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09120069CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10150 LOCKWOOD DR CONTRACTOR: TBD -TO BE DETERMINED PERMIT NO: 09120069 OWNER'S NAME: PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION F F r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH f— RESIDENTIAL COMMERCIAL r Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 655 SQ FT TO KITCHEN, BEDROOM & BATH (commencing with Section 7000) of Division 3 of the Business & Professions STRUCTURAL 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: $150000 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: 342141 11.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. 1 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 PERMIT 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 180 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 �_/��71-- Date: Signature Date ❑ OWNER -BUILDER DECLARATION RE -ROOFS: All roofs 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 installed without first obtaining an inspection, I agree to remove all new materials for the following two reasons: inspection. 1, 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, 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 declarations: HAZARDOUS MATERIALS DISCLOSURE 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 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 Health & 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, I : S/ 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 APPLICANT CERTIFICATION I hereby 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 which this permit is issued (Sec. 3097, Civ C.) correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, 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. �, V �/ O Signature Date J � / Licensed Professional REVISION #_ i CITY OF CUPERTINO BUILDING PERMIT L"Al r BUILDING ADDRESS: 10150 LOCKWOOD DR I CONTRACTOR:-`F rL ""^` D I PERMIT NO: 09120069 I OWNER'S NAME: . 1 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION License Class iE> Lic. # Contractor Oym Date 1 hereby affirm that 1 am licensed under the provisions o Chapte 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 1 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 fogwhicj�this pen -nit is issued. � L APPLICANT CERTIFICATION 1 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, 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 - Code, Section 9.18. Signature Date tT ❑ OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: 1, 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 construct the project (Sec.7044, Business & Professions Code). 1 hereby affirm under penalty of perjury one of the following three 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 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 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 forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I ague 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, 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 9.18. BUILDING PERMIT INFO: BLDG 7 ELECT I— PLUMB " I MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: ADD 655 SQ FT TO KITCHEN, BEDROOM & BATH STRUCTURAL 7/22/10- REV#I;REVISE ON 2 SHEER -WALL, ONE FROM 240" INTO 1.8' SHEERWALL & THE OTHER FROM 5'6" INTO 5'0" SHEERWALL Sq. Ft Floor Area: I Valuation: $150000 APN Number: 342141 l 1.00 I Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: `JlDate: RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof s installed without first obtaining an inspection, 1 agree to remove all new material for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 22555005�25533, and 25534. Owner i CONSTRUCTION. AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name r Lender's Address ARCHITECT'S DECLARATION Signature Date I understand my plans shall be used as public records. CITY OF CUPERTINO 1�1 FEE ESTIMATOR - BUILDING DIVISION DATE: REVIEWED BY: 4wADDRESS: APN: BP#: *VALUATION: $100 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: OVER THE COUNTER. Q Yes 0 No APPLICATION 1 R3SFDADD/REM TYPE: MECHANICAL Q Yes Q No PLUMBING Q Yes Q No ELECTRICAL Yes 0 No W a O� 3� OCCUPANCY TYPE: TYPE CONSTR. FLR AREA s .ft. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,III-B,Iv,v-B 0 $0.00 $0.00 TOTALS: 0 $0.00 $0.00 NOTE: These fees are based on the vreliminary information available and are onlv an estimate. Contact the Devt for addn I info. FEE ITEMS (Fee Resolution 09-051 f fl, 7/1 %09) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:0 Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction "I"-, Acoustical Fee: © Yes Q No $0.00 0 0 Work Without Permit? Q Yes (F) No $0.00 Planning Fee: $0.00 Select a Non -Residential Building or Structure 0 Strong Motion Fee: IBSEISMICR $0.50 = hrs $252.00 Standard Hourly Rate Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $1.501 $252.00 TOTAL FEE: $25150 Revised: 6/30/2010