09110074I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10181 STERN AVE
OWNER'S NAME. TOM SIDLAUSKAS
NNER'S PHONE: 4089739033
6--"— LICENSED CONTRACTOR'S DECLARATION
License Classy� qq Lic. # 7 0 6—// / 0
Contractor /VD`.1 C%/ _�i� Date (! ( zjO
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.
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.
APPLICANT CERTIFICATION
I 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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
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
with all non -point source regulations per the Cupfrtino Municipal Code, Section
9.18. `
Signature Date (� 2 ��
❑ WNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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.
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
Compensation laws of California. If, after making this certificate of exemption, 1
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.
APPLICANT CERTIFICATION
I 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
to building construction, and hereby authorize representatives of this city to enter
-on the above mentioned property for inspection purposes. (We) agree to save
,emnify 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
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
CONTRACTOR: GUILLEN
PERMIT NO: 091 10074
CONSTRUCTION CO.
10660 CULBERTSON DR
DATE ISSUED: 11/12/2009
CUPERTINO, CA 95014
PHONE NO: (408)725-0782
F_ �.
BUILDING PERMIT INFO: BLDG
ELECT PLUMB
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: IST FLR ADD 2 WINDOWS TO LIVING ROOM,I WINDOW
TO
BEDROOM& OMIT I SMALL WINDOW @2ND FLR. ALL IN ONE
WALL ON ONE SIDE OF HOUSE
Sq. Ft Floor Area: I Valuation: $300
APN Number: 37511065.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by. Date:
RE -ROOFS:
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
inspection.
Signature of Applicant: _ Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and
d 534.
Owner or authorized agent: Date:
CONSTRUCTION LENDING AGENCY
1 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.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
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Permit Number 09110074
Status
C - Closed
ContractorDefined Fields
Master Number
IQ1 Notes
Project
-
-
Apply Date `
11/12/2009
E Operator
Permit Issue Date
11/12/2009
Operator
Certificate Issued
12/03/2009
Operator
Certificate Type
CO -CERTIFICATE OF OCCUP
Certificate Number
0
Address' I 10181 STERN AVE
City/State/Zip CUPERTINO
0 APN 37511085.00
I� Unit
patg i �.,, =i r��ii.,Infnrrrriur
patg I Owner Name xl TOM SIDLAUSKAS
suety Use Default ❑
Address Home 10181 STERN AVE
City/Stake/Zip CUPERTINO
Permit ` Property
Zoning Applicant
ContractorDefined Fields
Permit Details
Permit Type'
1GENRES
IQI
RESIDENTIAL GENERAL BUILDING
Usage Class "
II/III B,
IQI
II/III B, IV -HTV -B NEW
Applied Value '
300
SQUARE FT.
0
Calculated Value
01-31
US C-404 Type
434
IQI
ALT: RESIDENTIAL
Permit Form"
AUTOPERM- PERMIT
Ownership
1 -Private
Project Size
COUNTER - OVER THE COUNTER
Permit issued 1111212009
Fnhar Fko ni irnncF nr Anw cr orW rnnr &innc Fnr Fhic narmiF
CA 95014
CA 95014
Purpose/Special Conditions
1ST FLR ADD 2 VINDOVS TO LIVING ROOM,1 VINDOV TO
BEDROOM& OMIT 1 SMALL VINDOV @2ND FLR- ALL IN ONE
WALL ON ONE SIDE OF HOUSE
SCANNED/ FILMED 8/2011
[]Add Default Text
lal
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10181 STERN AVE.
CONTRACTOR: GUILLEN
PERMIT NO: 091 10074
CONSTRUCTION CO.
OWNER'S NAME: TOM SIDLAUSKAS
10660 CULBERTSON DR
DATE ISSUED: 11/12/2009
OWNER'S PHONE: 4089739033
CUPERTINO, CA 95014
PHONE NO: (408)725-0782
LICENSED CONTRACTOR'S DECLARATION
F_ � F
O �/ ^
License Class Llc. # /
BUILDING PERMIT INFO: BLDG ELECT PLUMB
� � I
�� qq % /�,, �
MECH RESIDENTIAL COMMERCIAL
Contractor !VO`e ( bC%/ Z/I ✓d Date (% ! Z�
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: IST FLR ADD 2 WINDOWS TO LIVING ROOM,I WINDOW
(commencing with Section 7000) of Division 3 of the Business & Professions
TO
BEDROOM& OMIT I SMALL WINDOW @2ND FLR. ALL IN ONE
Code and that my license is in full force and effect.
WALL ON ONE SIDE OF HOUSE
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: $300
performance of the work for which this permit is issued.
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: 37511065.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 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
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST 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. Date:
with all non-point source regulations per the Cupfrtino Municipal Code, Section
9.18.
��
RE-ROOFS:
Signature Date t/ +I r(2
All roofs shal I 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
inspection.
E]WNER- BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
constrict the project (Sec.7044, Business & Professions Code).
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety.Code, Section 25532(a) should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
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
the Health & Safety Code, Sections 25505, 25533, and d 5534.
Owner or authorized agent: Date:
permit is issued.
—LL4(C
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, l
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
1 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that 1 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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
1 understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
11� a2
CITY OF
CUPEKrINO
CITY OF CUPERTINO
GENERAL BUILDING
PERMIT APPLICATION FORM
,031100-74
APN #2 7-6/ U Cp .�, d �//bg-
Date: D
Building Address /')
e, !ell
Mailing Address (if different from building ad ress):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work only) Yes ❑ No If yes,
provide letter from HOA
Owner's Name:
Phone #:
Q
/
Contractor*
r— �D
%
Phone: Y
ell >
Fax: 49
-D
Contractor License #: `7 D S-1 7
Cupertino Business License #:
Contact:
C
Phone:
Fax:
Residential ' Commercial Fj
S'
Job Description:A�K' ev' r��'�-d.�W
Building Perm/it Info:
Bldg L9� I Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class):
Occupancy Type:
- 0—T
1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV -HT, V -B
Valu ion: ^�
Square Footage:
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.builditgreen.or2
Revised 07/14/09
a
CITY OF
CUPEkTINO
CITY OF CUPERTINO
GENERAL BUILDING APPLICATION
FEE SCHEDULE
Quantity/Sf
Fee ID
Fee Description
Fee
Permit Type
Group
`1 GENRES or
1 GENCOM
1BBOILERI
For the installation or relocation of ea
M
boiler/compressor to & including 3
horsepower, or ea absorption sys to &
incl 100,000 Btu/h (29.3kw)
1BBOILER2
Installation /relocation of ea
M
boiler/compressor over 3 horsepower
to & incl 15 horsepower, or ea
absorption sys over, 100,000 Btu/h
1BBOILER3
Installation/relocation of ea
M
boiler/compressor over 15 horsepower
to & incl 30 horsepower, or ea
absorption sys over 500,000 Btu/h to
& incl 1,000,000 Btu/h
11313OILER4
Installation/relocation of ea
M
boiler/compressor over 30 hosepower
to & incl 50 horsepower, or for ea
absorption sys over 1,000,000 Btu/h to
& incl 1,750,000 Btu/h
11313OILER5
Install ation/relocation of ea boiler or
M
refrigeration compressor over 50
horsepower, or ea absorption sys over
1,750,000 Btu/h
1BAPPLOTH
For ea appliance or piece of equip
M
regulated by this Code but not classed
in other appliance categories, or for
which no other fee is listed in this
code.
1 ELECINSP
Other Electrical Inspections (per hour)
E
1MECHINSP
Other Mechanical Inspections (per
M
hour)
1PLMBINSP
Other Plumbing & Gas Inspections
P
(per hour)
1 MEETING 1 HR
Application Meeting
B
2 of 5