13120008 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10641 STOKES AVE CONTRACTOR:AMERICAN RESIDENTIAL PERMIT NO:13120008
SERVICES OF CA
OWNER'S NAME: HARVEL ROBERT W JR AND MARY J 965 RIDGE LAKE BLVD STE 201 DATE ISSUED:12/02/2013
OWNER'S PHONE: 4083130162 MEMPHIS,TN 38120 PHONE NO:(408)982-0405
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class C 3(o Lic.# 7(& 51 SS'
A R S/2 gsc-u a R0o�7-e+2 MECH r RESIDENTIAL r COMMERCIAL
Contractor 1TAAX PL.o AW-0-6-L Date ti 13
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions JOB DESCRIPTION:
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations: INSTALL PROPERTY LINE CLEAN OUT
1. 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.
2. 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. Sq.Ft Floor Area: Valuation:$8900
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is APN Number:32649014.00 Occupancy Type:
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,
costs,and expenses which may accrue against said City in consequence of the PERMIT EXPIRES IF WORK IS NOT STARTED
granting of this permit. Additionally,the applicant understands and will comply with WITHIN 1WDAVS OF PERMIT ISSUANCE OR
all non-point source regulati ns per the Cupertino Municipal Cod Se tion 9.18.
Date i�.y
180 DAYS LAST CALLED INSPECTION.
Signature
Issued by: Date: ?/ 3
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS'
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is installed
t. 1,as owner of the property,or my employees with wages as their sole without first obtaining an inspection,I agree to remove all new materials for inspection.
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) Signature of Applicant: Date:
2. I,as owner of the property,am exclusively contracting with licensed.contractors
to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three declarations:
t. 1 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 California
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. I will maintain compliance with
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Section
Section 3700 of the Labor Code,for the performance of the work for which this 25532(a)should I store or handle hazardous material. Additionally,should I use
permit is issued. equipment or devices which emit hazardous air contaminants as defined by the Bay Area
3. I certify that in the performance of the work for which this permit is issued,I shall Air Quality Management District I will maintain compliance with the Cupertino
Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and
not employ any person in any manner so as to become subject to the Worker's 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 Owner or authorized agent: Date:
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 for
APPLICANT CERTIFICATION 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
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
posts,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 with I understand my plans shall be used as public records.
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION 00ME P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION O
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 \�
(408)777-3228•FAX(408)777-3333•building
CUPeRTINO Ca7cupertino.org `�\ misc
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS
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OWNERNAME I/L E-MAIL
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STREET ADDRESSCITY, STATE,ZIP FAX
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CONTACT NAME �KDC tiq K L-Cj IA W R R6 Z PH(pp-ONE ata^o-I Lf 2 EMAIL
STREET ADDRESS CITY,STATE,ZIP FAX
2305 PHRtiUbN Ofd, 1 1609&�3 Vose( C-0 glrl-b
❑OWNER -❑ OWNER-BUILDER ❑ OWNER AGENT It CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME SA LICENSE NUMBER LICENSE TYPE BUS.LIC#
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COMPANY NAME E-MAIL FAX
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STREET ADDRESS CITY,STATE,ZIP PHONE
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ARCHrrECT/BNGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF IffSFD.,DUPLEX ❑ MULTI-FAIMY PROJECT IN WHALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL - URBAN INTERFACE AREA NO FLOOD ZONE 19 NO EICHLER HOME? NO -
DESCRIPTION OF WORK
�2EPLi9LE v� `5�W R �i9TSKAt_ W'/l`f! PRoPERT`1 Llai; c(,EJ'3fU0uT
o
TOTAL VALUATION: bf� QIP�. DrBYt 01-
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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 have 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 relatingto buildi ction. I authorize representatives of Cupertino to enter the above 'd ,tified property for inspection purposes.
Signature ofApplicant/Agent Date:
SUPPLEMENTAL INFORMATION REQUIRED „ p> cE�rs>yoly>g � _ .K
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MEPMisc,4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
imlFEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10641 stokes ave DATE: 12/02/2013 REVIEWED BY: Mendez
APN: BP#: "VALUATION: $8,900
*PERMIT TYPE: Building'Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 RPSS
USE: PERMIT TYPE:
WORK � ro ertv line clean out
SCOPE
�RIV y
'E,"`.
Mech.Plan(.'heckPlumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
1<tec4,.Permit Fee.: Plumb.Permit Fee: IPPERMIT F lec. P'ermi't Fee:
Fh
Afec�h.Insp. Other Plumb Insp. 0.0 hrs $47.00 Other Elcc.Insp.
.Insp. Fee: Plurnh. Insp. Tee: Elec,Insp,Fcc:
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These fees are based on the prelimina information available and are onl an estimate Contact the Dept for addn7 info,
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1113) FEE QTY/FF MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl.PC Fee: (E) Reg. ® OT 0.0 hrs $0.00 $24.00 1PRSEWER Sewer,Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Feely Reg. ®OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: _r_T $47.00
C;onsiruction ::Tax:
Administrative Fee: IADMIN $44.00 0
Work Without Permit? ®Yes (E) No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure 0A
Strong Motion Fee: IBSEISMICR $0.89 Select an Administrative Item
BldgYStds Commission Fee: IBCBSC $1.00
n " $139.89 $24.00 ¢. OTAEE• $163.89
Revised: 10/01/2013