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10020061 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22964 LONG DOWN RD CONTRACTOR:TAVARES CONSTRUCTION PERMIT NO: 10020061 OWNER'S NAME: MOSSOTTI VICTOR G ET AL 2333 CORY AVE DATE ISSUED:02/11/2010 1ER'S PHONE: 4088368235 SAN JOSE,CA 95128 PHONE NO:(408)472-2018 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.# MECH r— RESIDENTIAL r— COMMERCIAL Contractor Date JOB DESCRIPTION:SFR REPLACE LIKE FOR LIKE 100 AMP BOX 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:$100 1 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:34240022.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 D YS FRO AST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply ��1 with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: ! Date: 9.18. Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this 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 permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized agent: _ C I ( ( 0 Compensation laws of California. If,after making this certificate of exemption,I 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 I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name correct.I agree to comply with all city and county ordinances and state laws relatin; to building construction,and hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save *unify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION ,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature) Date 2 'I I l' CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34240022 . 00 DATE ISSUED. . . . . . . : 02/11/2010 RECEIPT #. . . . . . . . . BE000009733 REFERENCE ID # . . . : 1CO20061 SITE ADDRESS 2: 964 LONG DOWN RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER MOSSOTTI VICTOR G ET AL ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2652 RECEIVED FROM . . . . : K=LEEN MOSSOTTI CONTRACTOR . . . . . . . : SCOTT TAVARES LIC # 31516 COMPANY TAVARES CONSTRUCTION ADDRESS 2:333 CORY AVE CITY/STATE/ZIP . . . : S:kN JOSE, CA 95128 TELEPHONE (408) 472-2018 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- - 1BCBSC VALUATION 100 .00 1 . 00 0 .00 1 . 00 0 . 00 1BSEISMICR VALUATION 100 . 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 85 .50 0 . 00 85 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 85 . 50 07395B --------------- TOTAL RECEIPT 85 . 50 .. O v V CITY OF (,UPERTINO w/ CUPEk ANO GENERAL, BUILDING PERMIT APPLICATION FORM APN# Date: (v, A CJS�r- �'•. ©ak5 Building Address: L� y L r�� a r� `� �, C n C) Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes U No HOA: Exterior work only) Yes ❑ No ❑ If es, rovide letter from HOA Phone#: eft q n� A�� Z 3 .5 Owner's Name: 3`3 S Contract Phone: r_LU CC) [+ i ' vQf -S Fax: 2 — ZO ( Contractor License#: i 3 Cupertino Business License#: Contact: W C. 21L Phone: y,i,�c ��m.� �e l'� � � � 4 6 •-3�i 9 5 (" 5 0 '3 2�j— c, + ax: S y Residential H Job Description: 1+ �0.ur�ctE od I a C' ! " r Building Permit Info: Bldg ❑ Elect Q-- Plumb ❑ Mech ❑ Type of Construction(Usage Class): Occupancy Type: II/III/V-A 1-A, 1-B ❑ ❑ Valuation: - Square Footage: Project Size: Ex ress �---J3t�ndard ❑ Largo❑ 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.builditt reen.or Revised 07/14/09 { CITY OF CUPERTINO Cin OF GENERAL BUILDING APPLICATION CUPEkTINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacer-ent windows/sliding glass B door (ea 3 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) IEPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing;Permit Fee P l ELCPLNCK Stand Arne Electric Pln Ck(hourly) E 1MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standarc.Plan Check(when no E/M/P) B when not over counter) hourl -s land alone 1BCBSC Cal Bldj; Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1TRAVDOC Travel &Documentation B 1 BUSLIC BusineE s License B 5 of 5