14030138 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20135 FOREST AVE CONTRACTOR:JON R CRASE PERMIT NO: 14030138
CONSTRUCTION INC
OWNER'S NAME: CAMPBELL ROBERT W AND RACHEL C 164 GILMAN AVE STE A DATE ISSUED:03/24/2014
OWNER'S PHONE: CAMPBELL,CA 95008 PHONE NO:(408)370-1485
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑
REPAIR VEHICLE DAMAGE TO CORNER OR CAR
License Class_ Lic.# l GARAGE.
Contractor J6 tA L' CP45 a Cotte, Date
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. Sq.Ft Floor Area: Valuation:$1000
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:31633070 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 189 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 l
granting of this permit. Additionally,the applicant understands and will comply Issued by: _ Date:
with all non-point source regulations per the Cupertino Municipal Code,Section %
9 18.
? RE-ROOFS:
Signature Date 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
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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)
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 the Health&Safety Code,Sect' ns 25 5,25 ,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this l
Owner or authorized agent: Dater
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 CONSTR CTION 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
918.
Signature Date
CONSTRUCTION PERMIT APPLICATION v�
its COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•buildingQcupertino.org
VerALC P D
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT#
PROTECT ADDRESS FbP� A APN# 6 -9- 'l
OWNER NAME (' ` PHO E,^�3-2„70 E-MAIL A r(3 �T
STREETADDRES$�� '�� w ,� W� CITYCST T��b gVCX4 1 I NOW
FAX �
CONTACT NAME�� C C/�W J j,V-+I�I PHOl�r /(DCSC54 ft;, E Ivy_- ,nom.o -Sl a-CU
STREET ADDRESS/ CIT CITY TATE, I �p��•1C F J
Ave � - Dov vP--��
6
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONT.A r'rOR NAME may.,_, _ � - LICEj11SE NIVIfS41 LICENSE T�'PE BUS.LIC#
COMPANY NAM �{�] E-MAIL I (� FAX
.J P_ 0968 e� 1 Milo C�s�c�.�eu�•Com -374-02_34
STREET ADDRESS// &p CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICE;J NUMBER BUS.LIC#
COMPANY NAME - AIL ---- FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK VL
p C/I.2t?G►lv� $Arc 1),40
W C0 .1�3t c
'774Q ( gfla3 RJwzP wg fmr co R+AR oW PLA S
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
WOOD USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: LJ DETACH
❑ATTACH
#DWELLING UNITS: ISA SECOND UNrC I p❑�YES SECOND STORY ❑YES BEING ADDED? lam'NO ADDITION? INNO I
PRE APPLICATION E]YES IF YES,PROVIDE COPY OF IS THE BLDG AN El YES RE„-�El V ; r ;.- TOTAL VALUATIOI9:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO Is "I
By my signature below,I certify to each of the following: I am the property owner or authorized age t o act on the property owner's behalf. I have read this
application and the information I have provided is c rrect. 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 ction I a hori representatives of Cupertino to enter the above-identified prop for inspection purposes.
Signature of Applicant/Agent: Date: 3JZ /
SUPPLEMENTAL INFORM ION REQUIREDi M RouTucc si IP
_New SFD or Multifamily dwellings: A ply for demolition permit for
'OBER THE COTER ❑'BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building m
permit for new building. CSE I REss >` r❑�LANt.INc PLAN REVIEW
y§� Y q wu p i t
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure CI STANDARDfi�'r ❑ PVBLIcwoRxs
form if any Hazardous Materials are being used as part of this project. �t� -
h .�'r '^^s�: ❑. IREDEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to ❑x�o�R gad
❑ SANITARY SEWERDISTRYGT
submittal of Building Permit application. ,
.❑, NVIRONMENTAI'HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 20135 FOREST AVE DATE: REVIEWED BY: MENDEZ
APN: BP#: *VALUATION: j$1,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION
USE: PERMIT TYPE:
WORK REPAIR VEHICLE DAMAGE TO CORNER OR CAR GARAGE.
SCOPE
bfxch_ flare 0,1(2(k 11himb, Man C'he k Ch,,("'
Other Plumb
ica`f fpf yr. y' v 71haruhIrsp. Fee: f 'ee.Inst CC
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 11-053 Eff.' 711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: Reg. ® OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly Only? ®Yes (F)No $0.00
Suppl. Insp. Fee-(F) Reg. (:) OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C`vttsttirc�iiora 1 SIX.
frltnini.flwtive Fee: 0
Work Without Permit? ® Yes (j) No $0.00 E)
Advanced Planning Fee. $0.00 hours Inspections G
Yruvel 13o(,.wn ,n1a1ion Fees: $139.001 ISTINSP Inspection,Hourly
Strong Motion Fee: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee
Bldg Stds Commission Fee: IBCBSC $1.00 $44.00 ]ADMIN
F B OPALS TOTAL FEE:
A
$1.50 $183.00 . $184.50
Revised: 01/15/2014
Jon R. Crase Consh l �i, Inc. JOB y
164 Gilman Avenue CAMP St-LL 4.
CAMPBELL, CA 95008 201-35 EbRigsf A-os
(408) 370-1485
FAX (408) 370-0238 CUP ud 9So%
Lic. #611547 jL A k/Z
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