13080151CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10881 S BLANEY AVE CONTRACTOR: ON S ��
PERMIT NO: 13080151
CitiS 7M 0 c77 o!V
OWNER'S NAME: PACIFIC RIM PARK, LLC
DATE ISSUED: 08/21/2013
OWNER'S PHONE: 4082554163
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALS
LICENSED CONTRACTOR'S DECLARATION
License Class Q Lic. # t 22 6 5 !y
STORAGE AREA ONLY - RE -ROOF (E) TORCH DOWN
Contractor 6 til �� i f -�— oto $ 1'�% c���5`ate g 1 l 3
WITH
(N) TORCH DOWN ROOF SYSTEM. ADD (N) TR 1-11 SIDING
I hereby affirm that I am licensed under the provisions of Chapter 9
OVER (E) SIDING
(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: $4800
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: 36934052.00
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
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 ALLED 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
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granting of this permit. Additionally, the applicant understands and will comply
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with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
&I
RE -ROOFS:
Signature Date—q zi
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.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I 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 I 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 I
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, 255;3, an 5534.
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Owner or authorized agent: 1 Date:
permit is issued.
I 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, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I 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 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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I 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
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(Wcupertino.org
CUPERTINO
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PROJECT ADDRESS O St C Q i\ "e ' r '�
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMEI-as
LICENSE NUMBER 22 G �^
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LICENSE TYPE ,/2
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BUS. LIC #
COMPANY NAME tt
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STREET ADDRESS
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CITY, STATE, ZIP CA_ Q s' S -I
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ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK ; ' � n I l' 541!1) t 1!1 w -e (. �L 1 c✓ I -i N S
—WOOD
I 4W�Z ata X 12 3 6o s . �-r 3 �f V,low—
EXISTING USE
PROPOSED USE
CONSTR.TYPE
#STORIES
USE TYPE OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
4 �
AREA
AREA
AREA
NET AREA
BATHROOM
REMODEL AREA
KITCHEN
REMODEL AREA
OTHER
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
[]ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
BEING ADDED? []NO
SECOND STORY ❑ YES
ADDITION? ❑ NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES y
- -- TD I.� VALUATION:
CPC
PLANNING APPL # ❑ NO PLANNING APPROVAL LEITER
EICHLER HOME?
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.
By my signature below, I certify to each of the following: I am the property owner ora prized agent e property owner's behalf I ave read this
is I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
application and the information I have provided correct.
ordinances and state laws relating uilding cons ctio . th.- representatives of Cupertino to enter the abov -identi ed property for inspection purposes.
t
Signature of Applicant/Agent: Date:
SUPPLEME AL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
OVER-THE-COUNTER❑
BUILDING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
_
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
❑ STANDARD
❑ PUBLIC WORKS
_
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER DISTRICT
_
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp_201 Ldoc revised 06/21/11
-e 7
CITY OF CUPERTINO
FRF ESTIMATOR — RITII,DING DIVISION
[,tech. flan Check
:tihzch. Permit Fee..
Other hlech. InsP.
Tech. Insp. Fee:
Plumb, Plan Check
Plumb. Permit Fce:
Other Plumb Insp.
Plumb. Iusp. Fee:
Elec. Plan Check
Elec. Permit Fee:
Other Elec. Insp.
Elee. Insp, Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). "[heseees are based on the rellmma
ADDRESS: 10881 S BLANEY AVE
DATE: 08/21/2013
REVIEWED BY: MELISSA
QTY/FEE
APN: 369 34 052
BP#:
*VALUATION:
1$4,800
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE: Commercial Building
PENTAMATION
PERMIT TYPE: 1COMMLROO i
WORK
STORAGE AREA ONLY — RE—ROOF E TORCH DOWN WITH N TORCH DOWN ROOF SYSTEM.
SCOPE
ADD (N) TR 1-11 SIDING OVER (E) SIDING
[,tech. flan Check
:tihzch. Permit Fee..
Other hlech. InsP.
Tech. Insp. Fee:
Plumb, Plan Check
Plumb. Permit Fce:
Other Plumb Insp.
Plumb. Iusp. Fee:
Elec. Plan Check
Elec. Permit Fee:
Other Elec. Insp.
Elee. Insp, Fee:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, eta). "[heseees are based on the rellmma
to ormatlon available ana are onl an esumare contact the �e t or aaan [ m o.
FEE ITEMS (Fee Resolution 11-053 E . 711/12)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
360 s.f.
$383.00
Re -roof
IREROOFCOM
Suppl. PC Fee: (E) Reg. ® OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
=s.f.
$627.00
Siding
1SIDEOTHER I All Other
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
Consiruciion Tax:
Adininistt ative Fee:
0
E)
Work Without Permit? ® Yes (E) No
$0.00
Advanced Planning? Fee:
$0.00
Select a Non -Residential
Building or Structure
i
Travel Documentation Fees:
Strong Motion Fee: IBSEISMICO
$1.01
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
.a� y
$2.01,$1,01
:0 00
$1,012.01
Revised: 07/01/2013