/
OWNER'S NAME: rzla PHONE# v 8 34l
GENERAL CONTRACTOR: N BUSINESS LICENSE# D
ADDRESS: 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:
Signature Date
Please check applicable subcontractors and compl ate the following information:
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