15110063-CANCELLEDJuly 21, 2017
Community Development Department — Building Divisioi
10300 Torre Ave. Cupertino, Ca 95014-3055
Attn: Permit Issue
Re: Cancellation of Permit
Permit #: 15110063
Project Address: _10405 Brewer Ave. Cupertino, Ca
95014
Please cancel Building Permit for 10405 Brewer Ave. Cupertino, Ca 95014 Permit
#15110063. The Contractor was fired and therefore the Kitchen Remodel Project
was cancelled.
Thank you,
Betty Blais Dahlin - Homeowner /
RECEIVE1D.
JUL 20?7
BY
Section 3700 of tfie' 1:,abokCode, for the performance of the work for which this
AP Number: 6410 6. 0
permit is issued, � � ;` ; ;.:. ••, "� .:.: ' � Occupancy Type:
'APPLICANT C { RTIFIC ION
I certify that I have resd•this application and state th t the abo information P T EXPIRES IF WORK IS NOT STED
T
correct' I, agrde'to, comply with all city and county dinances state laws lating
to building'construction,' and fiereby authorize repr entattves o this city to er WITIHN 180 DAYS OF PERMIT ISS CE OR
upon the above mentioned piopb.ity for inspection urposes. (We) agree to a 180 DAY LED SPECTION.
indemnify and keep }iarmless-tlio City of Cupertin against liabilities, judg e
costs, and expepses• which inay accrue against sai City in consequence o the
granting of this•,perint. i Additionally, the applican understands and will omp " y: Date: ii 130
with all; non -point soiiice regulations per the Cupe ino Municipal Code, ectio
"' i is , :r • r. ;'i , : -ROOFS:
Signature i i' i , ; ; Date All roofs shal/inspected y roofing material being installed. If a roof is
installed withinspection, I agree to remove all new materials for
inspection.
°`OWNE _ER DECLI hereby affirm (haf,i am exempt from the Contractor's License Law for one ofSignature ofADate:
the following two'r' a'sons: ,," !1as owner of the;property;'ormy employees with wages as their sole compensation,ALNGS TO BE CLASS "A" OR BETTER
will do the woil ;,a d the`§tr66tuie is not intended or offered for sale (Sec.7044,
Business,&Professions Code):' t
I, as owner of tbeigroperty; am exclusively contracting with licensed contractors toHAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business &Professions Code).
/avereadhe hazardous materials requirements under Chapter 6.95 of the
t California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I h far t `$fs:' under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code Chapter 9.12 and the
declarations: '!i�; r': ; :�:• . P � P P , P
Health & Safety Code, Section 25532(a) should I store or handle hazardous
Pave and -will main. in'a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous
compensation; as prgvided for by Section 3700 of the Labor Code, for th air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will;mainfain Worker's Compensation Insurance, /provi or by the Health &Safety Code, Sections 25505,25533, and 25534.
Section 3.700'of thelaboror the performance of the wh this i
permitis issued !,; °i?12! :'�;¢.; Owner or authorized agen„i�/%��
I certify thatin the performance of the work for which this permit is issued, I shall
not employ any pergoi fn any inanner so as to become subject to the Worker's
Compensation lgiys of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY
fortbech re' %8o, r ct;to tli$ 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 compty with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (See. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read us, plication and state that the above information is
correct. I agree'to comply with ail city and county ordinances and state laws relating
to building,construetioii;,and Hereby authorize representatives of this city to enter
upon the above mentioned pzopeity for inspection purposes. (We) agree to save
inderpnifyyand keepiharmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION
costs, and expenses whicfi'may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting ofthis permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional
9.18,'. :: I f ' ; • IT 'I.I, I
Signature/"'(C J 7ir2t Dated%--7D—lel
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:' A.405 BREWER AVE
CONTRACTOR: DAHLIN BETTY B
PERMIT NO: 15110063
TRUSTEE
OWNER!,t .DAI3L•IN•BETTYBTRUSTEE
.
10405 BREWER AVE
DATE ISSUED: 11/10/2015
:..., ,
OWNERtS PHONE::40869i7514
.:
CUPERTINO, CA 95014-1306
PHONE NO:
CENSEl)� CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIALL)i
License,Clas's " ' "' ' ''Lic.
KITCHEN REMODEL (260 S ).
:. #
Contractor Date
I hereby affirm4had ain:licensed under the provisions of Chapter 9
(commenCing'with:Sectiaii 7000) of Division 3 of the Business & Professions
Code!ancl 4hat my:laceu'se:istin full force and effect.
I heretiy affirin'under penalty.of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self -insure for Worker's
Compensation; as piovided for by Sdction 3700 of the Labor Code, for the
performance of the work,for,whiclithis permit is issued.
.,, .
S q. Ft Floor e .
Valuation: $15000
I have.and�wilf4paiiiWn Wdrkdr's Compensation Insurance as provided for b
Section 3700 of tfie' 1:,abokCode, for the performance of the work for which this
AP Number: 6410 6. 0
permit is issued, � � ;` ; ;.:. ••, "� .:.: ' � Occupancy Type:
'APPLICANT C { RTIFIC ION
I certify that I have resd•this application and state th t the abo information P T EXPIRES IF WORK IS NOT STED
T
correct' I, agrde'to, comply with all city and county dinances state laws lating
to building'construction,' and fiereby authorize repr entattves o this city to er WITIHN 180 DAYS OF PERMIT ISS CE OR
upon the above mentioned piopb.ity for inspection urposes. (We) agree to a 180 DAY LED SPECTION.
indemnify and keep }iarmless-tlio City of Cupertin against liabilities, judg e
costs, and expepses• which inay accrue against sai City in consequence o the
granting of this•,perint. i Additionally, the applican understands and will omp " y: Date: ii 130
with all; non -point soiiice regulations per the Cupe ino Municipal Code, ectio
"' i is , :r • r. ;'i , : -ROOFS:
Signature i i' i , ; ; Date All roofs shal/inspected y roofing material being installed. If a roof is
installed withinspection, I agree to remove all new materials for
inspection.
°`OWNE _ER DECLI hereby affirm (haf,i am exempt from the Contractor's License Law for one ofSignature ofADate:
the following two'r' a'sons: ,," !1as owner of the;property;'ormy employees with wages as their sole compensation,ALNGS TO BE CLASS "A" OR BETTER
will do the woil ;,a d the`§tr66tuie is not intended or offered for sale (Sec.7044,
Business,&Professions Code):' t
I, as owner of tbeigroperty; am exclusively contracting with licensed contractors toHAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business &Professions Code).
/avereadhe hazardous materials requirements under Chapter 6.95 of the
t California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I h far t `$fs:' under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code Chapter 9.12 and the
declarations: '!i�; r': ; :�:• . P � P P , P
Health & Safety Code, Section 25532(a) should I store or handle hazardous
Pave and -will main. in'a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous
compensation; as prgvided for by Section 3700 of the Labor Code, for th 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;mainfain Worker's Compensation Insurance, /provi or by the Health &Safety Code, Sections 25505,25533, and 25534.
Section 3.700'of thelaboror the performance of the wh this i
permitis issued !,; °i?12! :'�;¢.; Owner or authorized agen„i�/%��
I certify thatin the performance of the work for which this permit is issued, I shall
not employ any pergoi fn any inanner so as to become subject to the Worker's
Compensation lgiys of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY
fortbech re' %8o, r ct;to tli$ 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 compty with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (See. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read us, plication and state that the above information is
correct. I agree'to comply with ail city and county ordinances and state laws relating
to building,construetioii;,and Hereby authorize representatives of this city to enter
upon the above mentioned pzopeity for inspection purposes. (We) agree to save
inderpnifyyand keepiharmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION
costs, and expenses whicfi'may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting ofthis permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional
9.18,'. :: I f ' ; • IT 'I.I, I
Signature/"'(C J 7ir2t Dated%--7D—lel
/c
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:' J'0405: BREWER AVE
CONTRACTOR: DAHLIN BETTY B
PERMIT NO: 15110063
TRUSTEE
OWNEA!.NA`M`E:".DAHLIN-BETTY B TRUSTEE
10405 BREWER AVE
DATE ISSUED: 11/10/2015
OWNERS PHONE:; 4086917514..
CUPERTINO, CA 95014-1306
PHONE NO:
❑ :LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E]
REMODEL (260 SQ FT).
ItyKITCHEN
License Lic. #
o mraet i� Date
0
Contractor
I hereby affirm that'.1 am:li&fiscd under the provisions of Chapter 9
(comniencingi�ithiSe'etiofi' 7000) of Division 3 of the Business & Professions
Code'a4d filiatiny" licen's'c' isin full force and effect.
I hereby afflrm uner pe Analty.of perjury one of the following two declarations:
"
7 "
' "
I have and will !"in.a.certi.icate.of consent to self -insure for Worker's
Compensation; as provided for by S66tion 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $15000
perfbrman�ce o`filie w6ric',f6r,which this permit is issued.
Worker's Compensation Insurance, as provided for by
1,
'
. �; �3! �-I. * � 1,
Sectionthe e LAb.or,.C,0,de,fioi the performance of the work for which this
APN Number: 32641066.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify I that I llave read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correctA agrde'to comply with all city and county ordinances and state laws relating
'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
i! .;
t o buildin construdion,'an.d hereby authorize representatives of this city to enter
upon the above mentioned p{6p6ity f6r inspection purposes. (We) agree to save
180 DAY �LED SPECTION.
indemnify and keept.armlegs' tile City of Cupertino against liabilities, judgments,
costs, and expenses which may against said City in consequence of the
/,?o
'accrue
granting of this• permit.; Additionally, the applicant understands and will comply
Date:
with !all, non -point source regulations per the Cupertino Municipal Code, Section
9.18.1
RE -ROOFS:
Signature p 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 (haf I am exempt from the Contractor's License Law for one of
Signature of Applicant: Date:
the following two're'asons':,'-
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
as owner of thetpr6lierty,' or, my employees with wages as their sole compensation,
twill
, 4 ; !,
do the• work'. and. theI struduie is not intended or offered for sale (S e c. 7 044,
Busin�Fss P,
rofessions''Code).'
1, as owner of the property; am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the pr6ject'(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. 1 will
I hereby''afflir'm','�u:nder''pena,lo 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
:will riiain;t'a'in'aCer tificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
.9�,eand
01ml, pensation; as p0y'ided for bySection 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the i6rk'forwhic, . h this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will Worker's Compensation Insurance, as provided for by
`abor'&��,�ior the the for this
the Health & Safety Code, Sections %25505, 25533, aitd-25534.
-
Section 3700 �of the'performance of work which
•Code,
l/ -JC Owner or authorized ageint-o!D.W.0
permit is' 0u.6d.;.—
I certify that in performance of the work for which this permit is issued, I shall
. person, -, I manner not employ any person in an manner so as to become subject to the Worker's
y
, '
Compensation la��s oiCaliforilia. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become'..,,,u.bjecfto ffie 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 h'at'e "read this, application and state that the above information is
correct. I agreeld comply with all city and county ordinances and state laws relating
to buildlfig'co.nsiruciion,;,ani Hereby authorize representatives of this city to enter
uponthe above mentioned for inspection purposes. (We) agree to save
I edpr
. 1; 1-, 1 11�� .,
indemnify and keepi harml ss'the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs', and expenses whichmay accrue against said City in consequence of the
' 1' '
I understand my plans shall be used as public records.
granting ofthis permit.
- Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.'
4
Signature. Da
L
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • buildino(olcuoertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at: -
SITE ADDRES -
APN..3 /�
BP#
OWNE AM.E�
T! .Z//dam
OWNER DRESS n
B /LJ'5 I(—)E
DESCRIPT.I/ION OF WORK:
We are providing you with an Owner -Builder Ackhowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having thus permit issued in your name as the Owner -Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
building permit that erroneously implies that the property owner is providing his or her own labor and material
ally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
,ensed person and his or her employees while working on my property. My homeowner's insurance may not
coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
ice coverage for injuries to workers on my property.
I understand_ building permits are not required to be signed by property owners unless they are responsible for
struction and are not hiring a licensed Contractor to assume this responsibility.
. I understand as an "Owner -Builder" I am the responsible party of record on the permit. 1 understand that I may
t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
instead of my own.
I understand Contractors are required by law to be licensed and bonded in California and to list their license
rs on permits and contracts.
I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
ue of my construction is at least five hundred dollars ($500), including labor and materials, I may be
red an "employer" under state and federal law.
I understand if I am considered an "employer" under state and federal law, I must register with the state and
I government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
)loyment compensation for each "employee." I also understand my failure to abide by these laws may subject
serious financial risk.
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
tial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
d subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
rmed under contract with a licensed general building Contractor.
I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
ncial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
I understand I may obtain more information regarding my obligations as an "employer" from the Internal
even e Service, the United States Small Business Administration, the California Department of Benefit Payments,
and th California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-C'SLB (2752) or www.csib.ca.gov for more information about licensed
contrac=ors.
I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
mudarty legally and financially responsible for proposed construction activity at the site address listed above.
Vil. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
all applicable laws and requirements that govern Owner -Builders as well as employers.
PL2P2. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information l have -provided on this form. Licensed contractors are regulated bylaws designed to protect.the-public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial- loss you may sustain as a. result of a complaint -Your only remedy against unlicensed
Contractors maybe in -civil court. If is also important for you -to understand that if an unlicensed Contractor or
employee of that individual or firm is injured .while working on your property, you may be held liable for damages. If
you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or note
those Contractors. are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's si nat e.
Property Owner's Signatures D!..�_
-
------------------------------------------------------------------------------------------------------------------------------------------
--
(NOTE: The following Authorization Form is required to be completed by the property ov✓ner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature,
Property Owner's Signature:
Date:
OwnerBuilderFOrm 2010.doc revised 0/14/10
J
v e -
Y, 4$ o ,�J �y� ��� c��c/ �lo-o- , ado, a
L.
CITY OF CUPERTINO BUILDING PERMIT
...............
BUILDING ADDRESS:' 5 BREWER AVE
CONTRACTOR: AAA CONSTRUCTION PERMIT NO: 15110063
SERVICES
OWNER'S. NAME:! -DAHLIN BETTY B TRUSTEE
PO BOX 110971 DATE ISSUED: 11/10/2015
OWNER'S PHONE: A086917514
CAMPBELL, CA 95011 PHONE NO: (408) 510-9382
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
icense, C las: Lic. #
KITCHEN REMODEL (260 SQ FT).
Aontiactor/A Ir. ro' /z,/',
I hereby affirm, that I am lice' used under the provisions of Chapter 9
(commencing with �§ccti6n'%70-00) of Division 3 of the Business & Professions
Code �ai d 4liat"niy ficiiise.i '.i' full force and effect.
L.
I hereby affirm under penalty of perjury one of the following two declarations:
I have andwill maintain a'certificate of consent to self -insure for Worker's
Compensation, ks:provided for by Section 3700 of the Labor Code, for the
.perfbrmance of the Wbrk.fbf which this permit is issued.
Sq. Ft Floor Area:
Valuation: $15000
0have a id"wiil'maintain. :Wo.rk:6'r's Compensation Insurance, as provided for by
Section 3700 'of the Labor Code,for the performance of the work for which this
APN Number: 32641066.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that'l have read this •application and state that the above information is
'
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply ' ith 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 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
.
by: Date:
Issued ve
granting of this permit.' : Addition ally, the applicant understands and will corn ply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
!Signature_ —Dat
RE -ROOFS:
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
1, as owner of theproperty, : or my employees with wages as their sole compensation,
will . do the: and the'st r ruc I ture is not intended or offered for sale (Sec.7044,
Business & Professio ris Code)
1, as owner of the property,, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Se6.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
of
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereliy'affirm:'�nd&:penilty perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declaratious.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I hav6 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 tfi6•work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and! �vill maintain Worker's Compensation Insurance, as provided for by
Section 37'00`o'fthe Labor C6d'e'Jor the for
the Health & Safety Code, Sections 25505,25533, and 25534.
the performance of work which this
twner or authorized agent gent-:L�!i��7 Date:
permit is issued..• '01,
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
Compensatioii�la%�s'6f.Califomia. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become 4ject i6 thcWbrkei'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 (see. 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 me.htioned property for inspection purposes. (We) agree to save
.
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and cxp8n�ses� ��hich'rriay 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
.19,
CUPERTIPIO
CONSTRUCTION PERMIT APPLICATION
COIViMIUNITY DEVELOPh/TENT DEPARTIAENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - buildino(g).cuDertino.org
❑ NTEW CONSTRUCTION ❑ ADDRiON ALTERATION / TI ❑ REVISION / DEFERRED ORIGIN?AI. PERMIT
011NERNAI \—ley
r.44ML
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_ �
STREET ADDRESS I CITY, STATE, ZIP
I FAX
CONTACT NAME
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
OR'NtR ❑. OWNER -BUILDER ❑ OWNnR AGENT 54, CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCRE_I CT ❑ ENGINEER ❑ DEI'ELOPER ❑ TENANT
LICn'NSENU1JiBER
j I LICENSE TYPE
<
I BUS. LIC
COI�ANY NADiE
E-NLAIL
FAX
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ea.
I CITY STA ZIP
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�ON�
ARCHITECTrNGINEER NF1111E
LICENSE NU.NSER
BUS. LIC R
COMPANY NANS
I E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
I PH01 iE
DESCRIPTION OF WORK
E7ISTLNGUSE PROPOSED USE CONSTRTYPE ISTORIES
I
USE I
TYPE. I OCC.
SQ -FT.
VALUATION (S)
EXISTG
NEW FLOOR
DE1,40
TOTAL
AREA
AREA
AREA
NET AREA
T
BATHROOM
O T I -._.R
7KrrcHEN
REMODEL .AREA
REMODEL AREA
RE2,40DEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH ,4a:A
I GARAGE AREA: DETACH
❑ ATTACH
:D1IELLDGUNTTS:
ISASECOND UNIT ❑YES
SECOND STORY ❑YFS
BEING ADDED? E3 N,
ADDITION? ❑NO
PR ,-,tunr KATION ❑ 1' -ES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ 1i5
TOTAL VALUATION:
PLANNING ADPL m ❑ NO PLANNING APPROVAL LE FTER
EICHLER HOME? ❑ NO
U U
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 relating to building construction. I authorize representatives 'of Cupertino to enter the above -identified ro erty for inspection purposes.
Signature of Applicant/Age
Date:
SUPPLEMENTAL INFOMMATION REQUIRED -
_
New SFD or Multifamily d,,vellinas: Apply for demolition permit for
existing building(s). Demolition is required to issuance of building
�O«R SHE�COL1tTERBUIIDLNGPLREVIEW'
—
x
permit prior
permit for new building.
s
EREss
PI._A\AL�GPL4T� FZE�LEF�
! Bldgs: Provide a completed Hazardous Materials Disclosure
P7, -BSO
cTNDARD�� r
_Commercial
form if any Hazardous Materials are being used as ,part of this project.—�
_
�❑
T
of Planning Approval Letter or Meeting with Plan_*ling prior to
_Copy
submittal of Buildir..g Pe='t application.-_-
.�
�ESA?�TE7iRY SER ERIDIS� RIOT v
^`
B1dg-App_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
w>
ADDRESS: 10405 Brewer Ave
DATE: 11/10/2015
REVIEWED BY: Sean
BP#:
'EVALUATION:
1$15,000
0, 0
hrs
$0.00
PME;Unit'Fee:`: a:
I
*PERNIIT:TT.E:,;; ;:.;Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARYSFD
1.'orDuplex'
PENTAMATION
1R3SFDREM
�I. ,
PERMIT TYPE:
wok
`Kitehen' Remodel 260 sq ft
SCOPE:
I1 t
iM1 t.'l e'i'b „ Alan C.#8f;k
I
II /Pff#.:I3.'lY12f1.�'t;t': Pl?dnw. ller".ili '{"r.': .'l£ 1r£<P`:r?i#1`t'r':
l
C1Flur .l'1#rr iI� r#.s} C1
-her I lec'. Ir# z7.
I
'Erfech, 1 5T7I k: r I I' i'I##�1)..17JQj1„ -e: �.:"t'C.. fYi:4J7.
: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 De t or addn'1 info.
FEE"'ITEVIS'(F ee'Resolution 11-053 Eff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Cl e&:Fee: `, , j $0.00 260 s.f. Remodel, Kitchen (<=300 sfl
!I.
Suppl PC {Fee`: Reg.,(:) OT 10.0 1 hrs $0.00 $645.00 1 REMRESKIT
PNM Plan lClieck: ! ,,
$0.00
Permit Fe"ei' '` ,;' '
$0.00
Supp'1' Insp,` Feer'! Reg. 0 OT
0, 0
hrs
$0.00
PME;Unit'Fee:`: a:
I
$0.00
PME �PermitFee "' ' ti '
$0.00
1./. i.l �fl�ll Vf'v j7 i•!>)�Id'd, 6RJ4 i, ,
4thnin.t, 1 Cd1llC'.
W6rk`Nith6ut?erm1t9. 0 Yes No
$0.00
A'dva'nc'ed:PlaririingFee
$0.00
Select allon-Residential
Building or Structure
St'ron.Nlotiori Fee: '.;:• .• 1BSEISMICR
$1.95
Select an Administrative Item
Bldg Stds'"Commission Fee: IBCBSC
$1.00
r RTOTALS
$2.95
$645.00 TOTAL FEE `
$647.95
Revised: 10/01/2015
;r a� `f • .�� �\ p rir#c calzs kr1 a ion. It is unlawtul to malts any
` �1��
i-13 o, affi a is ns on surae, or to deviate
Sul! � �... .! •.; ..'.: r ... P A•..1E iFf"fr^71.��� (i.? oval frorn the Building Official.
jj� J yyf/ 3 0�OjR��.k The s mipinr of this plan unci specifications SHALL NOT
bs i _i w per, nit or to b,Y an approval of the violation
1 Ufa C:UD� COMPLIANCE of any provisions of any Cit Ordinance or State Law.
euiewed By: ;,
' ' BY
DAr .a�4�� Wil• ID •/ �^
A" PERMIT 1�10.
Note: This drawing is an artistic
nter re �(
ip Cation of the general
appearance of the design. It is
�y not meant to he an exact rendition.
R 170? ft t- L- it
Designed: 8/18/2015
Printed: 8/18/2015
.. ..�-.A:.1:': rlra�iiinn ii• 1
UUPERTIN
Building Dep- rtmeni
NOV 1. 0 2015
REVIEWED FOR (;ODF COMPLIANCE
BPviewed By
�Xz: � �- / -�- /,� xew /`�
Note: This drawing is an artistic
interpretation o r the general
appearance orthe design. It is
not meant to be an exact rendition
Designed: 8/18/20
Printed: 8/18/201 _`
' Tha.vina t
j�Zf5e
r
HXIO�
Reuje�ed BY
Note: This drawing is an artistic
interpretation of the general
appearance of the design. It is
not meant to be an exact rendition.
817021'6e.kit
All
Designed: 8/18/201
It Printed: 8/18/2015
Drawing #: