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10020083 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20282 PACIFICA DR CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10020083 OWNER'S NAME: MATT BORDONI DATE ISSUED:02/16/2010 ER'S PHONE: 6505330936 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT[— PLUMB 7 � License Class !� Lic.# /�9� / 2 —! MECH[— RESIDENTIAL r COMMERCIAL Contractor Date -2 -14 —(0 I hereby affirm that am lice 'ed under the provisions of Chapter 9 'OB DESCRIPTION:REMODEL(E)BATH(85SQ);LORETZ CONST PD FOR BSL (commencing with Section 70 00)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. q,Ft Floor Area: Valuation:$14000 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. E.PN Number:36944016.00 Occupancy Type: 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 upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAROM LAST 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 with all non-point source regulation per the Cupertino Municipal Code,Section 9.18. Issued by: �-� �� Date: Signature Date ^(0 RE-ROOFS: Lr OWNER-BUILDER DECLARATION /,II 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 hereby affirm that I am exempt from the Contractor's License Law for one of i ispection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, c ignature 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 permit is issued. 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 I lealth&Safety Code,Sec' ns 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner�Opr --/0Compensation laws of California. If,after making this certificate of exemption,IDate: �j 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. ONSTRUCTION LENDING AGENCY I hereby affirm that the a is a construction lending agency for the performance of work's APPLICANT CERTIFICATION f>r which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is bender's Name 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 bender's Address upon the above mentioned property for inspection purposes.(We)agree to save -nnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION giking of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. w itia all non-point source regulatio s per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date 2�r � CITY OF :�UPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36944016 . 00 DATE ISSUED. . . . . . . : 02/16/2010 RECEIPT #. . . . . . . . . BS000009751 REFERENCE ID # . . . : 10020083 SITE ADDRESS . . . . . : 20282 PACIFICA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MATT BORDONI ADDRESS 1335 GRANT RD CITY/STATE/ZIP . . . : LOS ALTOS CA, CA 94024-7152 RECEIVED FROM . . . . : RICHARD THOMAS LORE 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 14, 000 .00 1. 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 14, 000 . 00 1.40 0 . 00 1 .40 0 . 00 1BUSLIC FLAT RATE 1. 00 114 . 00 0 . 00 114 . 00 0. 00 1REMRESBAT SQ FEET 84 .50 570 . 00 0 . 00 570 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 686 .40 0 . 00 686 .40 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 686 .40 MC --------------- TOTAL RECEIPT 686 .40 CITY OF t--.'UPERTINO ADDITION/REMODEL CUPEkTINO PERMIT APPLICATION FORM APN# 60- Date: _ f� Is a 2 nd unit being added? Yes ❑ No If yes, please fill out the permit application for 2" unit. Building Address: 2-O 2 93 _ c-_ J G Mailing Address (�if different from building address): t �� _ Gr9 �� -z- *, f Owner's Name: Phone# : M ATT_ D P_D a wI 66�0 Contractor: Phone#: l0� Z G!U +i'-� 5��T/ dam Fax #: -56 Contractor License#: .3 Lrg /-7 2— Cupertino Cu ertino Business License#: Contact: Phone#: lam-l G l,< Zo �c ( Z— Fax#: a `- b 5<0 Building Permit Info: Bldg. ❑ Elect. F!,S" Plumb. �jc " Mech. ❑ Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? Remodel Includes Re-Roof: Yes ❑ No If yes list number of squares Remodel Includes Structural: Yes ❑ No .� Do you have the pre-application planning apr roval? 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 OZI,SJ Other Type of Construction(Usage Class): Occupancy Type: I-A, 1-13 ❑ II/III/V-A ❑ IUIII B, IV-HT,V. Valuation: Please check this box if the project is a I"�, second-story addition ❑ Project Size: Express Standard ❑ Lar e❑ 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 0 Revi d 07/06/09 CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft DECKS 1R3SFDADD OR 1R3SFDREM 1 DECKWOOD Deck (Wood)-F ach B (Each) 1 DECKRAIL Deck Railing-Each B (Each) GARAGES 1R3SFDADD OR DETACHED 1R3SFDREM 1GARDTW<=1K Wood Frame up to B 1,000 SF (each; 1 GARDTM<=1 K Masonry up to 1,000 SF B (each) 1BCONSTAXR Construction Tax Res (new detached garage) PATIO'S OPEN 1R3SFDADD OR 1R3SFDREM 1PATIOWOOD Wood Frame up to 300 B SF 1 PATIOMETAL Metal Frame up to 300 B SF 1 PATIOOTHER Other Frame ur to 300 SF B PATIO'S CLOSED 1R3SFDADD OR & SUN ROOMS 1R3SFDREM 1PATIOENCLW Enclosed Wooc up to 300 B SF 1PATIOENCLM Enclosed Metal up to 300 B SF 1PATIOENCLO Other Enclosed Patio up B to 300 SF 1 COVPORCH Porch Covered-Each B (Each) REMODELS 1R3SFDREM 1 REMRESKIT Kitchen Remoc el up to B (Deduct "$"for ea plan 300 SF check Cly s 1REMRESBAT Bath Remodel lip to 300 B " �S SF 1 REMREOTH Other Remodel up to 300 B " SF CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1MECPLNCK Stand Alone W-chanical M Pln Ck(hourly 1PLMPLNCK Stand Alone Plumbing P Pln Ck (hourly) 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES 1 Commission Fc e 1BSEISMICRE Seismic Residential B 1TRAVDOC Travel &Docunentation B 1BUSLIC Business Licen3e B .l i r � , I U 4i f V 14 I � E '{ r �" j ,joc� i 1 i 1. 1 1