13050038 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10136 LEBANON DR CONTRACT0R TRU-Tn RF DETERMINED PERMIT NO:13050038
OWNER'S NAME: PULIMOOTIL PHILIP M AND PHILIP ANNA � C„ S DATE ISSUED:05/06/2013
OWNER'S PHONE: 5105857050 CQ PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
�,,1,�� / �j�j BUILDING PERMIT INFO: BLDG F ELECT I— PLUMB
License Class Lic.#_ / 6 0-9
MECH F RESIDENTIAL r COMMERCIAL
Contractor r ate
I hereby affirm tha I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APPLY 2,000 SQFT STUCCO TO EXISTING SINGLE FAMILY
(commencing with Section 7000)of Division 3 of the Business&Professions DWELLING
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 Sq.Ft Floor Area: Valuation:$14500
permit is issued.
APPLICANT CERTIFICATION APN Number:34214022.00 Occupancy Type:
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
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Date
Issued by--
. r �r )�
Signature Date � �
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first_obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: _ Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). i:'
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three I I :),
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined'by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Cddes Sections 25505,25533,and 25534.
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 Owne or an to ' edA4:
forthwith comply with such provisions or this permit shall be deemed revoked. Date: 6_ I
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
05
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•building(&cupertino.org
❑NEW CONSTRUCTION ❑:.ADDITION ❑ ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS r 0 0 2 �. I y-- .® \ _P� APN# '� �- 6
j yr/ Iv ,_,
OWNERNAME I t �AP i O r r��— E-MAIL
-01
STREET ADDRESS � ^ r"1" C 1 � FAX
CONTACT NAME PH NE E-MAIL
STREE CITY, CJ`��i Ci9 t J 1 FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICE $ LICENSEVE BUS.LIC#
COMP NAME E-MAIL FAX
CITY,S,69 ,ZIP\ ��( ' ,A �1 PHO
ARCHITECT/ENGINEER NAME LICENSE NUMBER (T/ J l BUS.LIC# b
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
W�� l
C-0
EXISTING USE PROPOSED USE CONSTR.TYPE I #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
AREA NEW FLOOR DEMO TOTAL
AREA
AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODELAREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL.DECK/PORCH AREA GARAGE AREA: U DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? []NO ADDITION? [:]NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF .IS THE BLDG AN ❑YES 'RECEIVEDBY:81 TAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVALLETTER EICHLER HOME? ❑NO
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I Aave read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building con truc n. I audArize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: ✓ — K> — '��
SUPPLEMENTAL INFORtATION QUIRED PLANCHECKTYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for OVER-THE-COUNTER 17r BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARIi ElPuBLIC WORKS
form if any Hazardous Materials are being used as part of this project. p LARGE ❑ FIRE DEPT'
_Copy of Planning Approval Letter or Meeting with Planning prior to 0' MAJOR ❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10136 lebanon dr DATE: 05/06/2013 REVIEWED BY: bobs.
191APN: BP#: *VALUATION: 1$14,500
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PENTAMATION 1GENRES
PRIMARY SFD or Duplex PERMIT TYPE: A
USE:
WORK a I 2000 s.f. stucco to existing sfd.
SCOPE
w
m
u a
leclr.Plan C:'heck Plurrrb.Plurr Check Elec:.Plan C"heel,
Illech.Permit Fee: Plumb.Permit Fee: Elec.Permit Fee:
Other Afech.Insp. Other Plumb Insp. Li
Other Elec.Insp.
/tech.Insp.Fee: Plumb.Irrsp.Fee: Elec.Insp.Fee:
p2Ld
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the preliminarp information available and are only an estimate. Contact the Dept for addn'l info
[FEE ITEMS (Fee Resolution 11-053 E . 7ff 11112) FEE QTY/FEE MISC ITEMS
an Check Fee: $0.00 2,000 s.f. Restucco
ppl.PC Fee: Q Reg. Q OT T 0.0 hrs $0.00 $603.00 1STUCOAPP
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp.Fee-.0 Reg: Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax:
Administrative Fee
Work Without Permit? ®Yes Q No $0.00
Advanced Planniniz Fee: $0.00 Select a Non-Residential G
Building or Structure 0
Travel Documentation Fees: I A
Strong Motion Fee: 1BSEISMICR $1.45 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$2.45 $603.00 x $605.45
W N Revised: Ni2g/2013