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10050108CITY OF CUPERTINO P UILDING PERMIT BUILDING ADDRESS: 10355 STERN AVE ^ VNER'S NAME: MIRO KURTICH —WNER'S PHONE: 4082463881 ❑ LICENSED CONTRACTOR'S DECLARATION License Class / terLie• # / "I S Contractor i P A)d 4/ �/Date I 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. 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. 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 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- i ource regulations per the Cupertino Municipal Code, Section 9.18. Date 'Zi gnature I ❑ OWNER -BUILDER DECLARATION COPITRACTOR: TBD - TO BE DETERMINED PERMIT NO: 10050108 DATE ISSUED: 05/11/2010 PHONE NO: 101' DESCRIPTION: RESIDENTIAL LJ COMMERCIAL REMODEL 231 SQ FT TO KITCHEN, REPAIR OVERHANG SABLE END RE -ROOF 30 SQUARES Sq, Ft Floor Area: Al'N Number: 37510053.00 hereby affirm that I am exempt from the Contractor's License Law for one of he following two reasons: as owner of the property, or my employees with wages as their sole compensation, vill do the work, and the structure is not intended or offered for sale (Sec.7044, lusiness & Professions Code) , as owner of the property, am exclusively contracting with licensed contractors to :onstruct the project (Sec.7044, Business & Professions Code). I 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 m 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. Valuation: $210000 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: 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 ,ipon the above mentioned property for inspection purposes. (We) agree to save ndemnify 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 -poi e regulations per the Cupertino Municipal Code, Section 9.18. Date -51/1 Signature RE -ROOFS. It roofs shall be inspected prior to any roofing material being installed. If a roof is i rstalled without first obtaining an inspection, I agree to remove all new materials for i ispection. I ignature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE [ 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 I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino o Municipal 255 ode, Chapter 9.12 and the Health & Safety Cod 5 10 5, DaterOwner or authorized agent: 7 CONSTRUCTION LENDING 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 Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10355 STERN AVE CONTRACTOR: TBD - TO BE PERMIT NO: 10050108 DETERMINED OWNER'S NAME: MIRO KURTICH DATE ISSUED: 05/11/2010 OWNER'S PHONE: 4082463881 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALEI License Class Lic. # 75A (6S % REMODEL 231 SQ FT TO KITCHEN, REPAIR OVERHANG A� / Ly GABLE END RE -ROOF 30 SQUARES Contractor lkr J0,4A) Date (13 /�" 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 Sq. Ft Floor Area: Valuation: $210000 performance of the work for which this permit is issued. l 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 APN Number: 37510053.00 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 FROM 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 granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non- ource regulations per the Cupertino Municipal Code, Section 9.18. % RE -ROOFS: Signature Date S "% I ' All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ 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 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have 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 material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Cod5505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner or authorized agent: Dater 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 ofCalifomia. If, after making this certificate ofexemption, I CONSTRUCTION LENDING AGENCY 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. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender'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 upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 -poi a regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date 11I CITY OF CUPERTINO CITY OF CUPERTINO ADDITION/REMODEL PERMIT APPLICATION FORM I oCf� b 10 k APN #'375,- lo - 0 53. 0/C_1 Date: D 6//,D/",9D> t Is a 2°d unit being added? Yes ❑ No If yes, please fill out the permit application for 2" unit. Building Address: /6 355 9 ic"Rl Mailing Address (if different from building address): Owner's Name: Phone # Contractor: MIA --6:- y Phone # Fax # 4 D 6" - -Contractor Contractor License #: Cupertino Business License #: Contact: �- Phone #: �-0 6— Fax #. Building Permit Info: Bldg. 0 Elect. F] Plumb. [(],- Mech. [_q-----___ Hillside ❑ Job Description: Addition -What is being added?(Be Specific): N/ - What is being remodeled (not including addition)? p �QornoG ' � / l G%i �n t Re � � Cc� Ve_&,, � ��c. Gnl e Includes - esE ,& o I list a CD Remodel I c udes Re Roof: Yes © N ❑ ��s number of squares � Remodel Includes Structural: Yes [i]' No ❑ Do you have the pre -application planning approval? Yes ❑ No If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV -HT, V -B [�-�'' --3 Valuation: 0 o Please check this box if the project is a second -story addition ❑ Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, Green Building Points Achieved: include in plan set & the sheet index. ***For Office Use Only*** Over -the -Counter ❑ Revised' 07/06/09 r �.r CITY OF CUPEkTINO CITY OF CUPERI'INO ADDITION/REIVIODEL FEE SCHEDULE Quantity Sq Ft Fee ID Fee Description ,Fee Group Permit Type ADDITIONS 1R3SFDADD 1PLLONGRNGR Long Range Planning/Residential PL 1 R31NSP Dwellings Inspections B 1R3PLNCK Dwellings plan check B 1 R3REPINSP Dwellings Repeat Inspection B 1 R3REPPLNC Dwellings Repeat Plan Check B 1 R3HINSP Dwellings Hillside inspection B 1R3HPLNCK Dwellings Hillside plan check B 1 R3HREINSP Dwellings Hillside Repeat Inspection B 1R3HREPLNC Dwellings Hillside Repeat Plan Check B 1 R3ALTINSP Dwellings Alternate Materials Inspection B 1R3ALTPLNC Dwellings Alternate Materials Plan Check B 1 PCESS Cesspool P 1PPRSEWG Ea. Private Sewage Disposal System P�. 1PRSEWER Sewers P 1 BPSPRINK Lawn Sprinkler/Backflow P 1BPWSVCS Main Water Service P 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICRE SeismicResidential B J 1RER00FRES Residential Re -roof Each 1:00 SF B CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: PERMIT OWNER'S NAME:. Z PHONE # D — D DS— GENERAL CONTRACTOR: C7,9 % BUSINESS LICENSE # 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 AL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. / 1 am not using any subcontractors: S r I l na ure Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date 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