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10010142 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10910 BARRANCA DR CONTRACTOR:HERSH&DIANA GOLDEN PERMIT NO: 10010142 �.OWNER'S NAME: HERSH&DIANA GOLDEN 10910 BARRANCA DR DATE ISSUED:01/26/2010 4ER'S PHONE: 4087359553 CUPERTINO CA,CA 95014-0102 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ELECTRIC METER SERVICE RELEASE (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 permit is issued. APN Number:32602001.00 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 186 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DA F OM 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 l with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: ' I 2 6� 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&S7fety Co ,Sec'ons 2 5, 33 and 25534. I certify that in the performance of the work for which this permit is issued,I shall _ not employ an person in an manner so as to become subject to the Worker's ` P Y Y P Y J Owner o authorized agent. Compensation laws of California. If,after making this certificate of exemption,I 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 relating 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 nify 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 r th Cupertino Municipal Code,Section 9.18. f-.26_/v Licensed Professional Sig CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32602001. 00 DATE ISSUED. . . . . . . : 01/26/2010 RECEIPT # . . . . . . . . . : BS000009618 REFERENCE ID # . . . : 10010142 SITE ADDRESS . . . . . : 10910 BARRANCA DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : HERSH & DIANA GOLDEN ADDRESS . . . . . . . . . . : 10910 BARRANCA DR CITY/STATE/ZIP . . . : CUPERTINO •CA, CA 95014-0102 RECEIVED FROM . . . . : HERSHEL F GOLDEN CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : HERSH & DIANA GOLDEN ADDRESS . . . . . . . . . . : 10910 BARRANCA DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-0102 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 100 . 00 1 . 00 0 . 00 1. 00 0 . 00 113SEISMICR VALUATION 100 . 00 0 . 50 0 . 00 0 .50 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 ---------- ---------- ---------- ---------- TOTAL PERMIT 85 .50 0 . 00 85 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 85.50 VISA --------------- TOTAL RECEIPT 85 .50 CITY OF CUPERTINO CITY OF CUPEF�TINO GENERAL BUILDING PERMIT APPLICATION FORM APN # Date: Building Address: Mailing Address (if different from building address): Are Hazardous Materials being used as part of t ' project? Yes ❑ No [R HOA: Exterior work onl Yes Ej No If es, pro We letter from HOA Owner' Name: Phone#: Contractor: Phone: Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential;K Commercial ❑ Job Description: lee -e -t s-;ey-il/ c-e 12--e I-e er J--e Building Permit Info: Bldg ❑ Elect [� Plumb Mech ❑ ❑ Type of Construction (Usage Class): Occupancy Type: 1-A 1-B II/III/V-A II/III B IV-HT V-B Valuation: Square Footage: Project Size: Express El —'gGandard ❑ 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.buildit reen.or Revised 07/14/09 ., . . CITY OF CUPERTINO CITY OF GENERAL BUILDING APPLICATION CUPEf�TINO FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1 GENCOM 1 STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry(includes plan ck fee) / 1 EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK 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 1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1 BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1 BUSLIC Business License B L6 0 5 of 5 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CCTV OF Fax(408)777-3333 .:UPEkTINO Building Department JOB ADDRESS: PERMIT # �t c;�r�'{n t r j� i � D l `-d l� v �3 � D � � I OWNER'S NAME: A C R s"ct. GO('0 6-r%j PHONE # 4 U9 - 7 3 5-4I S5 3 GENERAL CONTRACTOR: OR FAX # oe I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: 21 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/C.Q a v�Signature Date