15080162FM
M
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10422 DENISON AVE
CONTRACTOR: GRIDLEY COMPANY
PERMIT NO: 15080162
OWNER'S NAME: COPRIVIZA MICHAEL ANTHONY AND MARY
122 ORCHARD CITY DR
DATE ISSUED: 09/01/2015
OWNER'S PHONE: 4088936041
CAMPBELL, CA 95008
PHONE NO: (408)374 -0900
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑
KITCHEN REMODEL (162 SQ FT); REMODEL OTHER (719
License Class .6 Lic. # J —�J��y
SQ
Contractor �izr�t.��y �a�a�,.y Date �,
FT); REPLACE (5) WINDOWS AND (2) DOORS; GAS
T
FIREPLACE WITH GAS LINE; REROOF COMPOSITION
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
Sq. Ft Floor Area:
Valuation: $235000
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
permit is issued.
APN Number: 31629072.00
Occupancy Type:
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
to building construction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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
1 V /5
granting of this permit. Additionally, the applicant understands and will comply
Issued by: , /� �% Date:
with all non -point source regulations er 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.
11 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
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 25505,2 33, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: l Date: Iq / '
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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
FM
M
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10422 DENISON AVE
CONTRACTOR: GRIDLEY COMPANY
PERMIT NO: 15080162
OWNER'S NAME: COPRIVIZA MICHAEL ANTHONY AND MARY
122 ORCHARD CITY DR
DATE ISSUED: 09/01/2015
OWNER'S PHONE: 4088936041
CAMPBELL, CA 95008
PHONE NO: (408)374 -0900
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑
KITCHEN REMODEL (162 SQ FT); REMODEL OTHER (719
License Class .6 Lic. # J —�J��y
SQ
Contractor �izr�t.��y �a�a�,.y Date �,
FT); REPLACE (5) WINDOWS AND (2) DOORS; GAS
T
FIREPLACE WITH GAS LINE; REROOF COMPOSITION
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
Sq. Ft Floor Area:
Valuation: $235000
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
permit is issued.
APN Number: 31629072.00
Occupancy Type:
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
to building construction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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
1 V /5
granting of this permit. Additionally, the applicant understands and will comply
Issued by: , /� �% Date:
with all non -point source regulations er 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.
11 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
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 25505,2 33, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: l Date: Iq / '
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 ^ build ingna cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION F I ALTERATION / TT I I RFVTST0N / T)FFFRRFT) ()RTCUNAT. PFRMTT if
PROJECT ADDRESS `
APN #
OWNER NAME( /�
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STREET ADDRESS,,,".",,
CITY, STATE IP
FAX
CONTAC NAME
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STREET ADDRESS
CITY, STATE, ZIP
FAX
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❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR KCONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACT RNAME ~P�''F C%iC.iJC-��
LICENSENUMBER
LICENSETYPE
BUS. LICL
COMPANY NAMES
E -MAIL
FAX
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STREET ADDRESS
CITY, STATE, ZIP
HON
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C,-len
2C o rC3F, a
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK -
EXISTING USE
PROPOSED USE CONSTR.
TYPE
#STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
REMODEL AREA
KITCHEN r�
REMODEL AREA// L
OTHER
REMODEL AREA
/
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
I
# DWELLING UNITS:
IS A SECOND UNIT []YES
SECOND STORY ❑ YES
BEING ADDED ? ❑NO
ADDITION? ❑NO
PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF
PLANNING APPL# [J NO PLANNING APPROVAL LETTER
IS THE BLDG AN ❑ YES
EICHLER HOME? NO
RECEIV BY
t �, '
TOTAL VALUATION:
•�T' `r`�V r
,
_ V C)
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 havelpad the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bui] struction, orize representatives of Cupertino to enter the above- dentif�d property for inspection purposes.
Signature of Applicant/Agent: �^ Date: f_ ' S
SUPPL NTAL INFO TION U
RE IRED
Q
PLAN CHECK TYPE
itQUTINGSL7P
_ New SFD or Multifamily dwellings: Apply for demolition permit for
ixE
❑ BuuTilNC
existing building(s). Demolition permit is required prior to issuance of building
ovEli cotJrrTER G
PiANREVIEw
'
permit for new building.
❑ EXPRESS 4J
❑ PLANNINGPLAN32EVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ r sTANDnRD + '
❑ Pusl rc woRKs
_
Form if any Hazardous Materials are being used as part of this project.
_
❑ � '
LARGE'
FIItE DEPT �,
_ Copy of Planning Approval Letter or Meeting with Planning prior to
j] nuaoR
=
❑ SANITARY SEWER DISTRICT '
submittal of Building Permit application.
r }:
` °r
❑ :ENVIItONMENTAIiHEALTA ,�- , _
BldgApp_201 1. doc revised 06121111
y. C-a
CITY OF CUPERTINO
IF W FEE ESTIMATOR — BUILDING DIVISION
ImlADDRESS:
10422 DENISON AVE
DATE: 09/01/2015
REVIEWED BY: SEAN
rL7e1/1 Pel-110 Fee:
APN:
BP #:
*VALUATION:
$235,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
I
PENTAMATION 1 R3SFDREM
PERMIT TYPE:
WORK
KITCHEN REMODEL 162 SQ FT • REMODEL OTHER 719 SQ FT); REPLACE 5 WINDOWS AND
SCOPE
(2) DOORS; GAS FIREPLACE WITH GAS LINE; REROOF COMPOSITION ROOFING (2100 SQ FT).
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 only an estimate. Contact the De t or addn'l in o.
FEE ITEMS (Fee Resolution 11 -053 E ..' 711113)
Ifech. Plan ('hack
Plumb. Plan Check 0.0 hrs $0.00
I Yer., Plan ('heck
rL7e1/1 Pel-110 Fee:
Plumb. Permit Fee: IPPERMIT
E.kw. Perneir Tea:
Other ,,Wech. Irap.
Other Plumb Insp.' 0.0 hrs $48.00
Ur /icl• Llec. Insp.
Adach. Insp. Pict:
Plumb. Insp. Foe
Elec. Insp. Fee:
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 only an estimate. Contact the De t or addn'l in o.
FEE ITEMS (Fee Resolution 11 -053 E ..' 711113)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0 �00
162 s.f.
$645.00
Remodel, Kitchen (< =300 sf)
1REMRESKIT
Suppl. PC Fee: (j) Reg. 0 OT
0.0
1 hrs
$0.00
PME Plan Check:
i
$0.00
= s.f.
$575.00
Remodel, Other
1 IREMRESOTH
Permit Fee:
$0.00
Suppl. Insp. Fee-(E) Reg. Q OT
0.0
hrs
$0.00
# Window / Sliding Glass Door
$431.00 1 WINREP Replacement
PME Unit Fee:
$0.00
PME Permit Fee:
$48.00
2,100 s.f. Re -roof
$357.00 IREROOFRES
("onsiruction Taal':
Administrative Fee: 1ADMIN
//$45.00
1 #
$72.00
Plumbing
1 IPGASRES Piping, Gas < =4 Outlets
0
Work Without Permit? Yes E) No
$0.00
Advanced Plannin g Fee:
$0.00
0 #
$503.00
Fireplace
1FIREPLFAB Pre- Fab/Metal Fireplace
0
G
Travel Documentation Fee: 1TRAVDOC
$48.00
Strong Motion Fee: IBSEISMICR
-/$30.55
Select an Administrative Item
Bldg Stds Commission .Fee: IBCBSC
V$10.00
srtrBTOmAs
.55
,
F$181 EE
$2,764.55
Revised: 07/02/2015