10040021 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20833 FARGO DR. CONTRACTOR:TBD-JO BE DETERMINED PERMIT NO: 10040021
OWNER'S NAME: NANCY A KATO DATE ISSUED:04/05/2010
VER'S PHONE: 4086552539 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG f- ELECT f- PLUMB
License Class
MECH RESIDENTIAL COMMERCIAL
Contractor Date Tis �0
1 hereby affirm th t I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:90 L.F.LINE FOR HOT TUB(FUTURE)UNDERGROUND
(commencing with Section 7000)of Division 3 of the Business&Professions 50AMP;CONTRACTR PD FOR BUS LIC
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:$1600
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:32630131.00 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 enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree too 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 rmin c consequence the 180 DAYS FROM LAST CALLED INSPECTION.
granting of thi eit. Additionally,the applicant understands and will comply
with all non- of t source regulat'ons per the Cupertino Municipal Code,Section
9.18. _ Issued by: Date:
Signature Date
L, 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 #One QL'a rized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
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
i 7nify and keep harmless the City of Cupertino against liabilities,judgments,
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-p t ource regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
` 0 �,s_11VLicensed Professional
Signature l Date
Ci
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 32630131. 00
DATE ISSUED. . . . . . . : 04/05/2010
RECEIPT #. . . . . . . . . : BS000010097
REFERENCE ID # . . . : 10040021
SITE ADDRESS . . . . . : 20833 FARGO DR.
SUBDIVISION . . . . . . :
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER NANCY A KATO
ADDRESS 20833 FARGO DR.
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : HAYNES BUILDERS
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, 600 . 00 1. 00 0 . 00 1 . 00 0. 00
1BREMMISC FLAT RATE 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00
1BSEISMICR VALUATION 1, 600 . 00 0 . 50 0 . 00 0 .50 0. 00
1EPERMITFE 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 211 . 50 0 . 00 211 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 211.50 #1084
---------------
TOTAL RECEIPT 211.50
o cD �va�
`Sit;.:_, CITY OF CUPERTINO
CITY Of
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date:
Z(P�
Building Address: 1
CA
Mailing Address (if d erent from buil ing 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#: ._
11 r `�'�)
ontrrc r: Phone: (4vt)a Z S- a t
Fax:
Contr6ctor License#:
Cupertino Business License#:
Contact: . , 1 Phone:
Fax: (/vi 372 Z3
Residential ® ommercial El
Job Description:
Building Permit Info:
Bldg ❑ Elect E3- Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A
❑ IUIII B, IV-HT, V-B 1—'.t cA.; L, _
Valuation: Square Footage:
Project Size: Express 12 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.org
Revised 07/14/09
CITY OF CUPERTINO
, I a"��
CUP TY OF O GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Applications (up to 400 sfl B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural she B
wall/masonry(includes plan ck fee)
1 EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1 PPERMITFEE Plumbing Permit Fee P
IELCPLNCK 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-stand 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
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