10040115 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18911 TUGGLE AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10040115
OWNER'S NAME: LOU ANN FLAUGHER DATE ISSUED:04/19/2010
.VER'S PHONE: 4087251372 , PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONI—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class S Lic.# q 5\Sfl3f—
MECH RESIDENTIAL COMMERCIAL
Contractor,WAEg� X29!-MAID Date t4(%1[1 b
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RENEW ELECTRICAL PANEL&WIRING W/MODERN
(commencing with Section 7000)of Division 3 of the Business&Professions MATERIAL.
UPDATE GFCI&AFCI AS NEEDED.NO ADDED LOAD,NO
Code and that my license is in full force and effect. NEW DEVICES,SWAP"LIKE FOR"LIKE"**SEE NOTES**
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. Sq.Ft Floor Area: Valuation:$11690
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:37533064.00 Occupancy Type:
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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date4( (� Issued by: Date:
G OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
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. Ow er or authorized�ge
Date: O
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
mify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature � Date � �O
Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 37533064 . 00
DATE ISSUED. . . . . . . : 04/19/2010
RECEIPT # . . . . . . . . . BS000010211
REFERENCE ID # . . . : 10040115
SITE ADDRESS 18911 TUGGLE AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : LOU ANN FLAUGHER
ADDRESS 18911 TUGGLE AVE
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM JAMES ECKERMAN
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 11, 690 .00 1. 00 0 . 00 1 . 00 0 . 00
1BREMRECEP NO. OUTLETS 40 . 00 82 . 00 0 .00 82 . 00 0 . 00
1BSEISMICR VALUATION 11, 690 .00 1.20 0 . 00 1 .20 0 . 00
1EPERMITFE FLAT RATE 1 . 00 42 . 00 0 .00 42 . 00 0 . 00
1ERT<200 UNITS 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 210 .20 0 . 00 210 .20 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CASH 210 .20
---------------
TOTAL RECEIPT 210 . 20
C
CITY OF CUPERTINO
CITY Of
CUPEf�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # _ Date:
Building Address:
-f ('5(sL eCAVA
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work only) Yes ❑ No [K If yes, provide letter from HOA
Owner's Name: Phone#:
Contractor: Phon :�3 k ZSZ-r��18
`S' ��,_V_AA Atr Fax: 3► qv Z�53
Contractor License#: S's ISO 3
Cupertino Business License#: ?Ci-3Di1 SSBI(F
Contact: 11 Phone:Qi3l)2.52 d15-4
�►tMES E�_NW A N Fax: %Si Lf o 1 --2,6S 3
Residential_®__ Commercial ❑
Job Description: ��E,nJ 6%_ZCr1ZAC-44 R>ANe;;�- AaO „a\VIIrJCr WCk" Mnti
MP,-\-eNZ"A L-. ��OA�c' csC-r-V A"�:, fl r c._1 ,AS 0 rcXrbEQ . NO A Mc^b t�040 , Wa
5•,.JA P "u«� troll tr►W.
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
I-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-
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, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buflditgreen.org
Revised 07/14/09
CITY OF CUPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPEf�T1NO FEE SCHEDULE
Fee Description Fee Permit Type
Quantity/Sf Fee ID p 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)
1WINMEWSTR New Window-structural shear B
wall/masonry (includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
IPPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric 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 Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
/ 1BCBSC Cal Bldg Standards Commission Fee B ALLP RMIT
IBSEISMICR Seismic Residential
B T PES
/
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
/ B
IBUSLIC Business License
z 200
5 of 5
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Building Department
City Of Cupertino
[011 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: ►$ I vl A PERMIT# h9 'Ve �
OWNER'S NAME: (�pAAO t1i 'F PHONE# O I3g2-
GENERAL CONTRACTORS �hc"e�1r� BUSINESS LICENSE # 1J
ADDRESS:S&%ir o I.DS lbs C"950—S:S CITY/ZIPCODE: L & GA&03 So3
*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 ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. "'1 l% C, ( `O
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
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