10050085 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20833 FARGO DR. CON'rRACTOR:HAYNES BUILDERS PERMIT NO: 10050085
"VNER'S NAME: NANCY A KATO 56 CIIERRY LN DATE ISSUED:05/10/2010
. VNER'S PHONE: 4088236811 CAMPBELL,CA 95008 PHONE NO:(408)823-6811
LICENSED CONTRACTOR'S DECLARATION I—
Y BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class �j
.may Lic.# MECH RESIDENTIAL COMMERCIAL
Contractor A1) to
I hereby of rm t am licensed under the pr �s� of Chapter 9 JOB DESCRIPTION: EXTEND WATER(2')LINE,ELECTRICAL LINE(7')
(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:$400
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
permit is issued. APN Number:32630131.00 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, 1_80 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-poinertino Municipal Code,Section Issued by: S z d' v Date:
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
insta led 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, Sigmaure 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 Cali'ornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the coml)liance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safe y Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Add tionally,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 cont iminants as defined by the Bay Area Air Quality Management District I will
permit is issued. main tain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
p Health& ety C e,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 OWr
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 revoked. CONSTRUCTION LENDING AGENCY
I her,-by affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for v,hich 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 Len,ler's Address
ur the above mentioned property for inspection purposes.(We)agree to save
iify and keep harmless the City of Cupertino against liabilities,judgments,
cu-6,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 CUEERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: lot :
APN 32630131. 00
DATE ISSUED. . . . . . . : 05/10/2010
RECEIPT #. . . . . . . . . : BSOOOC10358
REFERENCE ID # . . . : 10050( 85
SITE ADDRESS 20833 FARGO DR.
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER NANCY A KATO
ADDRESS 20833 FARGO DR
CITY/STATE/ZIP . . . : CUPER�7INO, CA 95014
RECEIVED FROM . . . . : HAYNES BUILDERS
CONTRACTOR JIM HAYNES LIC # 31658
COMPANY HAYNES BUILDERS
ADDRESS 56 CHERRY LN
CITY/STATE/ZIP . . . : CAMPBELL, CA 95008
TELEPHONE (408) 823-6811
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----------- ---------- ---------- ----------
1BCBSC VALUATION 400 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 400 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 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 L27.50 0 . 00 127 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- - -------------------
CREDIT CARD 127. 50 VESA
---------------
TOTAL RECEIPT 127.50
CITY OF CU PERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
Date:
Building Address:
Mailing Address (if dfffer6nt from building address):
Are Hazardous Materials being used as part of this project? Yes-0--No �--�
HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: Phone#:
/ /�h
Contr to . Phone:
Fax: i
Contr for License
Cupertino Business License#:
Contact: Phone:
Fax: - 2
Residential,Z5, Commercial ❑
Job Description:
Building Permit Info:
Bldg ❑ Elect Pluinb Mech ❑
Type of Construction (Usage Cl ss): Occupancy Type:
1-A, 1-B ❑ IUIII/V-A ❑ IUIII 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, in:.lude in plan set& the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditgreen.)r
Revised 07/14/09
CITY OF CUPERTINO
CUPEt�F GENERAL BUILDING APPLICATION
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 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
1EPERMITFEE Electrical Permit Fee E
1 MPERMITFEE Mechanical P,-rmit Fee M
1PPERMITFEE Plumbing Per-nit Fee P
1 ELCPLNCK Stand Alone l;lectric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Plar. Check (when no E/M/P) B
when not over counter) hourly-stand ;alone
1 1BCBSC Cal Bldg Star.dards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Doc.umentation B
1 BUSLIC Business License B
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