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15110130_A CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21589 GRAND AVE CONTRACTOR: AMERICAN VISION PERMIT NO: 15110130 WINDOWS INC OWNER'S NAME: PHAM TUAN A AND NGUYEN SHELLEY S 0 MATHEW ST DATE ISSUED: 11/18/2015 OWNER'S PHONE: 4086370629 SANTA CLARA, CA 95050 PHONE NO: (408)617-0901 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL E] REMOVE AND REPLACE (6) WINDOWS. License Class R Lic. # 77732-6 tractor/¢gah-fFrd dfS/ea b✓u&rPate 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: $7000 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: 32624058.00 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 FROM LAST CALLED INSPECTION. indemnify and keep harmless tt e City of Cuperti gainst liabilities, judgments, costs, and expenses which ay accrue again ai ity in consequence of the d �ionally, th/appli t ' jy� >! f [+�, _/� Issued by: /l� �7`�j Date: ! `L/ granting of this permit. understands and will comply with all non -point so ce gulations er the upertino Municipal Code, Section 9.18. I RE -ROOFS: ignature 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 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 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) 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. 1 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 Cup rtino Muni 'pal Code, Chapter 9.12 and 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 the Health &Safety Code, Sections 05, 25533, d 25534. O ner or authorized agent: Date: permit is issued. r 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, atter 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. S ignature Date CUPERTIt40- GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (LOB) 777-3228 • FAX (408) 777-3333 • build inO(a�cuoertino.ora /�/ to F-PT-TJI<<1'TIN G I-INP_rRA1\ZCAL nF'TF.r'TRTrAT. M1,/�i CrFTTAhrFrlTiC PROJECT ADDRESS _r 9 � I A2N # �y ' % v� O��TiRN ?11E Yiv>,�iV1 � PPHONE�OR—S3%-06�� p1 E-1JaIL STREETADDP SS 21 CITY,CTAT~ t. ! j0/ y I Fye J U U li CONTACT NAIJE i„� P'rIONE �D n 0qo E -ill -CA TL e STREETA.DDRESS 11 In.._, ' I CITY, STATE, ZIP fAV4 C� , lm jbr,X ❑ OP,' _R ❑ Ow1,r7,-BUIL E ❑ OW.1,�tAG-L!,'T 5� CONPLJCTOR ❑COINTPACTOR AG NT ❑ ARCHITECT ❑ ENGL'�uR ❑ DEVELOPS ❑ i-_Kk1,r CO?-TR4CTOR I PJ,L fA r, S / I LICENSE T YYE LICENSE NU]v ERI �8 3--c I BUS. LIC COI1.P.4A'Y 1;.417 E-N,.t IL F.A X STREET ADDRESS ci Oo / ( CITY, STATE, ZIP F-RCIIITECT/ENGWEERNAME LICENISE NTLMMER II CO1,12ANAMG E-MAIL FAY" STREET ADDRESS CITY, STATE, ZIP I PHONE USE OF SFD o, DGYL ❑ MULTI -F.4,'= . PROnCT LN wILDLF1q7 ❑ .S PROi:CT IN El �t5 BUILDNIG: COh�R�' CIAL I UPB<� L�RFACLARE O IS T -rt BLDG CN _g �j"O ❑ FLOOD ZOMB =1Ci�LERHOM=? DESCRIPTION OF VIORK - WRJOWS iv, �u i ► ��. —�a V- 1( TOTALVAJ_UATION: �coO ILRFCEIy�D�� r `- a c nip ua i ,3 By my signatu-e below, I certify to each of the following: I ani the propefty owner or authorized agent to act on the property owner's behalf. I have read this application and the Lnformation I have provided is correct. I have read the Description of'Work and veru it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building con Lection. orize representatives of Cupertino to enter the above -identified property for inspection purposes. SigmatLre of Auplicant/Agent:� i Date: �•--'6 —/ r - SU-PP_EMEN1 ALT LNIrORvIATI01\ REQUIRED gg .: o�ER axF cou^:aER Z a ygry 04. �� 1 41, ❑6R((���Y y MEFMI'isc DP_7011.doc revised 06121/11 CITY OF CUPERTINO W,, -W FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 21589 Grand Ave FEE DATE: 11/18/2015 REVIEWED BY: Sean APN: BP#: 'EVALUATION: 1$7,000 PERMIT TYPE: Building Permit 0.0 PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: PME Plan Check: PENTAMATION 1 GENRE PERMIT TYPE: WORK Remove and replace 6 windows. SCOPE Suppl. Insp. Fee:Q Reg. Q OT 0 0 Flech" 1''r'i'rW Fee: 01her 'Afeeh. hiq). 44ech. inso, 1'1wrfb. 1' twiii F CO: 1'1id lb1 Ins'l.Fee: l�lcr,•..1'?s:rri t:`rrtr;,i., (.)11"ei' Elec. blsp. NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc). 7hesejees are based on the preliminary information available ana are only an estimate. Contaet the wept for aaan-1 lnjo. FEE ITEMS (Fee .Resolution .1.1-053 .F,f 7i1/13� FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 © # Window / Sliding Glass Door $431.00 I WINREP Replacement Suppl. PC Fee: @ Reg. 0 OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 r LlF3?z7Pi:S`1F"t1Zti'i' Fee: 0 Work Without Permit? 0 Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential E) Building or Structure 0 1-avelDocurrentation Fees Strong Motion Fee: 1BSEISMICR $0.91 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS $1.91 $431.00 :. `, TOTAL FEE., a�5io Revised: 10/01/2015 ,7 (S-901 cu r -84&o cry c to i y ZG q° G L✓ z0'(aG2 b ww, dws (i4 AZA 2\4d -f ic0V-- �6H0 ZGNO Lw C�w COMIVIUNIT DEVELOPMENT DEPARTMENT BUILDING DIVISION - CUPERTINO APPROV _D This set of plans ar-,1 specifica� I job site during c Tnstructron. It is unla� e kept at any changes or aler�ations on sarne, or to Y therefrom, withc ap rov ' F ,� deJiate Tho c� ii y ficial. ""y u' t ��s lan and specifications SHALL NOT be held ti) pernl,l ; Io be an approval of the violation of any pro, ;s of any C,t Ordinance or State Law. BY �5��V DATE PERMIT # ow cW PWT PLAN CKED BY DATE / lz 01S - PLANNING DEPT CUPERTINO