13040133 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS. 11128 SUTHERLAND AVE CONTRACTOR:FIVE STAR WINDOWS PERMIT NO:13040133
OWNER'S NAME: KOPP ROGER G AND RIENA 1450 DELL AVE STE C DATE ISSUED:04/17/2013
OWNER'S PHONE: 4088024371 CAMPBELL,CA 95008 PHONE NO:(408)370-3331
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL
License Class \ Lic.#�'.�`Zg3 REPLACE 14(E)WINDOWS,1 (E)SLIDING DOOR&2(E)
PATIO DOORS
Contractor C--N -S�rrr '�hy`d11S Date
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. Sq.Ft Floor Area: Valuation:$18500
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 APN Number:35617058.00 Occupancy Type:
permit is.issued:
APPLICANT CERTIFICATION
I certify that.1 have read this application and state that.the.above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.:I agree comply with all city and. WITHINunty 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 O AST 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 sued b Date l
granting bf this permit: Additionally,the applicant understands and will comply
with all non-point source'regulations per the Cupertino Municipal Code,Section
9.18 I
f RE-ROOFS:
Signature' E l"r �� " Date 4 3 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 newmaterials fof
inspection.
0 . OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I here 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
I;as owner of the property,or my employees With,wages as their sole compensation,
will do,the work,and the structureIis'not intended or offered for sale(Sec.7044,
Business&,Professions Code)
I,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 YVorkei's,Coinpensation Insurance,as provided for by the Health&Safety Code,Sectio 55 5,25533, ¢d 25534.
Section 3700 of the Labor Code,for! performance of the work for which this Owner or authorized agent: �i /�— Date:y t- ".'
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 iso as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California.' It after•making this certificate of exemption,I
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 readis 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.Aove',memioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keepl barmless the City of Cupertino against liabilities,judgments,
costs',an&expenses which;.may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this pemut Additionally;',the applicant understands and will comply
with all non point source the regulations;per Cupertino Municipal Code,Section Licensed Professional
illi I. �
-
Sigriature Date
CONSTRUCTION PERMIT APPLICATION \�
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTiNO (408)777-3228•FAX(408)777-3333•building(a1cupertino.oro `�O
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS\X1zh O 5p
OWNER NAME !?nGIJ �� P•HO �dtrs
E-MAIL
STREET ADDRESS � , ^, CITY,STATE(f�k �0N0 v` ' ots Ot FAX
CONTACT NAMEU6 ,e '. ^ PHQTIE _ - � �``� E-MAIL
STREET ADDRESS 1 ` CITY, T E,ZIP �^ C 1 q-y czz FAX
❑ OWNER 11 OWNER-BUILDER OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR N LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME✓ E-MAIL
y,�v v FAX
STREET ADDRESS \�� �M` t ` CITY,STATE,ZIP '/I ��i, PHONE
C�t `►2AqPS 10 -133'1
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK `
EXISTING USE PROPOSED USE CONSTR TYPE I #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NEC AREA
BATHROOM KITCHEN - OTHER
REMODEL AREA REMODELAREA REMODELAREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH
❑ATTACH
I t
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEINGADDED? []NO ADDITION? I []NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN YES RECEIVED BY: - TOTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER E[CHLER HOME? NO -T
�O
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I haLread the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating t ildin tructio a representatives of Cupertino to enter the above-identifi d property for inspection purposes.
Signature of Applicant/Agent: C Date:
SUPPLEMEN INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for El OVER-THE-COUNTER El BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
�' BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 11128 SUTHERLAND DR DATE: 04/17/2013 REVIEWED BY: 7MELISS7A
APN: 35617058 : : BP#: VALUATION:
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY
rQTAMNE.
ON1 GENRES
USE: SFD or Duplex MI
WORK REPLACE 14 E WINDOWS 1 E SLIDING DOOR&2 E PATIO DOORS
SCOPE
w
L1ech.flan heck... Plumb. Plan Check Elec.Plan Check
C
�1ccFr..Permit Fee; Plumb.Permit Fee: Elec. Permit Tee:
Other Alech.Insp. Other Plumb Insp. OtherElec.Insp.
Alech Insp.Tec: Plumb,Insp.Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc). These ees are based on the relimina information available and are onlyan estimate Contact the Dept or addn'l info,
FEE ITEMS(Fee Resolution 11-053 E . 7f/ 11112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F 17-1 # Window/Sliding Glass Door
Suppl.PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $666.00 1 WINREP Replacement
PNIE Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp..Fee- Reg. ®OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative.Fee:
Work Without Permit? 0 Yes No $0.00
Advanced Planning—Fee- $0.00 Select allon-Residential
Building or Structure
Travel Documentation Fees: A
Strong Motion Fee: 1BSEISMICR $1.85 Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC $1.00
$2.851 $666.00 . - $668.85
Revised: 04/01/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C O P E RT I N O Fax:408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT#
OWNER'S NAME: PHONE# q-o'%
GENERAL CONTRACTOR: r, BUSINESS LICENSE#
ADDRESS: �O ) Qk gyW g CITY/ZIPCODEr' .S� \
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL;BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: �� (Z 13
Signature Date
Please check applicable subcontractors and complete the following information:
t/ 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
CA eqsokli
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