09110010 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 853 LONNA LN CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09110010
OWNER'S NAME: DAVIS D D 1986 REVOCABLE LIV T DATE ISSUED: 11/02/2009
IER'S PHONE: 4089308967 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION Iw F
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# F F
MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE BATH TUB&REPLACE W/SHOWER
(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 Sq.Ft Floor Area: Valuation:$7500
performance of the work for which this permit is issued.
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:35919027.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save 180 D YS FROM LA T 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: ate:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain.a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by 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
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall Owner authorizednt:
not employ any person in any manner so as to become subject to the Worker's Date:
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 CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
1 certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating Lender's Address
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
it' -unify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses w ich may accrue against said City in consequence of the I understand my plans shall be used as public records.
giwiting of this pe rt.Additionally,the applic t understands and will comply
with all non-poi source regulations pe e u ertino Municipal Code,Section Licensed Professional
9.18. /f
Signature Date /��
CITY OF CUPERTINO
4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35919027 . 00
DATE ISSUED. . . . . . . : 11/02/2009
RECEIPT #. . . . . . . . . BS000009104
REFERENCE ID # . . . : 09110010
SITE ADDRESS . . . . . : 853 LONNA LN
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER DAVIS D D 1986 REVOCABLE LIV T
ADDRESS . . . . . . . . . . : 853 LONNA LN
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4324
RECEIVED FROM . . . . : SUSAN L DAVIS
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 7, 500 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 7, 500 . 00 0 .80 0 . 00 0.80 0 . 00
1PPERMITFE 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 .80 0. 00 85.80 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 85 .80 #2497
---------------
TOTAL RECEIPT 85.80
k J CITY OF CUPERTINO
CUPE�TINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 5 /-- t —U c) 7— 00 Date: A)n a J Ci
Building Address: ,
S_3 Lv,,nc, "c ie,
Mailing Address (if different from building address):
vci M
Are Hazardous Materials being used as part of this project? Yes 0 No F1 A0 1 ,4
HOA: Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA N
Owner's Name: Phone#:
Contractor: �-, I / Phone: L
Fax: _
Contractor License#: ?0,35_ �3
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial
Job Description: TA-6
Building Permit Info:
Bldg ❑ Elect ❑ Plumb'Q Mech ❑
Type of Construction (Usage Class): Occupancy Type: 2
1-A, 1-B E] II/III/V-A E] II/III B, IV-HT,V-1—�- �`�
Valuation: ?3--yT Square Footage: S 0
Project Size: Express ❑ Standard ❑ 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.buildit2reen.org
Revised 07/14/09
I alt, CITY OF CUPERTINO
CU
CITY
OF O GENERAL BUILDING APPLICATION
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 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
1PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck(hrly) M
1PLMBLNCK 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
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
/ 1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1 BUSLIC Business License B
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