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09120025 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 10156E ESTATES DR CONTRACTOR:HALE CREEK PERMIT NO:09120025 CONSTRUCTION,INC. OVINER'S NAME: BURNS ROBERT C AND SHERRY O TR 23500 CAMINO HERMOSO DR DATE ISSUED: 12/03/2009 6 iER'S PHONE: 4082554979 LOS ALTOS HILLS,CA 94024 PHONE NO:(650)941-4836 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB License Class Lic.# MECH f- RESIDENTIAL f- COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:PANEL UPGRADE TO 200AMO (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:$500 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:36907033.00 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 DAYS FROM 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 regulations per the Cupertino Municipal Code,Section Issued 9.18. 1 Sip-ature 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,1 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) I,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). 1 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. 1 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 pen-nit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the P Health&Safety Code,Sections 25505,25533,and 25534. 1 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 Ow r r a rized agent: Compensation laws of California. If,after making this certificate of exemption,I ,.z ` Date: Z'0 > ',?eO 7 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 U, he above mentioned property for inspection purposes.(We)agree to save tify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION 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 ��.c L Date Signature /C t✓ CITY Ott CITY OF CUPERTINO 0112,00�_�2 ADDITION/REMODEL UPERTINO PERMIT APPLICATION FORM APN # Date: f Is a 2" unit being added? Yes ❑ No ❑ If yes, please fill out the permit application for 2" unit. Building Address: 10 ( 5(0 E7 E. - ��"_\ Mailing Address (if different from building address): Owner's Name: Phone # S 14re - x`55 - -2,�J17 Contractor Phone Fax #: / Z I C.) Contractor License#: Cupertino Business License #: M736 Contact: / Phone #: Fax #: Building Pit Info: Bldg. ❑ Elect. Z3-' Plumb. ❑ Mech. ❑ Hillside ❑ Job Description: Addition-What is being added?(Be Specific): CA �J RAO 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 approval? Yes ❑ No ❑ If yes,. lease provide a copy of your planning approval letter_ planners name:_ Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction(Usage Class): Occupancy Type: 1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Pg (z —3 Valuation: -S'Z o Please check this box if the project is a second-story addition ❑ Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Please complete relevant portion of the Green Building Checklist& attach it to the application or if appli,:able, Green Building Points Achieved: include in plan set & the sheet index. ***For Office Use Only*** Over-the-Counter ❑ Revised 07/06/09 CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Descriptio:ri Fee Group Permit Type Sq Ft 1REMRES2 Remodel Residential B Greater than 1000 sq ft 1REMRES3 Remodel Residential B Greater than 2500 sq ft. IREROOFRES Residential Re-roof Each B 100 SF REMODEL PLNCK 1 STPLNCK(1-3 for Standard Plan Check B NOT FOR OVER THE remodel) COUNTER PLAN CKS. WINDOW/SLIDING 1R3SFDREM GLASS DOOR 1 WINREP Replacement windows B (ea 8 windows) 1WINNEWNSTR New Window(non- B structural) 1WINMEWSTR New Window (Structural B Shear Wall/Masoj ) 1WINBAYSTR Bay Window (Strictural) B SKYLIGHTS 1R3SFDREM 1 SKYL<10 SF Skylight less than 10 sf B 1 SKYL>10SF Skylight greater than 10 B sf or structural 1STAIRS Stairs-first flighth-,a addt'l B 1 EPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P IELCPLNCK Stand Alone Electric Pln E Ck(hourly) CITY OF (--'.UPERTINO ADDITONIREMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1 MECPLNCK Stand Alone M-1chanical M Pln Ck(hourly 1 PLMPLNCK Stand Alone Pl imbing P Pln Ck(hourly`, 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1TRAVDOC Travel &Documentation B 1BUSLIC Business License B 0- T © Community Development gay' 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 ;UPEkTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: (5,.1 4,L, -'1e w•WC-r VAkVXCC PHONE # b GENERAL CONTRACTOR: Hele cre.OA 4- (6v'64 FAX # 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 Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile O r/Contractor Signature Date