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10060150 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 8175 HYANNISPORT DR CONTRACTOR—139 4443= PERMIT NO: 10060150 ,13E FFft*ftNF$- 1 h `IWNER'S NAME: ISAAC CHEN&LAURA CHEN DATE ISSUED:06/23/2010 OWNER'S PHONE: 4083906637 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL License Class _ Lic.# /> %r a a � INSTALL SHOWER VALVE I / � *SEE NOTES* Contractor )C��C�' L t (' Date 3 C C 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:$1000 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 AFN Number:35611022.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I 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 180 DAYS OF 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 FRO LAST CALLED 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 Issued by: Date: O granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ,/G, RE-ROOFS: Signature �(�1�• � Date V l l A'I roofs shall be inspected prior to any roofing material being installed.If a roof is in;talled without first obtaining an inspection,I agree to remove all new materials for in;pection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,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) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I lave 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 m aterial. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the a r contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. w ill maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by tl a Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this C weer or authorized agent: G �*�C 'Lv' y�c Date: (� permit is issued. 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 CONSTRUCTION LENDING AGENCY 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 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. v ork's for which this permit is issued(Sec.3097,Civ C.) I ender's Name APPLICANT CERTIFICATION I ender'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 ,pon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION idemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,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. SignatureDate„/� CITY OF CUP'.�,RTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM COPY # : 1 Sec : Twp: Rng: Sub: Blk: LDt: APN 35611022 . 00 DATE ISSUED. . . . . . . : 06/23/2010 RECEIPT # . . . . . . . . . BS000010698 REFERENCE ID # 10060150 SITE ADDRESS 8175 PYANNISPORT DR SUBDIVISION . . . . . . . CITY CUPERq INO IMPACT AREA . . . . . . OWNER ISAAC CHEN & LAURA CHEN ADDRESS 8175 l:YANNISPORT DR CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM ANDREW LEE 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 1, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BPFIXTURE NO OF FIXTURE 1 . 00 8 . 00 0 . 00 8 . 00 0 . 00 1PPERMITFE 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 93 . 00 0 . 00 93 . 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER --------------- --------------------- CASH 93 . 00 8175 HYAANNISPORT --------------- TOTAL RECEIPT 93 . 00 CITY OF CUPERTINO CUPEfZTINO GENERAL BUILDING PERMIT APPLICATION FORM APN # Date: _ l Building Address: t5 Pe Mailing Address (if different from b ilding 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# =X6 G6�7 Contractor: Phone: o° y-E W Le � Fax: �� S`- � •>f Contractor License#: V1' ��'`?;� cf Cupertino Business License#: Contact: Phone: t rC�: � � Fax: Residential Commercial ❑ Job Description: Building Permit Info: Bldg ❑ Elect ❑ Plu nb`E� Mech ❑ Type of Construction (Usage Class): Occupancy Type: k3 1-A, 1-B [:] II/III/V-A F-1 II/III B, V-B [ Valuation: Square Footage: ' tit, 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. Points Achieved: For help, contact Build it Green at www.builditgreen.or Revised 07/14/09 611 CITY OF CUPERTINO CI OF GENERAL BUILDING APPLICATION - CUPEi�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applic�.tions (up to 400 sf) B additional stua;o application 1 WINREP Replacement windows/sliding glass B door (ea 8 wir.dows) 1 WINMEWSTR New Window-structural shear B wall/masonry 1 includes plan ck fee) 1EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1 PLMBLNCK Stand Alone F lumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand alone 1BCBSC Cal Bldg Star.dards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 1 TRAVDOC Travel & Documentation B 1 1BUSLIC Business License B 5 of 5 M.Indoor Air Ouality and Finishes '.' Low:'. c VDC Peet 1 IAC/Health pts y=yes 0 2.Use Low VOC,!Nater-Based Wood Finishes 2 IAC/Health pts y=yes 0 3.Use Low74c VOC Adhesnles 3 IAC/Health pts )-yes 0 4.Use Salvaged Materials for Interior Finishes 3 Re;,ource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AC/Health pts y=yes 0 6.Use Exterior Grade Plywoodfor Interior Uses 1 IAC/Health pts y=yes 0 7.Seal ail bpOsed Patclebnatb or MDF 4 IAC/Health pts y=yes D B.Use FSC Certified Materials for Interior Finish 4 Re source pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Re source pts y=yes 0 10.Install Whole House Vacuum System 3 IAo JHealth pts y=yes 0 E @ D K Flooring 1.Select FSC Certified Wood Flooring B Res)urce pts y=yes D 2.;lsa Rapidly Renewable Flooring Materlais 4 Res)urce pts y=yes D 3.Use Recycled Content Ceramic Tiles 4 Res)urce pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAC/Health pts y=yes D 5.Use Exposed Concrete as Finished Floor 4 Res)urce pts y=yes Mimi 6.Install Recycled Content Carpet with Low VOCs 4 Res)urce pts y=yes lid Total Points Available: 1 1401 1301 57 Total Points Project Received. 01 0 0 G:data/progs/greenbuildi igguidelines/remodelers/greenpointsfinal2.12.D4protected.xls Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# /806,U 1 S Q OWNER'S NAME: 1 S u c �+ PHONE# (`�" GENERAL CONTRACTOR: BUSINESS LICENSE # lf ADDRESS: � I.tr1cIl C �chw��:,d 0`f CITY/ZIPCODE: C�cdr .,c� �(4� U *Our municipal code requires all businesses working in the -ity to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INS'ECTION(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: -� ��f .r o�--�t Signature Date Please check applicable subcontractors and complete the following information: 6/ 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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21845 HYANNISPORT DR CONTItACTOR:ARGONAUT WINDOW& PERMIT NO: 10060101 DOOR,INC '?ER'S NAME: ROBERT L BRAGG AND EILEEN ROBERSON 1901 S 3ASCOM AVE STE 800 DATE ISSUED:06/17/2010 CAMP 3ELL,CA 95008 PHONE NO:(408)378-4018 O,,vNER'S PHONE: 4082579683 p LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:REPLACE 12 WINDOWS&2 SLIDING GLASS DOORS IN I hereby affirm that I am licensed under the provisions of Chapter 9 EXISTI vG LOCATIONS (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 Sq.Ft Floor Area: Valuation:$12914 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35613047.00 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 to building construction,and hereby authorize representatives of this city to enter P ERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save 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 130 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: Date: Si- -+ure Date OWNER-BUILDER DECLARATION RE-ROOFS: All ro ifs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of install A without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspec tion. I,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, Signa ure of Applicant: Date: 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). 4#- 1 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 hav,read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the Calif irnia Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain 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 I have and will maintain Worker's Compensation Insurance,as provided for by Addi I use a)should I store or handle hazardous material. a ddi:ionally,should use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this conts minants 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 I certify that in the performance of the work for which this permit is issued,I shall Heal h&Safety Code,Sections 25505,25533,and 25534. 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,1 Ow :r or authorized nt* ate: 4O 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 revoked y/J r� CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I herl:by affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for w hich this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lenuer's Name to building construction,and hereby authorize representatives of this city to enter UT ie above mentioned property for inspection purposes.(We)agree to save Lender's Address ii ify 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 with all non-point source regulations per the Cupertino Municipal Code,Section I un(erstand my plans shall be used as public records. 9.18. / /(] Licensed Professional Signature ��ILLL�G�(I/f"G�f/�- Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lct: APN 35613047 . 00 DATE ISSUED. . . . . . . : 06/17/2010 RECEIPT #. . . . . . . . . BS000010648 REFERENCE ID # . . . : 100601C1 SITE ADDRESS 21845 IYANNISPORT DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : ROBERT L BRAGG AND EILEEN ROBE ADDRESS . . . . . . . . . . : 21845 HYANNISPORT DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM EILEEN ROBERSON CONTRACTOR CHRIS ETTEMA LIC # 22820 COMPANY ARGONAUT WINDOW & DOOR, INC ADDRESS 1901 S BASCOM AVE STE 800 CITY/STATE/ZIP . . . : CAMPBE:jL, CA 95008 TELEPHONE . . . . . . . . : (408) 3'78-4018 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ----- ----- -- 1BCBSC VALUATION 12, 914 . 00 1 . 00 0 . 00 1. 00 0 .00 1BSEISMICR VALUATION 12, 914 . 00 1 .30 0 . 00 1 . 30 0 . 00 1WINREP EACH 8 1. 00 330 . 00 0 . 00 380 . 00 0 . 00 ----- ----- ---------- ---------- ---------- TOTAL PERMIT 332 .30 0 .00 382 .30 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ---------------- CREDIT CARD 382 .30 DISCOVER --------------- TOTAL RECEIPT 382 .30 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMEN r•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333• bLjhdina a5cjDertinc.orc CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your r ame listing yourself as the builder of the property improvements specified at: SITE ADDRESS / � QJ1h�f oj,�-�l� TAPN BP# 0 6 D (vI OWNER NAME Rob44"7^ /3 12 IvOWNER ADDRESS - nn a y5- jdmq_,ant'J 1 J2 aLtY DESCRIPTION OF WORK: l ZXx-� We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having tris permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialec your understanding of each provision, signed, and returned this form to us at our official address indicated. Ai agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF IN=ORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 1. 1 understand a frequent practice of unlicensed persc ns is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the prc perly owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and :ubject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while worki ig on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. L/ 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. L/ 3. 1 understand as an"Owner-Builder" I am the respon3ible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licens;d Contractor and having the permit filed in his or her name instead of my own. V 4. 1 understand Contractors are required by law to be I censed and bonded in California and to list their license numbers on permits and contracts. / 5. 1 understand if I employ or otherwise engage any pE!rsons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollar; ($500), including labor and materials, I may be considered an "employer" under state and federal law. /l 6. 1 understand if I am considered an"employer" uncle-state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also u-iderstand my failure to abide by these laws may subject me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intE nt to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. �8. 1 understand as an Owner-Builder if I sell the propety for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsegL ent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderFonn 2010.doc revised 04/14/10 the Internal igations 9. I understand I may obtain more information reg Adm ation,l he Californiaepar Dtmentarding my as an"employer"from of Benefit Payments, Revenue Service, the United States Small Bus inessand the California Division of Industrial Accidents.2I also ouunderstandrcI for contact t the California about licensed State License Board (CSLB)at 1-800 321-CSLB ( ) or contractors. for n my name, and f-10. 1 am aware of and consent to an owner-Builder p' buil'construction' ait pctiviitty at'the site address listed above. I am the party legally and financially responsible for proposed ✓/11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well asemployers. any of the i/ 12. 1 agree to notify the issuer of this form immediately s are aany d dilated yelaws des r cha f pro information the public. If information I have provided on this form. Licensed contra 9 you contract with someone who does not hlicense,sustainas a esult of a complaint•Your onlycenser emedy against bunl icensed bensed assist you with any financial loss you mayt if anContractor or Contractors may be in civil court. It is also important for you to understand thaou may be held liable for damages. If employee of that individual or firm is injured while working o-i your property, y Y you obtain a permit as Owner-Builder and wish to hire Conti actors, r workers' compensation u will be i'nsuranceble for rcov ageether or not those Contractors are properly licensed and the status of th CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lencing agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Ac dress: e't ner and ro ner and Before a building permit can be issued,thisform the uermit. Note.st be lA copy of the property ownereted and signed by the p's driver's license e, returned to the agency responsible for issuing p form notarization, or other verification acceptable to the city mz y be required to be presented when the permit is rssued to verifythe roe owner's si nature. Date: (o / Property Owner's Signature: -- - - - - --------------------------------------------- -------- ----------------------------------------------------------------- (NOTE: The following Authorization Form is required to be co-npleted by the property owner only when designating an construction permit br the Owner-Builder). agent of the property owner to apply fora AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to app y for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Tel No Name of Authorized Agent: Address of Authorized Agent: ownE!r for the address he declare under penalty of perjury that I am the pro y above information and certify its accuracy. Notecopy of tl e property ownerls dridverb 's licenseabove and)formnofal l y filled out t rization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners signature. Date: Property Owner's Signature: OxmerBuilderFornr_2010.doc revised 04/14110 Din Rm Kitchen Fam Rm 8068 XO 8068 OX 6040 XO Kitchen Garden Window does not get replaced! _ , '�-' g Z 1 Zr3 0o ~= ZD Office o p o f o Z m Z � m rn �� _ _ `�_ :z � x �� " D� 6040 XO:D y _ T Liv Rm Bath dn�n X0 3020 XO , = a with Grid ObsTemp o $ 64' a m >O30 Sn Cn y Q Robert & Eileen Roberson Garage 0 s 21845 H annis ort Drive 6040 Picture Y P With grids n c Cupertino, Ca. 950V 1St Floor ' FIrI 71 d CITY OF Ivi CITY OF CUP'ERTINO GENERAL BUILDING CUPERTINO PERMIT APPLICATION FORM Date: Building Address: D,i �C ttp,,,rhnu, CXR 15v )ll Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: Exterior work onl Yes ❑ No ❑ If yes, rovide letter from HOA Owner's Name: Phone#: 14 pg ;0*) 96,0 C l*`net Robert 6y—cUm (Inde te(11 Ober.(on QQg 973 -'110-J (6,1eeti Wilt Contractor: I Phone: i{o g '39 b -VO/9 1q on apt nO�JuI + Door Fax: Contractor License#: $QSg Cupertino Business License#: Contact: Phone: 40 9 4P�,Y ^ ®GAS/ S +e-Ue, KobI'S Oh Fax: U (v 6'X - ORIS Residential N Commercial Job Description: !Z ace I )_ wivto(0Lo- Ck�� . Slt � �►-�y � I�sS C'o�✓-S. Building Permit Info: Bld Elect ❑ Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: 1-A, 1-B 0 II/III/V-A ❑ II/III B,IV-HT,V-B }• ,1 Valuation:4 1-�, l g 13 , 3 SS- Square Footage: Project Size: Express El Standard [? Large ❑ Major ❑ Green Building: Please complete relevant portion of tb a Green Building/LEED Checklist& attach it to the application or if applicable,include in plan set& the sheet index. Points Achieved: j For help,contact Build it Green at www.build itereen.org Revised 07/14/09