15030089 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19976 PRICE AVE CONTRACTOR:JS MILLER PERMIT NO: 15030089
CONSTRUCTION
OWNER'S NAME: CHE HER-DAW AND JEAN Y 21701 STEVENS CREEK BLVD STE 292 DATE ISSUED:03/13/2015
O R'S PHONE: 4083908454 CUPERTINO,CA 95014 PHONE NO:(408)446-1407
LICENSED CONTRACTOR'S DECLARATIONr—
+� BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class__ 'p Lic.# OCiat�2() r r
Contractor��C, �A1�/�.(�>� Date
l� MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: STUCCO REPAIR(REMOVE TERMITE&FUNGUS)200 SQ
FT
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I howby affirm under penalty of perjury one of the following two declarations:
foave and will maintain a certificate of consent to self-insure for Worker's
mpensation,as provided for by Section 3700 of the Labor Code,for the
EE
fonnance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5000
ve and will maintain Worker's Compensation Insurance,as provided for by
tion 3700 of the Labor Code,for the performance of the work for which this APN Number:36904013.00 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 F T 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 pennit. Additionally,the applicant understands and will comply Issued by: Date: '3 `f`
with all non-point source regula ions per the Cupertino Municipal Code,Section
918.
l RE-ROOFS:
Signature Date 1 3) rS 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.
13OWNER- UILDER 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
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
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,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized agent: 1% D y Date:
Alk�,
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 55014=3255
(408)777-3228• FAX(408)777-3333•building Q_cupertino.org
CUPERTINO
❑NE. CONSTRUCTION 0."ADDITION ALTERATION/TI ❑_,REVISION/DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS APN R /� o r� iv i
OWNERNAME �`�/,• `y v v" \C� I PHONE -MAIL
MAIL
STREET ADDRESS' j CITY, STATE,ZIP. l I FAX -
PSM�c
CONTACT NAME �^ PHOA'E. E-MAIL
STREET ADDRESS ' ` CITY,STATE,:ZIP FAX
OWNER D-OWNER-BUILDER" O'OwpERA'GEENT q&CONIRACTOR r FICON]RACTORAGENT- '❑ .ARCHITECT D ENGINEER .-❑ :DEVELOPER D,TENANT
CONTRACTOR NAME , U t [� �\ Q� LICENSE 'j�l$R� LICEN TYPE BUS.LIC n
COMPANY NAME E-1,4AI`L�:l
STREET ADDRESS ��rm ^►�,S/`wd BVI Cl CTTY,STAGE ZIi',v` v VT�1 \( o�5 p t� PHO"4—b@
ARCHITECT/ENGINEER NAME • 1UJ SE NUMBER 1`— BUS.LIC R
COMPANY NAME E-MAIL FAX
STREET ADIDRESS CITY,STATE,ZIP I PHONE
DESCRIPTION OF WORK C-uz) V�
a
EXISTING USE PROPOSED USE CONSTR.TYPE £STORIES
USE TYPE OCC. SQ.FT. VALUATION(S)
E�ISTG 1 cW FLOOR DEMO TOTAL _T
AREA AREA TARFA - NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODELAREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA; D DETACH
D ATTACH
DWELLING UN S: ISA SECOND UNrr D YES SECOND STORY DYES
BEING ADDED? NO ADDITION? ENO
PRE-APPLICATION DYES IF YES,PROVIDE COPY OF IS THE BLDGAN El YES nE EI\ Ilk, - TOTAL VALUATION:
PLANNING ADPL ❑1Q0 PLANNING APPROVAL LETTER I EICHLER HOME? D NO -M
,,,'-�s T, V ..
By my Signature below,I certify to each of the following: Iproperty owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have pro,i correct 1,__
ha d the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildi cons ction. I auth epre tatives of Cupertino to enter the above-identifiprop rty fo ' spection purposes.
Signature of Applicant/Agent: Date: 71
SUPPLE-MENTAL INFORM
A IO REQ7D
Y
.�1✓AN
New SFD or Multifamily dwellings: Apply o demolitio pe it for
�� sOYE THE COUNTERsBLIIDLNGPL3��RE«�Y .
existing building s). Demolition permit is require rior to issu of building
i5-
permit for new building.
_Commercial Bldgs: Provide a completed Hazardous Materials DisclosuresT" D�xDl— fl�RLoRKs � -
form if any Hazardous Materials are being used as part of this project. g 01 -11 r � 5
L" GE � IEtE 33 J
Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. JOR �flsAnlT sEER�ls�xr T
.EI'X1AVNA1h1i1AL`.�:.L;TA
BldgApp_2011.doc remised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 19976 price ave DATE: 03/13/2015 REVIEWED BY: Mendez
APN: BP#: *VALUATION: 1$5,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: 1GENRE
WORK stucco repair remove termite&fungus) 200 sq ft
SCOPE
PIN 10,
1-1hi ?l3. /'lur€('heck C&,,€
onit Fee: 1'lasr}?I;, l c t z it d€r<:': l'!ec.
(.3t!' r'Xi" h,Imp, ()f'?er F'ra?raly Imp. C}a/i ?Lice.lrr tF.
?e€.It, Insp. lee: PI€knb,InT, Fee: 1l€t. ln.Fp. tee:
NOTE.This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the prelimina information available and are only an estimate. Contact the Dept/or addn'l in o.
FEE ITEMS (Fee Resolution 11-053 E . 7/U13,2 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 200 s.f. Restucco
Suppl.PC Fee: (F) Reg. O OT 0.0 hrs $0.00 $503.00 1STUCOAPP
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. ® OT 0,Q Thrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Cori stru(.:t ori 1 s,€.�:
Work Without Permit? 0 Yes No $0.00 G
Advanced Planning Fee. $0.00 Select a Non-Residential
7-Favel 13ocume toric t Fees, Building or Structure 0
Strong Motion Fee: IBSEISMICR $0.65 Select an Administrative Item
Bldg_Stds Commission Fee: 1BCBSC $1.00
y � � UBTyUTAJ�: $1.65 $503.00 01T,
FEE> $504.65
Revised: 02/14/2015